30 LEACH ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts &Y
C
Board of Building Regulations and Standards tSPEI I l L
SALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Dern#6 A 30 P 33 02
One-or Two-Family Dwelling
This S.eetjon For d oial Use Only
,9 Building Permit,Number.- . Date ed:
�.1 1 13vilding OfffCi'i1 fPriat Naaic) Signabas
SECT[ON TSITE V4FORMATION
1. roperty ddress:/ 1.2 Assessors Map&Parcel Numbers
- A - _
Map Number Parcel Number
1.1 a Is this an accepted street?yes_ no
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage 00
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Regained 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION!: PROPERTYOWNERSHIPi
2.1 Owerr off ecord•
N e(Print) i`—
<2s �P�.tl S7 E 1A s
No.and Street -�— Telephone
SECTION 3t DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Cl Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
61
k
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item abor and Mate 'als
1.Building $ I. Building Permit Few.$ indicate how fee is determine d:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cosh(Item 6)x multiplier x _
3.Plumbing $ 2: Other Fees: $
4.Mechanical (HVAC) $ Ltst'
(� 5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Cheek Amount: Cash Amount:
6.Total Project Cost: ❑Paid in Pull ❑Outstanding Balance Due:
•O •
rnlrsaLAM -M �L�b
SECTION S. CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) '
License Number Expiration Date
Name of CSL Holder;;i,ii, List CSL Type(see below)
No.and Street Type Deswrphon--
U I Unrestricted(Buildings up to 35,000 cu.it.
R I Restricted 1&2 Family Dwelling
City/Town,State,ZIP M I Masonry
RC I Roofing Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State,ZIP Telephone
SECTION 61 WORKERS'COWENSATIQN INSURANCE AP AVIT(NLG.I..e.152.§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 ..........Cl No...........O
SECTION'7ae OWNER AUTHORIZATION TO Big COMPLETED WHEN
WNER'S MG P
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.
Print Owner's Name(Electronic Signature) Date
SECTION 9b:OWNEW OR AUTHORIZED AGENT DECLARATION
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 accur o the best of my knowledge and understanding.—PM -
t wner's or Authorized Agent's Name(Electronic Signature) Date i
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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
m�tivw.mass.eov,'oca Information on the Construction Supervisor License can be found at 3MU .mass. ovg /dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
a
QTY OF SAUM, MMSAMUSE M
BUILDINGDEPAR7MENr
120 WASHNGTONSTREET,3"OFLoOR
TEL. (978)745-9595
KI1vIBERLEYDRIS0DLL FAX(978)740-9846
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLICPROPER7Y/BUILDING CO1VWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Dated
Job location 30 o
Home Owner Address
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'SSI
APPROVAL OF BUILDING INSPECTOR
O77Y OF SALEM KIASSA(HISETPS
B[IIDDIIGDBPARENT
IXWA9R4OWS"Wff7,3mFkOM
1kt(r!t 7�s959s.
FAX( 7d0-9&16
$D�ERLEYDRiSOQT.L
MAYOR 1ASSZPB31ni8
Dnacrca crpu 3ucnmFmy/BuLEaca3m& S4cmR
Construction Debris D1sposa/Aff1davit
(required forall demolition and,.renovation world
In accordance with the sixth edition of the State Bullding Code, 780 CMR, Section 111.S Debris,
and the provisions of MGL c40,S 54; Building Permit N is issued with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by. /
(na a of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date