6 LAURENT RD - BUILDING INSPECTION r
The Commonwealth of Massachusetts INSPE "IT SOF $
Board of BuildingRegulations and Standards p �
Massachusetts State Building Code, 780 CMR 2014 S Re2jd Nel"r1�i lQ
Building Permit Application To Construct, Repair, Renovate Or Demolish a t
One-or Tlvo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appli d,
Building OBicial(Print N:une). 5igtature
SECTION 1:SITE INFORMATION.'
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
, r_ Ravl� 'nP'P
I.la 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 11) Frontage(11)
1.5 Building Setbacks(rt)
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 ifes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP,
2.1 Ownert of Record:
IAr695 50/-V
NN me(Print) City,State,ZIP
6 LAu12y_YL4- AoAD 97LII -12dZ iLA !5� 'EJcomcA:5J-
Nu.mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Altemdon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units _ Other ❑ Specify:
Brief Description of Proposed Work-: ((� i_✓tT QCk 5:tA I RS A/-e(
SECTION 4: ESTIMATED CONSTRUCTION COSTS
[227t.
m Estimated Costs: Official Use Only
Labor and Materials)
Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/rown Application Fee
Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ P,0ther Fees:
4.NIcchanical (FIVAC) $ List:
5. \lechanic:d (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: .S 2 0Q 0 ❑ Paid in Full ❑Outstanding Balance Due:
YI �Vr0 mPk1L_tro 101 (
1 y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�' t �� •:fS= License Number Expiration Date
Name of CSL Holder
List CSL"type(see below)
No.+md Street Type Description
U Unrestricted(Buildings up to 35,000 ou. 11.
Restricted 1&2 FamilyDwelling
Cityfrown,State,ZIP Masonry
RoofingCovering
Window and Siding
Solid Fuel Burning Appliances
Insulation
Talc hone &nailaadd,,s9NDDemolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Cunrp:my Name or IIIC Registrant Name
No.and Street Email address
City/Town,State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.¢ 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 Istuance 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
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below,)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 understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 riot have access to the arbitration
program or guaranty fund under 1M.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass. �oL � Information on the Construction Supervisor License can be found at ww%v.ma;s.,-,ov!10
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) '� (including garage, finished basementlattics,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
'I'ypeofcoolingsystem Enclosed Open_
3. "I'oial Project Square Footage"may be substituted for"Total Project Cost"
I
QTY OF SALEK MASSAMUSEM
BUILDING DEPARTMENT
1✓ 120 WASFENGTON STREET,3m FLOOR
TEL. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
I2 Scrf—vtn i?-SCole -60cA.(j i 4 MA O R�-vv
(address of facility)
�Glict/m, �a-r�-I'T7
Signature of applicant
off- z6�- /!
Date
�b CITY OF SALEM, MASSAaIUSETTS
BUILDING DEPARTMENT
120 WASI-IINGTON STREET,3HD FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TYIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BIIILDINGCOMMISSIONER
i
,
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date (9° — 26 -IV
lob Location & 71_,}U 1q(rP4 R6AB ,SCtlrc YA &A A 0 161 � O
Home Owner Address 50---ly
Present Mailing Address _50.'Wk-0_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" 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 OXY'1�05 6o4O
APPROVAL OF BUILDING INSPECTOR