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420 LAFAYETTE ST - BUILDING INSPECTION
, �2;.5°; G�g� 3 , ..,. ��tE�Ef1/E� „ ��,, s � The Commonwealth of Massachusetts 'u4d Board of Building Regulations and Standards CITY OF m � Massachusetts State Building Code,780 CMR t��b A� :�"����3 �,U evr d m �.(� Building Permit Application To Construct,Repair,Renovate Or Demolish a � One-or Two-Family Dwe[ling -''Tltis Section For Offioial Use Ouly � I BuildingPcrmithFumbu.'" �Dai'g�� ppl�ed'. � , Y � �,,:i s�s l , ft*�, � � � °' t � Bmldiug Official(PrintNa�ne) '�> '^` ":Signatiae ^ Date • � � �i' �� � ;-'SECTION<L•SITE INFORMATLON �.:: � . � � � 11 Property Address: 1.2 Assessors Map&Parcel Numbers `c� l�2o LA��f1�;�,fif"E 5�z7 / \ 1.1 a Is this an accepted street?yes no Map Number Parcel Number . 1.3 Zoning Information: 1.4 Property Dimensions: . Zoning DisVict Proposed Use Lot Mea(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yazd Side Yards Rear Yard Required Provided Requued Rovided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Ouuide Flood Zone? Municipal� On site disposal system ❑ Check if yes0 SECTION 2i PROPERTY OWNERSHFA�: 2.1 Owner�of Rewrd: � �,if,an � �sf�� 5.a� iGts� t7tS7 � X`, Name(Print) City,State,ZIP I �\ 92J1..�'re?'�/W� � 1�'�J 3�7 37�jy �LUSTlZI�Q �� Ns✓�t� ✓�"ti+V, � � No.and SVeet ` Telephone Email Addres SECTION 3:DESCRIPTION OF PROPOSED WORKZ(eheck all that appty) � New Constrvction❑ Existing Building❑ Owner-Occupied ❑ �Repairs(s) ❑ Alteration(sj ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: ' ' Brief Description of Proposed Worl�: �� � � �-Na��wmn IO r.� S+sv� I � SECTTON 4:ESTIIVIATED CONSTRUCTION COSTS Item Estimated Costs: OfScial IIse Only � Labor and Materials � 1.Building $ Z�b 1• Building Permit Fe$i$ Indicat'e how fee is deteFrnined: 2.Electrical $ _o_ ��!�d City/Town Application Fee , ❑Total Project Cost�(Item 6)x multiplier x � 3.Plumbing $ _ o — 2 OtherFees: $ ���i--�� � � 4.Mechanical (HVAC) $ ;Lis[: ° . „ v t— 5.Mechanical (Fire $ � p� Total All Fees:$ � Su ression �� �� : �. � � Check No: Check Amount• Cash Ainount: ' 6.Total Project Cosh $ o�,�00 O Paid in FYild, �O,Outstanding BalanceDue: M D.���'rJ S � � i .—- :• > n, „ � t � ;" ' : SECTION 5: CONSTRUCI'ION SLRVICE� � k . " 5.1 Construction Supervisor License(CSL) ,.��� t �' '� f� �.- r 5,�j ;,��,, License Number Eacpiration Date . � Narne of CSL Aolder List CSL Type(see below) No.and Street TYPe Desa'iption � U Unrestriaed uildin s u [0 35,000 cu.ft.� � � R Restricted 1&2 Famil Dwellin City/Town,State,ZIP M Maso RC RooSn Coverin WS Window and Sidin SF Solid Fuel Bmning Appliances I Insulation Tel hone Email address D Demolition 5.2 Registered Home Improvement Contractor(fIIC) HIC Registration Number Expiration Date HIC Company Name or HIC RegisVant Name No.and Stree[ Email address Ci /Town State ZIP Tele hone � SECTiON 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G.L.c,152.¢ 25C(+�) 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...........❑ SECTTON 7a:O WN.ER AUTHORIZATION TO SE COMPLETEA WEEN OWNER'S AGENT pR CONTRACTOR APPLIE$FOR BIIII.DING PERMl'1' 1,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. Print Owner's Name(Electronic Signature) Date ECTION 7bi OWNER'OR AUTI30RIZED AGENT DECLARATION By enterin y name below,I hereby attest under the pains and penalties of perjury that all of the information containe n this applicatio 's We and accurate[o the best of my imowledge and understanding. X 6u- u � h�t 1tio14 '� � Print O ' or Autho ed AgenYs e(Electronic Signature) Date . NOTES: I. An Owner wh obtains a b ilding permit to do his/her own work,or an owner who hires an unregistered contractor (not registere in the Hom Improvement Contractor(I-IIC)Program),will not have access to the arbitration � program or gu anty fun under M.G.L.a 142A.Other impor[ant information on the HIC Program can be found at .ilvw.mass.>ov. ca I rmation on the Construction Supervisor License can be found at www.mass.�ov�, /dos � . 2. When subs[antial work is planned,provide the information below: Total floor area(sq.ft.) (including gazage,finished basemenUattics,decks or porch) , Gross living area(sg.ft.) ' � Habitable room count Number of fireplaces Number of bedrooms Number of batluooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open � 3. "Total Project Squaze Footage"may be substituted for"Total Roject CosY' S� � / `°� CITY OF SALEM, MASSACHUSETTS � � � 5tj r BUILDING DEPARTMENT ;45��y�._�����-�������! ` 120 WASHINGTOIV ST1tEET,3"0 FLOOR 2�`:�� : TEL. (978)745-9595 KIMBERL.EYDRISCOLL FAX(978)740-9846 MAYOR T�-IOMAS ST.PIERRE DIREGTOR OF PUBLICPROPERTY/BUILDING COMIvIISSIONER HOMEOWNER LICENSE EXEMPTION ' � PLEASE PRINT: \ Date Al�y l� ?sOl� Job Location �I2o �4r�ir ir� � �,w.�w. �� ����e Home Owner Address_ �Y� f,vt,�kt—'�'hG �: .� Present Mailing Address � � SALGdq, ul+',&1 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'shaii submit to the Building Official, on a form acceptable to the euilding Official, that he/she be responsible for ali such work performed under the Building Permit. The undersigned "homeowner" assumes responsibility for compliance with the State euilding 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 he/she will comply with such procedures and requirements. HOMEOWNER'SSIGNATURE I,b� �,,�� APPROVAL Of BUILDING INSPECTOR - - ii � - - - � • - - - - - �■ , _ . . . . r � - . . . .� � l�' � . i ---------------• �::::................ .................... �...................� � .::. .................... ■. �...................� .-_-. .................... , � ; , �:� �.................... ' ' ' " � . �� . ::::::::.'.'::.::::.'.' � 1 �� i � rsp�y '� :* � I�� � /1��. ��i�iiiiiiiiii�iioii� ti ;Y^r E�-� ' � I��\��I���\ �uo����o�������� ,-axh� ', +' . . �����w�.w����► � _L __________ �_ n w ��� i�i�i�i—i 7 �', �k "T �h . � - � ` � � ' 11 11 11 '. �1 . 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' . � . , � . � . . � . . � . . . ; � � . . � � �� � . . . . . . . . . � . . . i . . . . .. � . . � . . . . . . ' . . . . . . , � ` � . . . .. .. � I ' - . . . . -' � . . . . ..' • j 1 � '•� . " . � � . . . .. . � . . l .. . . .. . � � .. . . . . . . . . . � . . � � . �i. . � . . . . ' � . .. � . . . . ....�� � . . i . .. . . . . . . . . . . . . . . . . � . . . � .. .. � . . � . . ! . � � .. . . . . . . . . : . � ... . .. � � . . . � .. ' .. . . . . . .. . . . l � . . . . V I ' -.� � . . . . . � . . . . ' . . . . . . . : . . . . . . . 3 . . � . . � . ' REFERENCES ; ,. '' , i ;: � ;, : : , 1 . DEED RECORDED 1N BOOK 28167 PAGE 20 , ,; � I 1: �; + - ` � 2. ASSESSORS MAP 32 PARCEL 66 , ; ; � � ,' , w� ; . � : JUDITH P�,CClO1� T0 - . . 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