30 LEACH ST - BUILDING INSPECTION IX
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%lassachuscils State HuilJing ('OJe. 'SII ( \1R. ?:�� eJlw 1 NI
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HuiIdin,• Pernul :\PPlic,ulon TO CkIn?lI Ilk:L Rcpuu. RC114"AC l)r Will"li,h ,I <
Ora•- of /it"411ulllh lhll'Nul(!
rI h . . eciwn Fi _-
Huddinu Permu 'umber. - I ate .Appl et] _.
nl IdI FC%1nunl luau. Inp lul I �,
—� Sba"P[ON I: SI IT I\FUK\1.\ I'I()N
I.1 Property ddr•ess: I 12 \ssessurs Map & Parccl `umbt.rs
I I la [, ihu .m a11rptrJ ,Irret I P .
;.3 'oning Information; ! a Prnneri Di=:ralr,i;ln•:r
/.milp ,Jr.lncl P'.gruJ lv. I Lol lRa _a III _.__ 4'lunidpe itii I
1.5 Building Setbacks (ft)
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Frun1 Y'arJ Side Vanls N1❑i ! aid
l— Regwicd Pni�IJrd R.Llu:lsd—.__i__. Prk Ided Reyu n ell Pit n Id,j
y
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� 1.6 5V'atrr Supply: Al G L c. an. §9J1 IJ Flood Zone Information: 1 1.8 Sewage Disposal System:
Zone: _ Outside Fl,m,d Zone" Muma ❑I ❑ Qn .Ite du>,I,al ,"I.w ❑
Puhiic ❑ Prnale❑ Check II yee❑ P I J
I SECTION ?: PROPERTY OWNERSHIP'
_.i 7 I of Record: --------- r
i
\.ur.; I roll :\ddrrss for Scr sicC
1,
to
SECTION 3: ,-,FSC'RIPTION OF PROPOSED \VORK2(ctheck all that applvI
Ncv C'nnstrurtitm ❑ Existing P.ui!A ... ',;.nc r_OceuF Krp:u ni si _� Alleranunl,) ❑ I :\JJluun ❑�
JDemolition O Ac.e,wry L"Jg. Q r_^!u be- of Unl'._ Other ❑ SPec.Iy
H�n�e�t,De)scn peon of Pr!lipoNed --
/�`�`-`'`—_�1
r SECTION 4: ESTIMA.TED CONSTRUC f1Uc51 COSTS
Estimated
Item I I hnrmnd "v lerialsl Official Use Only
I Huddling ) w I. Building Perini l Frr: 3 _ Indicate hots ter IN deter III wd'.
—' ❑ Standard City/"hewn Apphcaunn Fee
'. I{kctncal 5 ❑ fowl Project
Coal (Item G) x muttlPlirr
�--) PlPlum—hm—g 5 -'. Other Fees: S ---_ —
1 .'.1l ech:Inlral Ili\':\C) 5
I� i \lei hanlc.Il IFvr
5 f"a.11 :111 Frr,
1u ne„wn, -------
,.._�—.__ —+ ('heck No _ lheLk .\mount ( .nh \In'iwll
b Cutal Project Cost 1 ❑ Paid In Full ❑OIII>I_ulJing H.ihn,c Due
SECTION 5: CONSTRIL c ri( I SP.*R% ICES
truction Super%isor I L'SIJ
cSI. 11,4&r 1,1,1 ( St.
\'JdI V" • I,Icd u , I, or J0 it I I
R Rc,w,1cd1 IX' F-widk
%I I �t I i r )T i I,
R R( -if
1" cphom- wal
5.2 Registered Ilome Impro,icnient Contractor (IIICI
III('(*,tjj)p.,,iy Nitric Jr IlIC Rcei,(rint Naine
\Jdrcs,
FX111'all"li Dire
slellatule
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(NI.G.L. c. 152. § 2506))
Workers Compensation Insurancealtidivit must be completed arid .,ubmitted with this application. F.oluiclopit'%ide
this affidavit will result in the denial (it (he Issuance of the building permit.
Signed Affidavit Attached? Yes ... ...... 0 NO 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the .,ubject property hereby
to act tin my behalt. in all it it
authorize tr'-Is
relative to woi kauthorized by this building permit application.
Sipature tit Owner Date
SECTION 7b: OWNEWOR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent heichy declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
rbehalf.
Name
sitzrialureol Owner Date
Pontk(S,'ri'vned under A�rhejinsand penalties of 2eEjury I
d
NOTES:
A 0 kkner " -i,icied
n Owner who obtams a building permit it)Jo his/her own work. or ano%%ner who hires III Limetv mtf.
ml
(not registered in the Home Improvement Contractor (II[C) Program). will not hj\e .icce,, I,, the .11hitiall'.11
program or guaranty Fund under M.G.L. c. 142A. Other IITIp0rt,InI inhumation on the Ill( Proerani .oid
Construction Supervisor Licensing WSLi can he found in 780('MR Regulations I M.Rf 1 11) R5. ic,l)"11"lk
When ubstantial work is planned, pio%ide the intormaiwn helow
Fatal floors area iSq Ft,i including garage. fim,hed hieinenUattiLs. Jerks or 1),,i,h,
Gro,s lnmiz area i Sq. Ft Kihitable room count
—
I Number of fireplaces_ — Number of hedrot-in,
Numher it hathi,,imis Numher or 11"10"ith,
Nuinher t:l Jock,, ji,i,hc,
3 roi.o i,rojeci Squ.treF,,otme- Ina) he ,LJh1t1TLJ1eJ Inc *F,aal Pr,)ject
CITY OF SALEM
f PUBLIC. PROPRERTY
DEPARTMENT
III •I'\-'4i 1 \C. 'i".S' '4= 'Ii L,
Construction Debt-is Disposal Affidavit
(retpuircd lbr all demolition and renovation work)
In accordance \\itII the sixth edition of the State Building Code, 780 C•MR section 1 1 1.5
Debris, and the provisions of v1GL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
I nantc ul hauler) � �L�-�i`� 1
I he debris will be disposed ol'in
(name of Ijcility)
lad\Ire�.ur gcJilvl
�i�natmn o(pennit appheant
,late
K
r
CITY OF SALE.M
PUBLIC PROPERTY
DEPARTMENT
NAro� 130wA"WGTM ST26M N SMA4 VAOA0ft-W 301970
TTi 9'. 1-743.9S"* FAx 97S.74&9646
HOMEOWNER LICENSE EXEMPTION
Plea" filet
Date �/GG `�—
Job Location �� - `��
Home Owner Address
Horse Owner Telephone
Present Mailing Address
The current exemption of"Homeowner'was extended to include owner-occupied
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.
DEFiNMON OF HOIMOWNER
Persons)who owns a parcel of land on which he/she resides or intends to reside,on
which dun 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 O>$ciak on a form acceptable to the Building
Official, that he/she be responsible for all such worst performed under the Building
PemriL
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and reguMons.
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 BUiLDCYG LNSPECTOR
See other side for state code /