379 LAFAYETTE ST - BUILDING INSPECTION 9
'rile Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
�I Massachusetts State Building Code, 780 CMR Revised.blur 2011
n Building Permit Application To Construct, Repair, Renovate Or Demolish a y
One-or Two-Family Dwelling e`
This Section For Official Use Only n
Building Permit Number: Date Applied
o' m
`lis ; m
Building Otlicial(Pont Name). Signature D O
SECTION t:SITE INFORNIATION �.
L1 Property Address:`,y, 1.2 Assessors,Nap& Parcel Numbers
�j
I.l a Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Y,vd
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
+ Zone: — Outside Flood Zone? Municipal❑ On site disposal system stem ❑
I ublic❑ Private❑ Check if es❑ p p
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner of Reco �,- n V�
throe(Print) � � City,State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
BK Description of Pr sed Work`-
v
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ ? Qther Fees: $
4.,\Icchviical (hi VAC) S List:
5, Mechanical (Fire S 'rand All Fees:S
Suppression) 00 Check Na._Check Amount: Cash Amount:_
6. Total Project Cost: $ / ❑Paid in Full ❑Outstanding Balance Due:
Mto -o c��Jl1E2 WifiEl�1 2 j
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date-
;� Naiierol'CSL Holder List CSL'rype(see below)
C• ^` Type - Description
No. and Street
U Unrestricted(Buildings tip to 35,000 cu. 11.)
` R Restricted l&2 FamilyDwelling
- :Ciayfro�%vn,Smte,ZIP M Mason RC Rooting Covering
r WS Window and Siding
• SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.$ 25C(6)).
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isluance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEM
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PER611T
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
conta a in this application is tr daccurite to the best of my knowledge and understanding.
FFP•erAs - rs- 1(4
Print O vnj szmioriicd Agent's Na a (L'lectr to Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or anowner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under%I.G.L.c. I42A.Other important information on the H[C Program can be found at
ww v niass.govoca Information on the Construction Supervisor License can be found at ww-w.mass.nov!dos
2. When substantial work is planned,provide the information below:
'total tloor area(sq. ft.) .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'fypcofcoolingsystem Enclosed Open
i. "total Project Square Footage"may be substituted tor-rotai Project Cost"
= ' p CITY OF SALEM, MASSACHUSETTS
.' BUILDING DEPARTMENT
120 WASHINGTON STREET,YD FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location
Home Owner Address Sy��
Present Mailing Address Sd4—✓�
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
N .