7 LAURENT RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts s4
WBoard of Building Regulations and Stan AL SERA iC�S SITY O
Massachusetts State Building CQO6{3'16, Revised Mar 2011
Building Permit Application To Construct,Repair,Renov�le,(�r DPVcQh1a2
One-or Two-Family Dwell AVu
This Section For Offtci l e Only
Building Permit Number: Dat Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1�1 Property Address: 11 1.2 Assessors Map&Parcel Numbers
x ) /n iff e RDQQ
L l a Is this an accepted street?yes no Map Number Parcel Number
II 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
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:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal stem ❑
Public❑ Private❑ Check if yes❑ p system
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Name(Print) City,State,ZIP
(r) 'el 1vf-CNo
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Re=[C] Specify:
tion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_
Brief Description of Proposed World:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate It w fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: '
5.Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
k 6.Total Project Cost: $ v5 ❑Paid in Full ❑Outstanding Balance Due:
1 '
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description.
U I Unrestricted(Buildings up to 35,000 cu.ft.
City/I'own,State,ZIP R Restricted 1&2 FamilyDwelling
M I Masonry
RC I Roofing Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street
Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 250(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 AUTHORIZ.ATION,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I 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
Cori A ti:0 1 NOTES: '
1. 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 can be found at
wtivw.mass.govioca Information on the Construction Supervisor License can be found at www.mass.<_>ov/dps
2. When substantial work is planned,provide the information below:
Total floor 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"
QTYOF SALEM, MASSACHUSETTS
n BUILDING DEPARTMENT
120 WASHINGTONSTREET,3"FLOOR
TEL. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOIvfAS STTIERRE
DIRECI'OROFPUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.,
Date S// L (� /r e� \
Job Location l 01)rw ROJ S02 ' YI
Home Owner Address 10of 4rDr]G lem p��/- r p�
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 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
APPROVAL OF BUILDING INSPECTOR