9 LAURENT RD - BUILDING INSPECTION (2) .. i
i - �, - - --- I'he C'unrnumvcalth ul'�biusiachuscus - -
Board or Building Regulations and Slandards CI 11,OF
\•lassachItsells Stine Building Code. 780 CNIR 5,\Lli\i
r
i?,,Ii.wd Ihit-2011
Building Permit \pplirnion To Cons(ruct. Repair. Renovate Or Demolish a
O11,'-or ]\ntJ411n111P Duv iqq
This Section For Olrcial Use Oul
Building Permit Number: Date Applied:
lluilding Ullkial(Print Mane) Sigttmu Oulc
SECTION I:SITE INFORMATION
r7oni_ng
perty Address: 1.2 Assessurs�Iap di Parcel Nu ben
his an accepted street? yes no Map Number Purcel Number
ning Information: 1.4 Property Dimensional
istrict I'r+puwd Uw Lot Area IN 11) Frontage(11)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public(3 Pr(vute O Zone: _ Outside Flood Luna? Municipal O On site disposals)item O
Check if csO
SECTION2. PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,Slam.ZIP
9 L,,,,,Ky4 icy.
No.and Street relephune Emuil Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing Building Owner-Occup(ed Repairs(s),® I Alteration(s) O I Addition G
Demolition O Accessory Bldg.O 1 Number of Units_ I Other O Spccily:
Brief Description of Proposed Work :
C
SECTION 4: ESTLMATED CONSTRUCTION COSTS
liens Estimated Costs: Official Use only
t Labur cold.\arterials) y
I. Building S ( Oo o I. Building Permit Fee: S Indicate how tee is determined:
'. lilectrical S O Standard City+Tucvn Application Fee
O Total Project Cost'(Item 6).1 multiplier
I'IumMitg S ,, Other Fees: S_��1 �' \
J. \Ieeh.tltiC.d ill\ \CI i List:.
5 \Iechaniad it Iry
<u++rr>sumt r,ual \II Fees: S
o Chak No, (heck.Anu a l: C.t)h \nnnmC
I, I'mal Projco Cwl: i Qp ' --
O P.tid in Full O Outstanding Bal• nce oue:
SEC I'IONS: ('ONS'I'RUCTION SERVI('F.S
5.1 Construction Supenisor License((Si.)
I icenee Number I viraliau Dane
\;one l)l'l'.SI. Holder Ilsl l'SI. I'>pe l.ec licluiU,__,_ _
-- I)PC Descriplion
N,1 and sIreel
(I 11nrex1rieleJ I DuilJin-s up to 34,022 cu. It
He+uieldJ Ltt?P,unil Dwcllin
011"Iml•.Slake,SIP St \lasnn
KC Ni>.H ilt l'.o erin
A'S Window,atd Sidin
SF Solid Fuellhirning,lippliances
1I Insulation
felt hone Fnlail addrem D Demolition
5.2 Registered llume Improvement Contractor(HIC)
I IIC'Rcgislruliun Numher F%pirnlion Date
I IIC Conlpao) Noma Ile I IIC Itegl9trum Name
No.mid Street Email address
Ci /Town,State ZIP Isle hung
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.c, 152.y 25C(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..........O No O
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Omiei s Nwne(Elcctlunic Signature) Data
SECTION 7b:OWNEW 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.
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I'riN Duncr'i ur:\udu inJ,\ycnt'+ anw lCluclrunlc.\Ignaluru) D°tu
NOTES:
I. .\n Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
inut registered in the Hume Improvement ContmcturiHlCl Program),will 1u1 have access to the arbitration
program or guaranty fund under M.G.L.c. W.A.Other important information on the HIC Program can be litund at
a nl.l••+ ; 1 Information un the Construction Supervisor License can be found at s:w ql.
2. \\'hen Substantial t or
is planncd,provide the information below:
rolal Moor area I W. Il,l . _ I including garage, lmished basement attics.Jerks or porch 1
Gross living area l iy. ll.l llabilabie room count
\wober of lircl+laces \tntiher o(hedruunls
\tlnlher of hathnwms Number of half haths
I)pe of he.ning s)+lelll \onihcr ol'decks porches
Ile of C.4Jlllg i1. Will 1,116+ed ..
lapel
I "local 'roleet tit wvc IIn4.lge Ilia\ he QlhiillllleJ lar..I 11.11 Ilrojw("INC
N
CITY OF S.u.EM
PUBLIC PROPERTY
DEPAM(ENT
uy�oetlraul
VAry I b WMHP Oro@*UQ•114 -14 VA11 AC&MM OW9
iti.Utf7119Sf! Yea.S'L7�7W
HOMEOWNER LICENSE EXEMPTION
Pkw inlet .
Data i7- ) 0- 1 a
Job Loeadas c1 L r c h Ql
HomeOwasrAddrat q La, ,rAn
"s Hama Owner Telephoaa 9� n 3 t A o -q I� %-
Present Maillad Addrew g LA u c e h Qt
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Unite or less and to allow such homeowners to engage an individual for
hire who.does not possess a liemee provided that the owner acts n aupaMxw.
DEFINMON OF HOMOWNER
Person(s)who owns a pareal O(WW on which he/she raids or Intends to reside.on
which that isi or is intended to bt, a one or two tinily dwelling/attached or detached
structures accessory to such use and/or firm structure. 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 helsho undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Will comply with said procedures And requirem
HOMEOWNERS SIGNATLM
APPROVAL OF BUILDING NSPECTOR
See other side for state code
CITY UE S.VzNf, AkSSACHUSETTS
8LIL06YG DEP.IRT1lE.VT
I 't) WASHNGTON 5rxw, )'O FLOOR
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!U3®t_RL.6Y ORLSCOLL
MAYOlI MOu.+d ST.Ptztus
OlUxTOEOPPLaLICPIIOPIRTY/SL DLNGCosalISSIONEx
Conitruction Debris DISPosal Affidavit
(required for 4 demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.J
Debris, and the provisions of MOL a 40, 3 54;
Building Permit Al is issued with the condition that the debris resulting from
ibis work shall be S I JOA. disposed of in s property licensed waste disposal racility as defined by ,NIGL c
The debris will be transported by:
(n4MG Of6Ulu)
The debris will be disposed of in :
(name o%%�)
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