31 LAWRENCE ST - BUILDING INSPECTION 1� The Commonwealth of Massachusetts CITY OF —
Board of Building Regulations and Standards SAL M
S,\LEh1
Massachusetts State Building Code, 780 CMR Revised.tlar toll
Ls.
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Familt,Duelling
This Section For Official Use Only
Building P rmit Number: n Date Applied:
7_57 %L
Building Olticial(Print Nt rc) Signature Date
SECTION 1: SITE INFORMATION
I.I Pro erty Address: L 1.2 Assessors Nlap& Parcel Numbers
�.47.Vr_eaLe Sl
1.1 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(sy tt) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 QQwner'of Reco d:
Name(Print) City,State.ZIP
978-��F/ �/ZsZ�S� 04 COS
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. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
C/ SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
_. Electrical S ❑ Total Project Cost'(item 6)x multiplier x
. Plumbing S 2. Other Fees: $4 --cog
^ gi��
. Mechanical (II\':\C) $ List: ��t\ y � �
5. \Ishanival (Fire Suppression) S Total All Fees: S
Check No. _('heck Amount: Cash Amount:__ _
6. Total Project Cost: S �r 0)00 0 Paid in Full 0 Outstanding Balance Due:.
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License t..Ther I'..cpirrtinn Uatc
N;une of C'SI. I lolder
List CSL'1'ypC(sec below)
Nu. :mJ Strcct Type Description
U Unrestricted(11 d1din gs up to 35,000 ca. 11.)
C'ity/folln.Stale ZIP R Restricted Ix2 Pamil 1-- -oi--
M Mason
RC Roofin C'overin
W'S Window and Sidi
SF Solid Fuel Burning Appliances
_ I Insulation
Tcic hone [,mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or I IIC Registrant Name HIC'Registrutlon NunJ+er Inspiration Date
No. and Street
Email address
Ci /Town, State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.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 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.
Pont Owners Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By ring my name bet , I ereby attest under the pains and penalties of perjury that all of the information
ntai ed in this appli tion is true and accur a to the best of my knowledge and understanding.
7- 1-a
rint ener's or Authi nze , gene's Nance(tile Signature) Date
NOTES:
1. An Owner who obtains a building permit 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 M.G.L. c. 142A.Other important information on the HIC Program can be found at
��W%,iu;i>..goc hc;) Information on the Construction Supervisor License can be found at t-%�wminS>.em ,Ip;
2. %Vhen substantial work is planned,provide the information below:
Total fluor area(sq. ft.) (including garage, finished basement'attics,decks or porch)
Gross living area 1 sq. 11.)_ Habitable room count
Number of Iireplaces--____----- Number of bedrooms
Num her of bathrooms
---------_------_— Number of halt-baths
I pe of m heating syste --__--- --
Number ofdecks porches
1)pe of cooling system ---
osed
3. "focal Project Square Footage-nnay be Substituted ror"Tolal Project Cost" - -
L
CITY OF S U.Exvf
PUBLIC PROPERTY
DEPARTMENT
Vwraa YA9YMf.�OM l7fea•Suay�rwsuor<scns ON'0
7tL 9'1.745-9s"•FAX 97L7N0.9"
HOMEOWNER LICENSE EXEMPTION
plea"Priest
Date -7- -�l
Job Le Aewn , --2)1 Laco c,Vic e :cs-4
Home Owner Address
Home Owner Telephone
Present Mailing Address
no current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
him who.does not possese a license.provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
persons) who owns a pared of land on which he/sbe resides or intends to reside, on
which then 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
a twrmowna"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 understands the City of Salem
Building Department minimum inspection ptro :ad and requirements and that he/she
will comply with said procedures uiremen
HOMEOWNERS SIGNATL
.APPROVAL OF BUILDING ECTOR v
See other side for state code