435 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
!y O Massachusetts State Building Code, 780 CMR, Tn edition OF SALEM
J Revisal Junuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
1 One-or Two-Family Dwelling
UThis Section For Official Use Only
Building Permit Num Date Applied: "� 0
�j Signature: �"t �• ( t7
Buildinj Commissioner/ pector of Buildings Date
UV SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
y 3 S [ a3FRYE7TE S%
1.la Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Propperty Dimensions:
/3�Z / SO
Zoning District Proposed Use Lot Area(sq 11) Frontage(fl)
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❑ Private❑ Zone: _ Outside Flood Zone?Check if yesCI Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: D t f�s L Louts ToNAJSoAI V- t IfF wITuiEcL "e7g S% S•4 svl
Nam nn Address for Service:
tgnaturc f Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.Cl Number of Units / Other ❑ Specify:
Brief Description of Proposed Work': �Me"W St: S/ $-E OG EYIrS'TIA[ C) V6GK OW
GIQST �Lov2 2Er¢R
,¢nlD RJJO /7 k // ' '0P699WA 400ve DECK
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011iil U Only
Labor and Materials ca Use n
y
I. Building S Ll oOO� 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire r
Suppression) S Total All Fees:S
6.Total Project Cost: S y OOb Check No._Check Amount: Cash Amount:_
/ ❑Paid in Full ❑Outstanding Balance Due:
�5
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expination Uute
Name ol'CSL•I lulder List C'SL Type(see below)
Type Description
Address U I InrestricteJ(up to 35,000 Cu.FL
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Rooting Covering
relephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installaliun
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
1 tic Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature 'relephune
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 ..........Cl No...........C3
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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.
Simmiture of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
i as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.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"
I
CITY OF S.UY.N(
PUBLIC PROPERTY
DEPART IMENT
.VAYOe 1ID WASdrac Ly1 STuar•SMAK%L%%ACMSIr is 019'e
nL VI-7159s9s• h.%X 970-74&994
HOMEOWNER LICENSE EXEIMMON
Please Print
Date
Job Location y3S Lr�1 GAYS i SaGs</i t rt
Home Owner Address _ <SA+✓>G')
Home Owner Telephone (cl78) 5"?V- S•70 I
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.
DEFINMON 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 yea period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Oillcial,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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and r uiremen
HOMEOWNERS SIGNATURE !c
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
u CITY OF SALEM
PUBLIC PROPRERTY
jM b
�• DEPARTMENT
I'.II: MI�1 "MIr I'll
\I .11'M 1SC��+IIL\L.JNl1'MkCT •5.111f1,}t.\+�\I111yI,+.PI•.
ffl:4747t4'1i4S �P�7(:N7t•laS'ItM,
construction Debris Disposal A171davit
(required lur all demolition atd renovatiun work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions of MGL c 40,S 54;
Building Permit p is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensW waste disposal facility as defined by MGL e
S 150A.
The debris will be transported by:
pmlta of hauler)
The debris will be disposed orin :
(nalneul achy .
1
t address of r ahlyl
0, ?�02,01 wd�
-- +I nature oflwrmit plicaM
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