7 LAWRENCE ST - BUILDING INSPECTION (2) •r
The Commonwealth o(Massachusctis Town of
I U Board of Building Regulations rnd Standards
^ � Massachusetts Slate Building Code, 780 CNIR, 7'a edition Building Dept
Bui d Permit Application To Construct, Repair. Renovate Or Demolish a
/ On
tar Tnu-fuiruI Duwllrng
This Sa
ral Usc OnlBwWing Permit Num c ppled:
Signature: BuddingCommissioner/ toofButDot
SECTION 1:SI E INFORMATION
LI o rty Address: 1.2 Assessors Map& Percel Numben
I.la Is this an acce led street''yea no Map Number Parcel Number
la Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(A)
L! Building Setbacks IR)
Front Yard Side Yet* Rem Yard
Required Provided Required Provided Required Provided
I.i Water Supply:(M.G.L c.40.134) 1.7 Flood Zone Information: I.B Sewage Disposal System:
Zone: _ Outside Flood Zone? Munieipel On site disposal system O
Public;t— Private O Check if s0
SECTION2: PROPERTY OWNERSHIPt
(Prints Address ro Service: _
9 >k'- -7
Si ure Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check AN that Apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed ork': �0
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Officie) Use Only
Item Labor and Materials
1. Building S I. Budding Permit Fee: S Indicate how fee is determined:
F , O Standard City/Town Application Fee
LJvtrj 2 Electrical S t7 Total Project Cost'(Item 6)a multiplier x
) Plumbing S 2. Other Fees: S
a Mechanical INVAC) S 'List:
s Mechanical (Fire S Total All Fees. S
Su ression
Check No. _Check Amount: Cash Amount:_
h Total Project Cost. S Q '�t ❑Pad in Full 0 Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
,.
• Limnx.Number Espuution Dute
Npee w SL Hyldn Lr.t CSL Type Ire heluwl
AddressT Description
U Unrestricted(up to 33,000 Cu. Ft
R Restricted l i2 Family Dwellin
slgMlure H %fasonry Only
RC Residential Roofinis Covering
Telephone K'S Residential Window and Sitting
SF Residential Solid Fuel Burning Apoliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. ISL 1 ISC(6))
Workers Compensation Insurance afftdavil 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 AffidavitAnsched7 yes..........O No...........O
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.
signiumorowner Date
SECTION 71b:OWNER'OR AUTHORIZED AGENT DECLARATION
I. 011,o A4 , as Owner or Authorized Agent hereby declare
that 1001stements and information on the foregoing application are true and accurate,to the best of my knowledge and
Print Noma
Silinatiareaf0si�aftorAults6rizedAgira Date t
signed under IV pains and penalties of
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered conlractor
(not registered in the Home Improvement Contractor(HIC)Program).will W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110 R5,respectively.
2. When substantial work is planned,provide the information below:
Total Goon area(Sq. Ft.) (including garage, finished basement(anics,decks or porch)
Gross living area ISq. Ft.) Habitable room count
Number of fireplaces Vumber of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number ofdecks/porches
Tnpeof cooling%ystern Enclosed Open
1 "Total Project Square Footage"may he.uhwmted for 'Total Project Coo"
CITY OF SALE.tiI
PUBLIC PROPERTY
DEPARTMENT
u,ututr nur'•,•
VAvOa 1304Au►K.MW STUNT 014AM%W&M34LWMON O
71<1.97a74i9s"•EO<976-740.9646
HOMEOWNER LICENSL EJKE.MMOL
Ptease Irrt.e
D:t.
,cb lae:doe � �-�•N ek c e �7"
He=Owner Address
Home Owner Telephone 9 7S- 7 5 6 7 a
Ptesast Mailing Address s e-
The current exempdon of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea and to allow such homeowners to engage an individual for
hire who does not possess a license.provided that the owner acts AS supervisor.
DEFINITION OF HONEOWNML
person(s) who owns a parcel of Lod on which he/she resides or intends to reside. on
which there is, or is intended to be.a one or two family dwellin&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 Ot]lcia4 on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Pamir.
The undersipwd "homeowner'assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Hill comply with said procedures
adireeNnta,m /
HOMEOWNERS SIGNATURE aPPROVALOFBUILDfYGC
See other side for state code
�\
CITY OF SALEM
s.
3i PUBLIC PROPRERTY
r' > DEPARTMENT
\I .,,ni 120\X,.%it It.(.;(,u St'BErr •SA I M,b1.%si.v
'Itt:478-70-9595 • FAX:978.740-9846
Construction Debris Disposal Affidavit
(required 1'ur 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 c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
1 11, S 150A.
The debris will be transported by:
y)nh�� Si�1P Gr'�G�.y
(name of hauler)
The debris will be disposed of in
(name of fan rty—f j
(address of 1'acilityl
17 signature of pennit applicant
date