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9 LAURENT RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts gFECTIONAIL S RVI CETY OF Board of Building Regulations and Stands tl5 S�A�L,EtiI qYt / Massachusetts State Building Code, 7S0 CMR77nn SS yy 3 �iZA/ar 2011 (� Building Permit Application To Construct, Repair, Renovate'6�Vol its h a One-or Tivo-Family Dwelling t ^ This Section For Mia se Only ~J ) V-1-3-u-Nding mit Number: Date ppliliireds \V 1 ticiul(Print Nune). - Signature Date SECTION 1 SITE INFORtNIATION Address: 1.2 Assessors Map&Parcel Numbers �ntrvat Qtaar� L I a Is this an accepted street?yes no Map Number Parcel Numhr 1.3 Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(sq 0) Frontage(It) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required - Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) t.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public[3 Private❑ Check if yesCI SECTION2: PROPERTY OWNERSHIP! 2.1 Owneru of Record: ( 1�� Sa�rv1 O (9r16 Tirno 't' $ JFcas"n2.I _ M G .NN me(Print) City(State,ZIP Lotur9A )2D 1'18-3�_jjC) tvtetnrKal7etO Cvm No.and Street Telephone mml Address SECTION.3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) Cl 1 Alteration(s) ❑ 1 Addition Cl Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': 1 J u tJ3; K SECTION a:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Costs(Item 6)x multiplier x 3. Plumbing S V Qther Fees: S q.Mechanical (IIVAC) S List: 5. \lechmiical (Fire ,S Total All Fees:S Suppression) Check No._(5eck Amount: Cash Amount:_ © G. Totui Project Cost C)OO.O0 ❑Paid in Full ❑Outstanding Balance Due: V e r3-�l_ C4 l'V IfK1 L4 i 3 mV'A( L, 1-o LA- o. i SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL'rype(see below) Description . No. and Street Type. . '.. U Unrestricted(Buildings tip to 35,000 cu. It. R Restricted 1&2 Family Dwelling Cilylrown,Stale,ZIP M Masonry RC Rooinat Covering WS Window and Sidinit SF Solid Fuel Burning Appliances 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 City1rown,State ZIP_ Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.4 c.152.1 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 ..........❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN', OWNER'S AGENT OR CONTRA it 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) Dale 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 a plicatio is true and accurate to the best of my knowledge and understanding. Print Owner's or Authi ' d r Nomc(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 nnf have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at Nvww.mass.aov:'oca Information on the Construction Supervisor License can be found at www.mass.��ov:!J�.Lts . 2. When substantial work is planned,provide the information below: Total fluor area(sq. ft.) N (including garage,finished basementtattics,decks or porch) Gross living area(sq. 11.) 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 ofcooliiigsystem Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" QTY OF SALEM, MASSAQiUSEIIS BUILDING DEPARTMENT ��Sy 1nTI' 120 WASHNGTON STREET,3"D FLOOR ' yttiso 'ILL. (978)745-9595 FAX(978)740-9846 KINMERLEY DRISCOLL MAYOR TrIOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COM14ISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: - I �- I S Date Job Location yz 1 Home Owner Address Cl `�G y c2 n 1� n rJ scj e� Mc, Present Mailing Address 1 L R y CQ nl R S G 1 Q W-N MR � 7 � 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 QTY OF SALEA MASSAMUSEM BUILDING DEPARTMENT 120 WASHNGTONSTREET,3A FlooR nL.(978)745-9595 KIIvIBERLEYDRISCI7L.L FAX(978)740-9846 MAYOR THOMAS STY ERRE DIRECTOR OFPUBLiCFROPEM/BUILDING CONSUSSIONER 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 ii 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) (address of facility) Signature of applica t LA s Date j � v Wes' 0 c \Li J . T �ya9 `r� l t� n k 1. n _ j --� � rhower