10 LAWRENCE ST - BUILDING INSPECTION I'lie Commonwealth or IMassachusclls
Board of Building Regulations and Standards CI I'1' OF
sr :.
Massachusetts State Building Code, 730 CNIR ti,\Lli,\I
Re vier) I li u'
Building Permit Application 'ro Construct. Repair, Renovate Or Dcmu '
(hlc- or ran-ka mlr Dwellhn%,
This Section For Otliciul .c nl
Building Permit Number: I Date Awl ied:
Ihlilding 011icial(Print Mune) Si tature Date
SECTION 1: SITE INFORMATION
LI P 12 AssessorMap S Parcel Numbers
/O F , ss/ —
I.la Is this an accepted street?yes r/ no Map Numhcr Parcel Number
1.3 Zoning Information: 1A Property Dimensions:
Cursing District I'mpuscJ Use Col Area(sy II) Frontage(Il)
1.5 Building Setbacks(fl)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zune? Municipal O On site disposal s)stem ❑
Check if cs❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
Mune(Print) City.State,ZIP
A/rrlReu/�JoSe?b:nr .F3F_Ij�RIJ 47S-7v0d9.3s
Nu.and Street 0 rclephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specilry:
Briet'Description ofProposed Work':
vs Cl va — es y "AChes h.o
SECTION J: ESTLNIATED CONSTRUCTION COSTS
Item Estimated Costs: OMCIIIl Use Only
(Labor and Materials(
I, Building S I. Building Permit Fee: S Indicate ho%v let is determined:
i '. Llcarieal $
❑Standard City.Tawn Application Fee
❑Tutal Prujat Cush I(tent 6)x multiplier _ __,x
1 I'IumMng S 2. Other Fees: S
�. \Iccll,mic.11 III\ 1<'1 S List' ---'�T.._�(JV
Cup+re..... S rotai .\Il Fees: S_.____—___
�. ChccA No. ( hcdl :\nnnu t: _ __.,_..Ca,h -\owunt:
n I'ulal Pntject CnsC i D0 O ❑ Paid in Full ❑Outstanding Balance Due:
i
��Q � �'lcYtieac�
SE( I ION 5: CONS I'Rll(,-riON SERVI( FS
.5.1 ('onstructioilSul)enisur License((St.) --- ' —*---- - -- - ' ' ---- *- —
pinuio
SI, I Foikicr L'SI. I'%
tic
No. ,ud Street
i pe
d'
1 01 —11 )
It
% I Window and Sidiiii
W Solid Fucl Ilurning Applimices
I Insulation
elvi'llong himil address L) Demolition
4.2 Registered I Ionic Iniljru%entent Contractor(HIC)
Wic
I IIC Compin) Name or I IIC Registrant Name
Date
*
No. mid Street Emuil Actress
City/Town. State,ZIP Tale hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 132.1 ISC(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 or the building permit.
Signed A Mdavit Attached? Yes.......... C! No...........0
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 Owner's Naine(Elcctrunic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
' a oa 0
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0
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in
Ow
ner r y.3 0
b
N behalf,the
a I f u 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.
Mitt
No rES:
1. An O%i,iier who obtains a building permit to do his,her own work,or an owner who hires an unregistered%:untravtor
I not registered in the Hume Improvement Contractor I HIC) Program).will no have have access to the arbitration
program or guaranty luiid widcr.M.G.L.c. 142.A. Other important information an the HIC Program can be found at
all,. �ok .,, i Information on the Construction Supervisor License can be found at
2. %%lien substantial work is planned, provide the information below:
rota) (lour area(4 111 ("'cluding gauge, Finished bal0lielft attics. decks or porch)
Gross lit tog area i sq. it.I Habitable room count
Number tit hvdrooini
\tintherot'liathrooms \tIllilicr tit halt'li.1111i;
I'N tit:of 11C.1ting >y ocill Number tit dccks pof%:fics
I%I,v oft:ooliog '�item Fo0o,ed .01'ell
I oI I I I'rk 11"t ;,I 11art: 1: 1 L!c' imi, he `tihNtlfillcd flor rJLll 11roic%:t
CITY OF S.UY-NL
PUBLIC PROPERTY
DEPAIMIENT
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tyros
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HOMEOWNER LICE.rSS EXE.I4BTI0►1
lob Lceadom r v j M 4,0R e A C
Home Ownet Addrear ,_ i ram_4 ce s r
Home Owner Telephone
Ptesed Mailing Address /O 1 f1WReoce s i
The current exemption of"Homeownare was extended to include ownaroccupied
dwellings o[two Unit@ or Iw and to silo�hat the ow acto as �vi� for
hire who does not posses a licenser prov{
DE,FINMON OF HOMEOWNER
Pawn(s) who owns a pttaeel o[tand as which bda w reddae or Intends to reside.an
which then isr or is intended to be,a one or two funily dwelling attached or detached
structures scceseory to such use and/or f'nm structures. A parson who consOucte more
than one home in a two year period shall not be considered a homed nSuc Building
„�eswnd'shall submit to the Building Official,on a form acceptable to
Official, that hdshe be responsible for all such work performed under the Building
Permit
The undersigned ,homeow"d'assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regalationa
no undersigned "homeownd'certifies that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
.vill comply with said procedures and requirements.
HO.MEOW`IERS SIGNATURE /
.kPPROV,IL OF SUILDING LVSPECTOR
Sea other side for state coda