403 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachusetts F
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i WA
Board of Building Regulations and Standards CITY ITY Massachusetts State Building Code, 780 CNIR Revised LE 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divel ing
This Section For Official Use Only '
Building Permit Number: Date Applieds
BuildingOtficial(Print N.une). - Signatures. Date
SECTION 1:SITE INFORMATION'
1.11
oilper Address: 1.2 Assessors Alap&Parcel Numbers
, o L 14r-ly r?rre 5T
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(R)
i 1.5 Building Setbacks(ft)
Front Yard Side Yank Rear Yard
r Required Provided Required Provided Required Provided
j 1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
P Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Checkif es❑
SECTION2: PROPERTY OWNERSHIP"
2.1 vnert of Record: S A-L�
Ie7I L� vCtU71s I �1/h
NJ me(Print) gity,State,ZIP
VdP3 Lq-(--A `f&T7c ST z 13Ve
No.mid Street Telephone Email Address
,
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
i New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ AIteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
rief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2'�9ther Fees: .S
4.Xlechanicai (FIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
�1 6.Total Project Cost: S 11 990`0 13 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1 License Number E.epiralion Date
Name of CSL Holder List CSL Type(see below)
Type - Description
N0.and Sueet
U Unrestricted(Buildings ug to 35,000 cu. ItJ
R Restricted I&2 Family Dwelling
City/Town,State,"LIP M Masonry
RC Rooting Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
1 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 ls4uance of the building permit.
' Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION:TOBE COMPLETED.WHEN?
"
OWNER'S AGENT OR CONTRACTORAPPLIE9 FOR BUILDING PERMIT
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.
l Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
® contained in this application is true and accurate to the best of my knowledge and understan�J(J�di��n .
Print Owner's or Authorizcd Agent' N;une(E•lecuonic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guarmity fund under M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
wvww etas,flov:'oca Information on the Construction Supervisor License can be found at www.nta� .
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) 4 (including garage,finished basement/attics,decks or porch)
Gross living area(sq. If.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open_
i. `"total Project Square Footage"may be substituted tor"futal Project Cost"
iv
b" QTY OF SALEM, MASSACHUSETTS
s. BUILDING DEPARTMENT
t rsi
120 WASHINGTON STREET,3"D FLOOR
�\ TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMbIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date (6 f �— \
Job Location �o3 LA-✓C,4 &T-1 -ST - SALMI yyy er
Home Owner Address 5/ -- I
Present Mailing Address S,Q-M
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 I
APPROVAL OF BUILDING INSPECTOR