14 LAURENT ROAD - BUILDING INSPECTION L4 C,t< Z 5�
The Commonwealth of MassachusettsSPECTIOFiAL S RVIQM$Y OF
� Board of Building Regulations and Stand a 3 SALEM
17! I Massachusetts State Building Code, 780 CNIR vt Llur 20l
Building Permit Application To Construct, Repair, RenovatjOg o is a
One-or Tivo-Family Dwelling
This Section For Official Use Only
I
U + BuildingPermitNumber: DatyApplied:
,(1 Building Olticial(Print Mune). Signature• Date
SECTION L•SITE INFORMATION
�• 1.1 Pr erty ddress: 1.2 Assessors blap&Parcel Numbers
I.I a Is this an accepted street?yes no Map Number Parcel Number
i.3,,' oning Information: 1. roperty Dimensions:
Zoning District.., Proposed Use Lot Area(sq.(I) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Requin:d Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) t.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP!`
24t,
n r afRceord: Inn
(Print) City,State,ZIP r Y 1
No.and Sued Tephoneel Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Rairs(s) ❑ep Altemtion(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description o ropo ed Work-:
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) -
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
[3nd Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost?(Item 6)x multiplier x
3. Plumbing S P Qther Fees: S
4.Nlechmtical (EIVAC) S List:
5.i\lahanic it (Fire S Total All Fees:S
Su ression)
/ Check No._Check Amount: Cash Amount:
6. utal Project Cust: S �J 0,C ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES d
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'rype(see below)
No. and Street Type - Description
U Unrestricted(Buildings u i to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Droning Appliances
I I Insulation
Telephone Email uddrcss D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or(IIC Registrant Name
No.and Street Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:C.ISL§ 2$C(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.,
R'OWNES 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 76:OWNE&t OR AUTHORIZED AGENT DECLARATION
By ente in my name below, hereby attest under the pains and penalties of perjury that all of the information
co ,u n this appMisue and accurate to the best of my knowledge and understanding.
Q
Pr wner's or uth, ized Agent's Name(Electronic Signature) Dale
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 not have access to the arbitration
program or guaranty fund under IM.G.L.c. 142A.Other important information on the HIC Program can be found at
www mans cov'oea Information on the Construction Supervisor License can be found at wwjK,!I�
t 2. When substantial work is planned,provide the information below:
'total floor area(sq. it.) .(including garage, finished basement/attics,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 of cooling system Enclosed Open
3. 'Total Project Square Footage'may be substituted for"'roCd Project Cost"
° , QT'Y OF SALEM, MASSACHUSE T n
` 5 F BUILDING DEPARTMENT
' 120 WASHNGTONSTREET,30FLOOR
\�� TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR TYIomm STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT,
Date
Job Location 141
Home Owner Address / L
Present Mailing Address z
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 t he/she understand the City of Salem Building Department
minimum inspection procedures and req a ments and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
07Y OF SALEA MASSACHUSE'I'IS
�'. BUILDING DEPARTMENT
120 WASIRICTONSTREET,310ROOR
7kL(978)745-9595.
FAX(978)740.9846
R.IIv18ERLEY DRISOl7IL
MAYOR 711CIAM ST.PIERRE
DIRECTOR OFPUBucmopEmy/BuE DmoammomR
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 8 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 applicant
Date