14 LAURENT RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts CITYa �< OF
Board of Building Regulations and Standards SAL M
Massachusetts State Building Code, Revised iL(nr 780 CNIR SdMar
2011
/ Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This SectioriFor'Offtcial Use Only —
Building Permit Number: . Date pli T /
Building Official(Print Name) ''Si at - Date
SECTION 1:SITE INFORMAT
A f�PropL-�a-v�-eerty Address:r � �V�� (1 1.2 Assessors Map& Parcel Numbers a
L l a 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 it) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2:, PROPERTYOWNERSHIPL. ".
k�2 Ownert of Re d:
.
//t
Name(Pri ) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORK'(check all that apply): ..
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': TPoe O � r
✓ Io
r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
(Labor and Materials) y`
1. Building S 1. Building Permit Fee S Indicate how fee is determined:
❑ Standard City/Town Application Fee. .
2. Electrical ❑To tat ProjectCosti.(Item6)xmultiplier x
3. Plumbing S 2. Other Fees: S 7 1
I Mechanical (IIVAC) 'S List: - �r
i. Mechanical (Fire $
Sri t ression) _ Ibtal All Fees: S
Check No, Check Amount Cash Amount.
6. "1'11tal Project Cost: 5 Q d 0 Paid in PuII ❑ Outstanding I:I;tlaitce Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number E.epiriuon Date
Name of CSL (folder
List CSL Type(sae below)
No. and Street VSFSolid
Description
icted [3uildin�s u to 35.000 cu. It.)
ted 19e2 Funil Dwellin
Cityrrown,State,ZIP
Coverin
and Sidin
uel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Hone Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or IiIC Registrant Name
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 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 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: OWNEW OR AUTHORIZED AGENT DECLARATION
By ntering my name below, I hereby attest under the pains and penalties of perjury that all of the information
c t ined in this a plication its true and accurate to the best of my knowledge and understanding.
Tint Own r'stor Autlwrircd:\;ent's Natne(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will nor have access to the arbitration
progr:un or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be found at
www.ncus.govyoca Information on the Construction Supervisor License can be found at wsvw.mass.,o�� (10
2. When substantial work is planned, provide the information below:
'rota) floor area(sq. 11.) _ _ _(including garage, finished basement/attics, decks or porch)
Gros, living area(sq. It.l _ _ Habitable room count
NnmberoFtirzplaccs —_ Numberofbedrooms -----_—_--
Number of bathrooms Number of haltibnths —
fvpo of heating system Number of'deeks/ porches _-_------ --
1\Pe of C001ing syaun Enclosed Open
1. Ford Ploiocr Square 14mt;t"e" muy be iubstinncd 6n Goal hoject Cott" --
CITY OF SM-E.ti[
PUBLIC PROPERTY
DEPAM. [ENT
U\.Ylllil eurvv�
4AVM I b Wind f UW•lKu4 VAYAOA seT1701f'0
ML 9'9-745.95" f Y.%a,r6.7409w
HOMEOWNER LICLNSB EXE.MFrj0,V
Ptew Mat
Date rr l /
lob Location l y �" d •1 2 ,,
Home Owner Addrala fl-�
Home Owoer Telephone 9 '2 8-
Pres"Mailing Addmas / N 79 7 K-71'_20 yr n
The cuseut exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or tvac and to allow ruck homeowners to cngsgs an individual for
hire who does not possess a Been=provided that the owner acts as aupa Wsw.
DEFMMON OF HOMEOWNER
Persona) who owns a peed of Lod on which hdA@ resides or intends to reside, on
which there is, or is intended to bel, a one or two thmily dwelWsg attached or detached
suvettrres accessory to such use and/or farm structure& A pawn who constructs more
than one home in a two year period shall not bs considered a homeowner. Such
"homeowner'shall submit to the Building OQlcial,on a form acceptable to the Building
Official, that helshe be responsible for all suck work performed under the Building
Permit
The undersigned "homeowners'asaumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner'certifies that hedihe understands the City of Salem
Building Department minimum i on educes equimments and that he/she
will comply with said procedur and omen
HOMEOWNERS StGVATL �
%PPROVAL OF BUILDIYG C iSPECTGR
Sce other side For state code
a
Y t CITY OF Sc1LENf) i�L-kSS:ICHUSETI-S
8ULLDLNG DFPARTM UNT
T S.
120 %V:ISHLNGTON STREET, 3�FLOOR
- TEL (978) 745-9595
KENMERI Y DRISCOLL F.+x(978) 740-9846
+LAYOX Tl-to+us ST.PIERRs
DIRECTOR OF PLBLIC PROPERTY/SUMDWG COSLNIISSIONER
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 11 1.5
Debris, and the provisions of tNIGL c 40, S 54;
Building Permit 1#this work 15 shall be
OA. is issued with the condition that the debris resulting from
lll, S disposed of in a properly licensed waste disposal facility as defined by NIGL c
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(namc ot racility) _
(address of Facility)�—
sign turc of permit applicant
Mate --
10
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