448 LAFAYETTE ST - BUILDING INSPECTION � ,�� .r ,
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�, � I'he Commumvcalth o(Massachusetts
�}µ� �� Doard ol'Building Regulations anJ Standards ��TY
1 !�'► ) Massachusrlis State �uilJing Code, 780 CMR, 7'h cJition �F SnLEM
b ��;r � Revisrd Jum�ur�
' I3uilJing Prrmit Applicaliun To Co ct,Repair, Renovate Ur Drmulish a l. 3DON
Onr-or Tw�Fu ily Owr!ling
�I � This Slction or Offi ial Use O
� W Building Permit Numbe . -� � Ap ie .
Signalure: �yT/ro N /�
I Iui l Jing CummissioneN I pec�or u f Bui n Date �
SECTIO � :SITE INFORAIATION
I.I Property Addrex�: 1.2 Aeeaaon Map& Parcel Numben
y c�-����sf s�l�M� ,�G 3i- oai3 -o
I.1 a Is�his an accep�ed street?yes_ no Nfap Number Parcrl Number �
1.3 Zonlog Informatloo: t.� Property Dlmmsiooe: I
2 t . aa� �,�es 5'9. 4� �e-e_f
Zuning District Proposed Use Lot Arta(sq il) Frontage pl) �
1.5 Building Setbacks(R)
Front Yard SiJe Yards Rear Yard
RequireJ Provided RrquireJ Provided Requircd Provided
�; r O �r ��/ _} 5 ti �'
U
1.6 Water Supply:(M.G.L c.J0,§54) 1.7 Flood Zooe Informatlon: 1.8 Sewage D�poaal Syetem: �
� Zone: Oulvide Fload Zone7 �
Public Private O Chak if esO Municipal�On site disposal system ❑
SECTlON2: PROPERTYOWNERSHIP�
2.1 Owner�of Record: n ' I1, 1` c \ li
�nd M4.S 1`� ��i . `(T � 's�G��/�fTT'L-�. lr FC M _�Q.
Nume(Prin�) AJdrcsv for Servia: '
� 473 239- �/9/�/
Signa Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK�(c6cek all thrf apply)
New Construction❑ Existing Building O Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition
Demolition O Accessory Bldg.O Number of Units Other ❑ Specify: -
Brief Des\criplion of Proposed Work': � ' �
f)1'e.C� �y � T! �y � ��r, 'T`!e� � �OJ.!-L� � L�� � S`j�f
�,-{-�." [^ Lo r0 T �n
SECTIOIV 4: ESTIMATED CONSTRUCTION COSTS
Ieem Es�imaied Costs: Offlcial Use Only
Labor anJ Materials
I. E3uilding s g 3, oo I. Duilding Permil Fee:S Indicate how fee is detertnined:
2. Elearical S ❑StanJard City/Town Application Fee
�j. O O ❑Total Project Cost'(Item 6)a multiplier x
3. Plumbing 5 �j , o O 2. Other Feer. S
1. Mechanical (FIVAC) S a. 0 � List:
5. Mechanical (Fire
Su ressiun S � •O � Twal All Pees:S
Check No. Check Amoum: Cash Amount:
6.Total Project CosC 5 g(�p 7 p paid in Full ❑Owstanding Balance Due:
�1- �� l� � 1 ,�,/
/��-�i�/ 70 /Il��r,v p �vy1�1�
^�
f , �� r
SECTION S: CONSTRUCTION SERVICES i
S.I Licensed ComtrucNun Supervlaor�CSL)
I.iccnx NumAer f:rpiratiun Uwe
N�une ol'l'SL-I luldat Lis�CSL�I'ype lue belowl
��� Ikxri �ion
AdJrcse U Umestricicd u tu JS,OOOCu.Ft.
R Res�ricted I.t2 Famil Dwallin
tiignaiurc M M• Ool
RC Rexidemial Roulin Cuvcrin
�f.l.phone WS ResiJemial Window anJ Sidin
tiF ReeiJenlial Sulid Fuel Bumin A li:uKe InstallWiun
D Residrn�inl Demolition
3.2 Reg�tered Home Improvemeot Contractor(HIC)
f IIC Company N;une ur kI1C Rrgistnm�N:une Regis�mtion Number
Addrcss Expira�ion Da�e
Signuture Telephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(6))
Workers Comprnsation Insurance atTidavit must be completed and submined with this application. Failure to provide
this etFdavit will result in the denial of the issuance of�he building permit.
Signed Aflidavit Anached? Yes ..........❑ No...........O
SECTION 7a:OWNER AUTHORIZAT[ON TO BE COMPLETED WNEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
� , ac Owner of the subject property hereby
aulhorize to act on my behalf,in all mattero
relative to work authorized by this building permit application.
Si aturc of Owner Date
SECTION 7b:OWNER�OR AUTHORIZED AGENT DECLARATION
I, ��[qn.a�S !C1< ,as Owner or Authorized Agent hereby declare
that the statemenls and information on the foregoing applicalion are We and accurate,to the best of my knowledge and
behalf.
�e '<� �iZ.✓
Prim Name
3- az - /o _
SignaWrc of( neror Authori ed Agent � Date
Si ned under the ains and naltief of 'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered cuntrector
(not registered in�he Home Improvement Contractor(HIC)Program),will�have access to the•ubitration
progrom or guaranry fund under M.G.L.c. Id2A.Other imponant information on�he HIC Progrrm�nd
Construc�ion Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
?. Whe�substantial work is planneJ,provide the infortnation belaw:
Tulal Iloors area(Sq. Ft.) ;�`7 2 Sy�G�' (including garage,finished basemenUattics,decks or porch)
Gross living area(Sq.F�.) Habi�able room count
Number of firepiace: Number of bedrooms
Number of bathroums Number of half'/ba�hs
Type uf haating system Number of Jecks/purcha 2
Type of cuoling systam Enclosed Open ✓
J. "Tu�al Projecl Syuare Footage"may be substiwted f'or'To�al Projec�CusP'
. ' CITY OF S.�L.E.�!
PUBLIC PROPERTY
DEPAR'I'�tENT
u.ara�sv nur•�•�•
Vnro� i3Do'�urK.��nra�S,usa�Vwa�anumoN'0
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HONEOVWEA LICE,�ISE EXE.riPTIOr
Pfew hi�t
DW 3�.42-/a
�ob c«a�os �/YS L�,��/.� ff-c s�. �/Ua , �a .
Home Ownar Ad�eat t�nn.
Home Owoa Telephon� -ri 7S' - �3 S - 49/�
�M,utn��mna. +3d Y �5 n��..51�.ktw .�, a i 9c1
The current acempdou oC'Homaownas"war extended w include ow�a�-0ccupiad
dwellingr of tavo Unib or lea�and w allow auch homeownen W eagage ao individual for
hire w6o.doa nat pouea�s Gemaa�pmvided that the own�acb ar auparviaar.
DEFIIVTITON OF HOIW:OWNER
Peraon(s) who oaRu�paeeel of laod on w6ic6 hdahe raida or interd�w raide, on
whic6 t6ere i�, or i� intended W be, a one or two family dwellinp. attached or detached
structiva aeceswry to suc6 use and/or fum sLputurp, A penoa who coo�tructa moro
than one home ia a two yar period�hatl not be coosidaad a homeowna: $ue6
"homeowna�'shall aubmit w the Buildin�O�oial,on s fortn accrytable w the Building
Otlicial, that hdahe be responsible for all auc6 wort performed uader the Building
Pertnit
Tha undmi�ud "homeownd'auuma responaibiliry for compliance with the State
Buildin�Code and ocha applicable by-lawt and rcgulations.
The undmi�ed "homeownd'certitia that hd�he undmtands the City of Salem
Buildin� Dryutrnrnt minimwn irupection procedura and requiremrnb and thu hdshe
will comply with said proc�dura and requiremmts.
H0�IEOWYERS SIGYAT(,'RE �
,�PPROVAL OF BUILDLYG G�iSPECTOR �
See otha side for state code
^
�S ' CITY UF SALEM
� PUBLIC PROPRERTY
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' �•, DEPARTMENT
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C'onstruction Debris Disposul AI'ftduvit
(rryuireJ I'ur ull Jcmulitiun:md rcnuvatiun wurk)
In accurJ:mcc �vith �hu si�cl� rJitioa of tha State Duilding Code, 730 CMR scetiun I I 1.5
Debris, rnd the provisiuns ut'MGL c 4U,S 54;
di������y�,���� p is ixwued wilh the condition that tha dcbris resulting from
this wurk shall At disposeJ of in •r properly licens�d waete disposal facility as defined by MGL c
I l l. S I S()A.
The debris will be tr•rnsportcd by:
.LnrJ�cp�� �•Jas-�'C�
�namc of hauler)
1'h�dcbris will be disposed of'in :
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