10 LEE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
QBoard of Building Regulations and Standards Tom
Massachusetts State Budding Code. 780 CMR. 7'"editionja
Building Dept
` Building Permit Application To Construct, Repair, Renovate Or Demoli
One• Tno-Fonuh Duelling
/Thij Section For Official Use Onl
Building Permit Num Dale pplied: it I
Buddin o issioner/Inspec B Ida Date
if
S CT N 1:SITE INFORMATION
jrpnrl G cl&3� 1.2 Assessors Map di Parcel Numbers
/ 1.la Is this an accepted street?yes I' no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq fl) Frontage 1 R)
13 Building Setbacks(B)
Front Ymd 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: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public O Private❑ Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
2. part of ecor
Name Pr 1). Address fo Service:
/�7� - 7 01- 64/1- 7Q
ature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
x New Construction❑ Existing Building ClOwner-Occupied O Repairs(s) ❑ Altcration(s)A<l Addition ❑
Demolition O Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Desert pt)on of Propo}wed W rk'.
/(J2t✓ 7C !/Cr��(J
N/
SECTION 1: ESTI
MATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item a I hnr and Materials
1. Building S ,.d Oro 1. Building retinal Fee: S Indicate how fee is determined:
❑Standard Ciry/Town Application Fee
2 Electrical S OQ ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S QO 2. Other Fees: S
4. Mechanical (HVAC) S List:
t Mechanical (Fire Su ression
S Total All Fees: S
nC `' Check No. _Check Amount: Cash Amount:_
X 6 Total Project Cost: S �vT mo ❑ Paid in Full ❑Outstanding Balance Due:
�4-
�-v r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
• Laense Numbr Expiration Date
N,4roe ut'CSL Helder List CSL Type bee below)
Address Type Description
U I Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&1 Family Dwelling
Signature N -.1asonry 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 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.c. 152.1 2SC(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.......... O No........... O
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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, 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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the psins and penalties of perjury
NOTES:
Fhcafing
Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
t registered in the Home Improvement Contractor(HIC)Program), will have access to the arbitration
gram or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
nstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.RS, respectively.
en substantial work is planned,provide the information below:
ors area(Sq. Ft.) (including garage, finished basemenUattics,decks or porch)
ving area(Sq. Ft.) Habitable room count
of fireplaces Number of bedrooms
of bathrooms Number of halfbaths
heating system Number of decks, porches
cooking sy stem Enclosed Open
3 "Total Project Square Footage"may be substituted for 'Total Project Cost"
CITY OF SALE.Lf
PUBLIC PROPERTY
DEPAIM, TENT
u,a�aary o••••+
.Nwraa �3t19r..sw.w,cM snFsr•suit Vnanntisa„s ON-o
rM 9'.L71y9s"•FAX 978•740.9a46
HOMEOWNER LICENSE EXEMPTION
Please "I
Date
Job Location /0 lee SI
Home Owns ju�-- d
Home Owner Telephone 9 fr - 7 - ff6 ;?J
present Mailing Address—�j4^1 e,
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
him who does not posseas a licenses provided that the owner acts as supervisor.
DEFINMON 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 dwellin& 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 fort acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeownee assumes responsibility for compliance with the State
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 requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
w
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I 11 nR 120 W.til I]\GI ONSIRLET * SA F.M. `t,41i\CIII til.l"i Jl'1
'frt:971l--7459i95 • FAX:978J4049846
Construction Debris Disposal Affidavit
(re(Juired 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 11 __ is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
prime of facl ny)
taddress of facility)
signature of permi applicant
�/Iy/ 9
date