30 LEACH ST - BUILDING INSPECTION (3) I
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a� I'he Commonwealth of Massachusetts _—
rj Board of Building Regulations and Standards CITY\ OF
v!I tI Ira' Massachusetts State Building Code, 780 CMR SALEM
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L. W Rrri.rer/.1lar?0/!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fumily Dvellinq
This Section For OfficiA Use Only
Building Permit Number: Dat Applied:
Lk 4
Building Official(Print Mane) SignatureI "Date
SECTION I:SITE INFORMATION .41
1.1 Pty Address: �1 1.2 Assessors Map& Parcel Numbers
ro er
L C--C. k � i�
I.la 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(sq R) 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.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP!
2.1 03unerl of Record:
N,un6(Print) C'ity.�Sl/ate,Z�IPj� /
No'.and Street Telephone Emaill Add s
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 or r
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SECTION 4: ESTIMATED CONSTRI ION COSTS
Item Estimated Costs: Official Use Only
Labor and \Iaterials)
I. Building S I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. MechanicalIIIVAC) S List:��_
5. Mechanical (Fire S —_
Suppression) Total All Fees: S
Check No. _Check Amount: _C'ash :\m t:oun
6. Total Project Cost: SJ ❑Paid in Full ❑Outstanding Balance Due: --_
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Number Expiration Date
Nano of('SI. I IolJcr
List C'SL rype(ice below)
No. and Street Type Des• plion
U l Inrestricied(6u' in gs u' to 35,000 cu. 11.)
ARC
Restricted 1 l'anul Dwelling
Cityll"mn.Slate.ZIP M:uonr
Rouli. CoverinWirfdow and SidinSolid Fuel Burning Appliances
Insulation
'1'ele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number Expiration Date
IIIC'Company Name or I IIC'Registrant Name /
No. and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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
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 Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering any 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.
- La/
' , ben s ;un ccuunic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do hisher 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 NI.G.L.c. 142A.Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at M10"z0k!1 t._x
2. When substantial work is planned, provide the information below:
Total fluor area(sq. ft.) (including garage, finished basetnent'attics,decks or porch)
Gross living area(sq, fl.) Habitable room count
`'umber of fireplaces_ Number of bedrooms
Number of bathrooms _ _ Number of half baths
1')pe of heating systenh — -- -- — Number of decks porches_— _ — _-- --
T)pe ofcouling system_ Enclosed
1 "folal Project Square Footage"may be substituted for Total project Cost.
CITY OF S.UYENf
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNSB EXE.NMjOjI
Pies" Prlat /
Job 1.4cados
Home Owner Address ,� r P� ��a
Home Owner Telephone �9io —3,1, z
Proud Mailing Address S21
The 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
hire who does not possess a lice s%provided that the owner acts as supervises:
DEFINITION OF HOMEOWNER
Peraon(s) who owns a pastel of land on which he/she resides or intende to reside, on
which than is, or is intended to be,a one or two family dwelling, attached or detached
structures accessory to such use and/or farm sttuctums. A person who constntcta more
than one home in a two year period shall not be considered a homeowner: Such
"llorueowner'shall submit to the Building OQlcial, on a form acceptable to the Building
Of lcial, 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 reguladonL
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
will comply with said procedures and requirements.
HO.tEOWNERS SIGNATL �
.APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF S,V-ENf, AASSACHUSETTS
E3UMDLVG DEP.1R1?LLNT
120 W.tiHLYGTON STREET, 3ie FLOOR
T-EL (978) 745-9595
FAX(97� 740.9846
K!J®ERLEY DRLSCOLL
NLAYOR T HO.+w ST.Pmntta
DIRECTOR OF PL'8L1C PROPERTYAWILDLYG CO\pttssl0.si ER
Construction Debris Disposal At'tldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section it 1.5
Debris, and the provisions of MOL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility 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 or racasty)
an+re of permit applicant
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