28 LEAVITT ST - BUILDING INSPECTION (4) t
The Common ve:dth of Massachusetts
OF
Board of Building Regulations and Standards CITY
1� SALEM
e ),Y) Massachusetts State Building Code, 780 CMR lle1.;s,,,1,11ur loll
y.
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-FautUr Duelling
This Section ForWINFORNIATION
e Onl iBuilding Permit Number: :Building OlTicil(PrintName) D toSECTION 1:SITATION1.1 Property Address: s Nlap& ar el Numbers'7,r Z,-4V1Z7 STI.I a Is this an accepted street?yes_ no Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Fronlage(II)
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:
s Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)stem ❑
1 Public❑ Private❑ Check if yes[] P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne f'of Record:
D19-rJ10 I &L-ey di 9 7 n
N.nme(Print) City.State,ZIP—T �
o�� G Eez I/ %7 S % 9/�7Y� �/T7 �yhCl/AOG7 (n�S79 Fi7 7i97f.
No.and Street 'Telephone Email Address a-,o
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed W
SECTION J: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
'_. Electrical S r
❑Total Project Cost (Item 6)x multiplier s
1. Plumbing S 2. Other Fees: S
a. Mechanical (I-IV:\C) S List:
5. Mechanical (Fire S Total All Fees:S
Su m mression)
Check No. _Check Amount: __Cash :\nwunt_
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
l
SECTION 5: CONSTRUCTION SERVICES
5.1 C'onstruction Supervisor License(CSL)
Licctuc Number I{ynimtion Dale
Name ulC'Sl I IuWer
I-ist CS_7)pe(See bCIO%%)
No, and Sircet Type Description
CI Unrestricted I Buildin,s up to 35,000 cu. 11.)
R Restricted l&2 Fatil Dwellint
Oily/lotto.Slate.ZII' M Rlasnt
RC Routin,C'overin
W'S Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered home Improvement Contractor(HIC)
I IIC' Registr;uion Number lispiratiun Date
HIC Company Nane or I IIC'Registrant Name EE
No.and Street
Email address
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION 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 Is
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
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.
tut Ott ner's ar Autharized Agent's Nome(10ectronic Signature) I 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 Hume Improvement Contractor(HIC) Program),will riot have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
woy.m:u..^ow oci Information on the Construction Supervisor License can be found at tt tut w.nmi:.,-ot ill,
2. When substantial work is planned,provide the information below:
Total fluor area(sq. R.) (including garage, finished basentent'attics,decks or porch)
Gross living area(sq. tl.) _ Habitable room count
Numberoffireplaces-_— Number of bedrooms
---
Numberofbathrooms --------.--- Numberorhalfbaths -------------
F)pe of heating sysicnn ___---_----------- Number of decks, porches
r)pcorcoolingSYstem._--. .. _-------...---- Inclosed __.___,----Open ---- -.----
3, 'Total Project Square Footage may be substituted Cor'Total Project Cost"
CITY OF S,Vt&Nf, NLISSACHCSETI'S
Bta 404C; DEPARTNtENT
f 120 W.UHLNGTON STREET, 340 FLOOR
ht. (978) 745-9595
Ki�®ERF Y DR=OLL FAX(978) 740-9846
MAYOR TncimuST.PtBz"
DIRECrox OP PLBLIC PROPERTY/aLMOLNG CONNISSIONER
Construction Debris Disposal Attldavit
(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 M is issued with the condition that the debris resulting from
this work shell be disposed of in a properly licensed waste disposal facility as defined by h1GL c
111, S 150A.
The debris will be transported by:
�1/MiJS TF�S' ,t®
/ (name of hauler)
The debris will be disposed of in
(name of ractiity)
(addreaa or facility)
aiyna a of permit applicant
dafe
:.h,,
CITY OF S.U.H.Ni
PUBLIC PROPERTY
DEPARTMENT
VwrOa I b wAswacrom ftuar•SAUK%&mAcw sum ai t'e
r".9-&715.95t1•F.AL 93-740,9646
HOMEOWNER LICLNSE EXE.MMON
Plow Prfnt
Dan
Job Lacatloe a?jr LFflv(77 $ 7 SSrPLF/'9 ,r(rl 619,70
Home Owner Address a? 4.64111 TT Agow 6ig7 v
Home Owner Telephone 9?8, 2 VS- - 4f3 7 S—
Pteaent Mailing Addraae 0- I--,9vr 7 7 S 7 .PA/ed
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units at leas and to allow such homeowner to engage an individual for
him who.does not posses a Uceoss,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intearde to reside,on
which then is, or is intended to bs, a one or two family dweWng, atnched 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. Stuck
"homeowner"shal 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 Stan
Building 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
will comply with said procedures and u'remen
HOMEOWNERS SIGMA
APPROVAL OF BUILDING INSPECTOR A�
See other side for state code