418 LAFAYETTE ST - BUILDING INSPECTION i\
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 71h edition Wilbraham
"\ Building Dept
Building Permit Application To Const t, Repa Renovate Or Demolish a 413-596-2800
One- or Two- andly Dwellr g Ext 118
This Sec on For Offigial Lise Only
Building Permit Number to pp ed:
Signature: v /S /
Building Commissioner/InsloWetor of uildings Dat
SEC ION 1:SITE INFqMAIATION
1.1 Pro erty Address: 1. ssessers Map& Parcel Numbers
44
L la Is this an accepted slucctl yes—\z pp Map Number Parcel Number
1.3 Zoning Information: _ 1.4 Property Dimensions:
Az f
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
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:
Public CY Private❑ Zone: _ Outside Floo
Check ify es
d Zon Municipal❑ On site disposal system 15SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: n W L
Na (Print) Address for Service:
-��ip
gna re Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) AI[eration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
13 f Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ !,d 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $\:;I 00 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ti
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL- Holder
List CSL Type(see below)
Address - T e Description
U Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
Signature M Mason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Expiration Date
Signature Telephone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑ _
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application..
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, / ,as Owner or Authorized Agent hereby declare
the a statements and information on the foregoing application are true and accurate,to the best of my knowledge and
V6 alf r r / /�r�
Print Name
Signature wn or Au[ oriz Agent X Date
_(Signed under[ ains and penalties of perjury
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner 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 M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I O.R6 and 110.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPAWINTENT
III i'S -4 i.'�i'•h I �C. 'i78 '4:
Construction Debris Disposal Affidavit
(required for all demolition and rl:novation %vork)
In accordance %k ith the sixth edition of the State Building Code, 7S0 C'b1R section I 11 5
Debris, and the provisions of 1v1GL c 40, S 54;
is issued with the condition that the debris resulting from
Building Permit t
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
111, S 150A.
The debris will be transported by:
z
I name (it hauler)
he debris will be disposed of in
(na1nC ut facility)
I;uldres. of l�cililvl -
,icnatwc of pcunit .ytphcunt
� o0
,latr
' 'aCITY OF $ALE.N1
PUBLIC PROPERTY
DEPARTMENT
ivaa�cuinr�.w.•..
MAYM 120 WAam+[.T M T ERT•&MAK MAMAa&ssrls 01970
TEL 9'.}731-9S9S* FAiL 976.7-6&9846
HOMEOWNER LICENSE EXEIMMON
Please Print
Date
Job Location
Horse Owner Address
Home Owner Telephone — al
Present Mailing Address
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 who.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 them is, or is intended to be, a one or two family dwellin& 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 "homeownee'certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING SPECTOR
See other side for state code