62 LEACH ST - BUILDING INSPECTION � Y
The Commonwealth of Massachusetts --- - - — --- -
$ ) Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
�..�W Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Our-or Two-Family Dmrelling
This Section For Official Use Only
Building Permit Number: Date Ap 'ed:
Building 011icial(Print N;une) Signature Date
SECTION 1:SITE INFORMATION
1.2 Assessors Nlap Sr P rc Numbers
I.Ia 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 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.t.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if ycs❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
N`;mi�Kc''•_(Print)t �Ej"Gi--tl C'it State,Z5
L
Nu.an Street fe ephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ElAccessory Bldg.ClNumber of Units_ Other ❑ Specify:
Brief Description of Pr osed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
'_. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 2. Other Fees: S
4. Mech:mical III\'AC) S List:
'e apical (Fire S —
Su tress ion) 'Total ,\II Fees: S_
Check No. Check Amount: Cash Amount:_____
h. Tut al Project Oust: S 0 Paid in Full ❑Outstanding Balance Due: ____
SECTION 5: CONSTRUCTION SERVICES `
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name uITS1. I folder ----
List CS1,Type(see below)
No. and Street Type Description
CI unrestricted(Buildin rs tio to 35,000 Co. It.)
R Restricted l&2 Tamil D%%ellin
City(fmtn, Slule.ZIP M Masonry
R I Roofing Covering
WS W'indow•anJ Sidin
SF Solid Fuel Burning Appliances
I Insulation
"I'cic hone Pmail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Numher Ifspiration Dale
I IIC 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.§ 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
co ine In this application is true and accurate to the best of my knowledge and understanding.
'riot Owner' or,\uthorized Agent's Nano(Flectronic Signature) Dale
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 Hume Improvement Contractor(HIC) Program),will riot have access to(he arbitration
program or guaranty fund under I.G.L. c. I42A.Other important information on the HIC Program can be found at
oca Information on the Construction Supervisor License can be found at o, g_tnl< -, N dll,
'_. \Then substantial work is planned, provide the information below:
Total floor area(sq, R.) (including garage, finished basemenUattics,decks or porch)
Gross living area(sq. 11.) _ Habitable room count
`umber of fireplaces_ Number of bedrooms
Nwmberufbathroonis _ Number ofhalf'batlis
1'\pe of heating S}stem _—_ Number of decks, porches --"-
l\pe ofawlingSyslem_ Enclosed _ Open --_-__- -
3. 'Total Project Square Footage-may be substituted for"fatal Project Cusp'
CITY OF S,V-&Ni, NLASSACHUSETTS
BL2nLVG DEPAR-MENT
110 W kSHNGTON STRM, Y"FLOOR
T1:L (979) 745-9599
KIJ®ERLEY DR13COLL FAX(978) 7 t0.9846
MAYOR T1to.+ua ST.PM"A
DIRECTOR OP PLauc PROPEAW/HLBALYG CONMUSSIONEA
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit g is issued with the condition that the debris resulting from
111 work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
ll1, S ISOA.
The bri`s/will be transported by:
(mane of hauler)
The debris will be disposed of in
-- (name of facility)
(address of facility)
signature ofpernnit applicant
ilJfC
CITY OF S U-F.*vi
PUBLIC PROPERTY
DEPARTMENT
wra. �]e v 7naaT•sKr+a wsuoRses,s oar.s
HOMEOWNER LICLNSE EXE.MMON
Pin" "I /
Date q.4 - 11
Job Loeatics
Home Owner Address
Home Owom?elephom
Prcaaot 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 who.does not possess a licenser provided that the owner acts as supervisor.
DEFINITION OF HObROWNMt
Persen(s) who owns a parcel of Ind on which hdshe resides or intends to resider on
which then is, or is intended to be,a ow or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
thm one home in a two year period shall not be considered a homeowner. Such
-tA meownwo shall submit to the Building Official,on a form acceptable to the Building
Ofllcial, 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 bylaws 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 requ'rements.
X HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING LNSPECrOR
See other side for state code