105 LEACH ST - BUILDING INSPECTION (3) Zg
The Commonwealth of LNlaSSacl1L15CttS
Board of Building Regulations and Standards INSPECT oHEa�UiCi
Massachusetts State Building Code,780 CMR Revised.tlar?01l
Building Permit Application To Construct, Repair, Renovate Or DemoaAP11 A 5; 1 b
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 1. Date Applied:
tholding Ot iciul(Print Name). Signature Date
SECTION L•SITE INFORNIATION'
LI Property Address: 1.2 Assessors blap& Parcel Numbers
10 Leach S�
I.I a Is this an accepted street?yes ✓ no Map Number Parcel Number l
1.3 'Lotting Information: 1.4 Property Dimensions:
"Coning District Proposed Use Lot Area(s q 11) Frontage(11)
IS Building Setbacks(ft) i
Front Yard Side Yams Rear Yard
Required Provided Reyuired Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) t.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal Cl On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTIONS: PROPERTYOWNERSHIPL'
2.1 Owncrl of Record: '1 MA �I `t 76
PAn ScerChu¢ I 4�oK
jtme(Print) City,Slate,ZIP
O 5 l Eo�cYt S'r 9'78 74b`i fgg -rncc<xicsieSC�`u r74;�,n
No. and Slrect Iclephona E,nai1 Address
SECTION 3: DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ l
De ualitiun ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
ti n 7c Q
Brief Description of Proposed Work-: Ci'\rr'tli� ' -r +' � •� �- ltr\F
ccnd f rchi, Id w to V E iv t�`nLK CAf"Lx 1C,b 1 �Ic�Sn,n<, is O✓
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building S ""��},C:G 1. Building Permit Fee:S Indicate how tee is determined:
❑Standard Cityllbwn Application Fee
2. Electrical S Cl Total Project Cost'(Item 6)x multiplier x
3. Plumbing S L Other Fees: S��^� � �(
I.Mechanical (FIVAC) S List: (/� r���7ryu
5. ;Mechanical (Fire ruhd All Fees:.S
StIPIsession)
Check No. Check Amount: Cosh:\mount:_
6.Total Project Cos[: .S ��� .L ❑Paid in Full ❑Outstanding Balance Duc:
SEcrtoN5: CONSTItucTIONSERVICES
5.11 Coils truitioii S6peivisor;License(CSL)
,
.~•,• License Number Expiration Date
Name of CSL'.HolBer 111Yl List CSL'rype(see below)
"type Description
No. and Street
D Unrestricted(Buildings tip to 35,000 ear. It.)
It Restricted 1&2 Family Dwelling
Cityfrown,Stale,ZIP iSt Masonry
RC Rooling Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'felt hone C•mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I11C Company Name or 111C Registrant Name
No. and Street Email address
Cit crown,State,ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L c. 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? 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
i
Print Owncr's N;mte(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
contained in this application is true and accurate to the best of my knowledge and understanding.
fA,chtel CcoK 4-111/1-e-1'4
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 Home Improvement Contractor(HIC) Program),will nnf have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information an the HIC Program can be found at
wwvv.nta"gov:'oca Information on the Construction Supervisor License can be found at www.uwss.uov'dLs
2. When substantial work is planned,provide the information below:
Total door area(sq. 11.) (including garage, finished basementlattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halflbaths
Type of heating sy stem Number of decks/porches
Type otcooling system Enclosed Open
1. "fuual Project Square Footage"may be substituted ti)r-r,t:d Project Cost" ��,
,!v ` QTY OF SALEM, MASSACHUSETTS
h BUILDING DEPARTMENT
120 WASHNGTON STREET,3R FLOOR
\ TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DateAPrd 11 J Z3fy
Job Location I S Lprxc h ST
Home Owner Address Lec-ch 57'
Present Mailing Address ldS LpcLCA 5�, 109✓1 01970
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'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
i vr.
CITY OF Si1LHm ;tiLNSSACHUSETTS
BUtLDNIG DEPARTMENT
130 WASHNGTON STREET,310 FLOOR
I'81. (978) 745-9595
FMX(978) 740-984b
tUJa3F.RL.EY DRISCOLL
rINUYOlt I1-10JLAS ST.PIERIM
DIRECTOR OF PUBLIC PROP ERTY/SUUDLNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
(n accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5
Debris, and 01e provisions of?YfGL c 40, S 54;
Building Permit tt 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 tY1GL c
111, S 150A.
The debris ill be transported by:
JC' ? r
(name ufhauler)
The debris will be disposed of in
_/vtirf115ic�� Ckr+Ir)e,
(name or racdi/ty)
SitikL.V� SCO/ I �cd t Sh cc— /11A
(address or facility)
signamra of permit applicant