12 LEACH ST - BUILDING INSPECTION Ct)[llmOnw'eallh of Massachusetts
s Board of Building Regulations and Standards FOR
III
Massachusetts State Building Code. 780 CMR, 7" edition 1il VIUSF\I I I )
W Building Permit Application To Construct. Repair, Renovate Or Demolish a RrrnrJ huuao r
One- or Tiro-Fuinih Lim elling 1,
This Section For Official Use Only
Building Permit Numbe . Date Applied:
Signature: '� '^-�� — �-/ 7 Ike-2
Building Commissioner/ la Spector or Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property :address: 1.2 Assessors N[up & Parcel Numbers i
p
I'la Is this an accepted street? yes 1. no_ Map Number Parcel Numfxr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(li)
1.5 Building Setbacks (R)
Front Yard Side Yards Rear Yard
7Water
Provided Required Provided Required Provided
upply: (M,G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Pr vate❑ Check if yes❑ Municipal ❑ On site disposal system OSECTION 2: PROPERTY OWNERSHIP[
. of Record: ��
n %Z Lim/�cw
Name 1 riot) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
ItemM-
aEstimated Costs: Official Use Only
(Labor and Materials)
I. Bui $ I. Building Permit Fee: $ Indicate how tee is determined:
❑ Standard Cityfrown Application Fee
2. Ele $ ❑Total Project Cosh(Item 6) x multiplier x
3. Plu $ n. Other Fees: $
4. MeAC) $ List:
5. Mec $5. rcTotal All Fees: S
Do Check No. Check Amount: Cash :\mount:6. Totost: $ QQ ❑ Paid in Full ❑ Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) 7 ---' %
License Number ES�pua wn Date
Nance of CSL" Holder .� List CSL Type(see helow)
T Description
>Jdress L' Unrestricted(upto 15.t11)O Cu. Fri
^�nC � R Restricted 18t2 Family Dsselhn
Signature _ N Masun On]
1 RC Residential Rou6u Coserin
Telephone _ \VS Rrsldenliai %vniduis and Sldin
SF Residential Sand Fuel lluriune l r it i.un: Iu.LJlawm
p Residemial Deniohoun
5.2 Registered Horne Improvement Contractor IHIC)
HIC Company Naine or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone i
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 1 2506))
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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , as Owner of the subject propertIrnavers
authorize to act on my behalf. i
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATIO7hcrebyjeclare
I , as Owner or Authorized Athat the statements and information on the foregoing application are true and accurate, to the best
behalf.
Pnnt Name
Signature of Owner or Authorized Agent Date
(Signed under the 2ains and nalues of r'u )
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 nor 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 floras area(Sq. Ft.) (including garage. finished busemenUattics. decks or porch)
Gross living area iSq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms j
Number of hathnxims Number of half/ba(hs j
rype of heating system Number of decks/ porches
Type of cowling system Enclosed Open j
3. 'Total Project Square Footage" may be substituted for"Total Project Cost"
• i;
L
BorXoruifJi's le8o7s Ann I
Construction Supervisor License
License: CS 34778 +
Birthdate'� 7/1/1945 -
" I Expiration 711/2009 Tr# 16353
Restriction f4`
DONALD W MOORE -£
9 OLIVER ST
SALEM. MA 01970 Commissioner
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.li\I .I'li l.l'.1 �'1(Ill.l_i1
.11.1Un( IdG W.vil IIyC:'I'i)N S TIiLHT 0 SAI PV,:YIAtii,A(:IILtil.l"fi 01'1/',
'flit:978-745')595 ♦ t'dr:9"8.740)N36
Construction Debris Disposal Affidavit
(re(Iuircd liar all demolition and renovation work)
In accordance with the sixth edition of the Statc Building Code, 780 CN1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ik is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal lacility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of IuciIity)
---._signe a of permit applicant
5`z//a s-
(lat
s
w
CITY OF SALE..
PUBLIC PROPERTY
DEPARTMENT
uanrnbv�w-•,,
UAYM 130 WA"NGRO"SnRr•SALEK MA4ACHLSEr1S 01970
7F1:9711-74S-MS• FAX 978-740-964
HOMEOWNER LICENSE EXEMPTION
Please Print
Date
Job Location 9 f-1
Home Owner Address /2 11,14 rrI4 Ste'
Home Owner Telephone �17fs 7LA5— "day
Present Mailing Address 14 tr
The current exemption of"Homeowners"was extended to include owner-mcupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFIMTION 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 that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR ✓ `
See other side for state code