5 LEAVITT CT - BUILDING INSPECTION _ The Commonwealth of Massachusetts
( � Board of Building Regulations and Standards CITY
OFSALEM
Massachusetts State Building Code,780 CMR,7i°edition Revised Jaary
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
ti.,. • This Section For.Official Use ly
-Building Permit Number: Dale Ap lied /
Signature: - (r/l I�i 0
Building Commissioner/Inspe or of Buil Date
SECTION 1:SI 9 EWORMATION
1.1 Propgr Address: � �� ` 1.2 Assessors Map&Parcel Numbers
�.cnV� U��
1.la 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ `
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: -
��r
Name t) ,t Address for Service:
oA - 51`A.-
4"" gnatuie J Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORIC(check all that apply);
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
a.
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials
1.Building $ b(,� J�l o �L 1.'Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
Total Project Costa(Item 6).x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
Check No. -Check Amount: -- Cash Amount:
6.Total Project Cost: $ �QQ�a 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
�?—v\���U�K•c� �tL�l\Y'�C�� License Number Expiration Date
Name of CSL-Holder C
�� List CSL Type(see be low) �\
Address s \ "• \ Type - Description '
U Unrestricted(up to ily D Cu. g
�C R Restricted 1&2 Famil Dwe llin
a M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Imps vement Contractor(HIC) N\\�
��
HIC Company Name or Hip,Registrant Name tl Registration Number
Address
Expiration Date
i;ature' Telephone
SECTION 6:WORKERS'C49WENSATtON INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to'pro'vide
this affidavit will result in the denial of the Issuance of the building permit
Signed Affidavit Attached? Yes ..........[Q� No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize \SJ-�" �Z' to act on my behalf,in all matters
relative ork authorized by building permit applica on.
of Own 7'Date-
SECTION 7b::OWNEW OR AUTHORIZED AGENT DECLARATION: - -
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Pr nt Name
i atu `of Owner or Authorized Agent ate
der the ains and enalties of )
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"maybe substituted for"Total Project Cost'
_ 1 _
The Commonwealth of Massach usetts
. Department of Industrial Accidents
+- - Officesflmesd9attens
600 Washington Sheet, f'h Floor
Boston,Mass. 02111
Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
Applicant information• - \ - Please PRINT legibly -
name ��\0.`c•�r� p,���`C1 \5
address {\ �
city J�-V �S state \W3 zip.` phone#
work site location(full address)' --- - —
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
g1fam an employer providing workers' compensation for my employees working on this job.
company name `�`C'K\t1..•C\C--car V�V'S- �iV•.`C��l.�inl 4 �5�'C���1\""'\11'�\ `�
address:
city �`''\sC\``� phone#•
insuranceco e '����Vs�� �rSUe � � policy#
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name: _
address•
city - phone it-
insurance Co Doliey It company name:
address:
city - phone#: -
insurance co poliev#
Attach additional sheet if necessary - - - - - - - - - - -
Failure to secure coverage as required under Section 25.4,of MGL 152 can lead to the imposition of criminal penalties of fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DMA for coverage verification.
I do hereby certify under the pains and penalties ofper)ury that the information provided above is true and correct
�j°c�O, bL///.(:/./lhf'� a J Date'
.. „w �a�l
Print name �t`\���\�—`e"r� �2�..z�-s' - s� --- Phone# ���' J� N
official use only do not write in this area to be completed by city or torn official
city or town: permidlicense# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
[]Health Department
contact person: phone#; ❑Other
(reviud5epc Zam)