105 LEACH ST - BUILDING INSPECTION (2) t r"
The Commonwealth of Massachuscus
1 s�� Board of Building Regulations and Standards Tow-
Massachusetts State Building Code. 780 CMR, 7"'edition Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a !k
One-or ruo-Funsils Duel ing
ecnon F r Officio Use Only
Building Permit umber: DAle pplied:
Signature: //�a0 /0! ►
Building Commis oneri inspector of I Dale
SECT( l: 4ITE INFORMATION
1.1 Propert Address:- 1.2 Assessors Map& Parcel Numbers
r S) LrA+ Sr
I.1 a Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 ProPe7y Denslonr. �d
Zoning District Proposed Use Lot Ares991--sq fl) Frontage Ifl)
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
a Private O eck if veto Zone: Y Outside Flood Zone?
Public Municipal�On site disposal system O
Ch
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record: ST
P'1 t C NAct- Cook l05 �cACN
Name(Print) Address far Service:
signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied O Repairs(s) Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ f Other O Specify:
Brief Description of Propo3Ad Work:
z"1zP!.e 24-lee* tat ing on 2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OAlelal Use Only
Labor and Materials
1. Building f 6co— 0 I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical so O Total Project Cost(Item 6)x multiplier x
) Plumbing so 2. Other Fees: s
4-Mechanical IHVAC) so List:
t Mechanical (Fire s O Total All Fees.All Fees. S—
SW rtssion
Check No. _Check Amount: Cash Amount:
6 Total Project Cost: s 4;O , 0 Paid in Full 0 Outstanding Balance Due:
r
✓ � r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supersisor ICSL)
" Licen,e Number - Esptrouon Date
Nyoe of CSL Ilylda Lid CSL Type(,cc below)
s --v - T Description
Address U Unrestricted u to 35,000 Co. Ft.
R Restricted 1&2 FamilyD„ellm
signature M Masonry Only
RC Residential Roofing Covenn
Telephone w'S Residential Window and Sidin
SF IResidential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 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? Yea..........O No........... 0
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
)� as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permil application.
r(�S_igmrd
f Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
. � ,as Owner or Authorized Agent hereby declareatements and information on the foregoing application arc true and accurate, to the best of my knowledge and
f Owner or Authorized Agent Date
er the Items and penalties ofperjury)
NOTES:
1. 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 y&have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0,R6 and 110.R5. respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. FL) (including garage, finished basement/attics.decks or porch)
Gross living area(Sq. Ff.) Habitable room count
.Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of healing system Number of decks/ (arches
Ty pe of cooling rystem Enclo,ed Open
t "Tool Project Syuare Footage'may he ,uh,fituted for- Total Project Cost"
CITY OF S.XLEM
PUBLIC PROPERTY
DEPART"MENT
Ttii 9'L7i}7SlS q F.%x 9 L 7iaosw
HOMEOWNER LICENSE EXEMPTION
Please "t
20 O°f
Job L.ocatica /05- C'ACH ST
Home Owner Address 54)f t C
HomsOwnerTelephottie 97B 740 9/8g N) oI S oej! Ce/�
Presaot Mailing Address I O S CCAC H ST:
The current exemption of"Homeowners"was extended to include owner-occupied
I of two Units or less and to allow such homeowners to engage an individual for
}are who don not possess a license.provided that the owner acts as supervisoa
pEFWMC)N OF HObMWNEA
n which he/she resides or intends to reside. on
fawn(s) who owns a pa"of land o
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
lding
ciali
n a form acceptable to the
Official. that he/she beespomeownce shall submit mble$for all suc®worlcoperform under the Building
Building
lamnt
The undersigned "homeowner"assumes responsibility for compliance with the State
uilding 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
.vill comply with said procedures and requirements.
E O.MEOWYERS SIGNATL72
.APPROVAL OF BUILONG LYSPECTOR
See other side for state code
1
=�S CITY OF SALEM
�a '' I
PUBLIC PROPRERTY
DEPARTMENT
..I\ll:. Olt) ' ON 0:I
M ..14 I'C l%l.'l SrNLVT •S.0 I'M, St.\�iAl illN Ii :Pl
I'FI:'!7y,'4i:)G95 ♦1:,%x:979-744'/846
Construction Debris Disposal Affidavit
(retwired I'or all demolition and renovation work)
In accor
dance with the sixth edition of the State Building Code, 780 CIVIR section 111.5
Debris, and the provisions of MGL c 40. S 54;
Building Permit ft . _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
M. C 1;, e I Ccx->k
(name of haultr)
'I'�Itye1 debris will be disposed of in
I lc�r�7�C�1ea� "1)0 Mef?gL btr)
i
(name of faci Ity)
UJPS� S{�p�2 �rt�L , ntr�elea�I MA
(address of lacitity)
.ignature of ptnntt applicant
//— ZO --0 cl
date