12 LEE ST - BUILDING INSPECTION (2) \ The Commonwealth of Massachusetts
\ } OF
Board of Building Regulations and Standards CITY SAL.EM
1 Massachusetts State Building Code, 780 CMR
Reri.rerl.11ar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-orT ]%jy Dwelling
Thisis Section
For Official Use Only
Building Permit Number: q �j n Date Applied:
Building Official(Print N")`k?g� V V I Signatur / Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
X 61 �fE 5T2FE; 5g 4 ✓h p
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 It) Fronlage(It)
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 ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Q z,' f Record:
Name(Print) City.State,ZIP
x �� EE 5i2EE- 9JX 2952�/�
No. and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied( I Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Speedy:
Brief Description of Proposed Work'-:
2�r P1a CIffri if66
X
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Mechanical (Fire --
Su ression) $ Total r\II Fees:$
Check No. Check Amount: Cash Amount:
X 6. Total Project Cost: L S 0 Paid in Full 0 Outstanding Balance Due:
TIOICON'IrRUCTION.
SERVICES
7���S,,EC
ervisor Licese(CSLnse Number Ecpiratien Dale
CSL'rype(see below)
ype Description
U Unrestricted Buildin s u' to 35,000 cu. ft.
R Restricted 1&2 Famil Dwelling
Clty/I own.State,ZIP Mason
RCMDemolition
Roofing t
WSSi--;-
,-
SFing Appliances
IInsulation
Tcic Iwnc Email address D
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC'Company Name or I IIC Registrant Name
No.and Street
Email address
City/Town,State,ZIP Tele hune
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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
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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of:theinfornn:ationcontained in this application is true and accurate to the best of my knowledge and understandinOwner's orluthorzedAgent's Name 1F.Icctronic Sgnature) p
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 riot have access to the arbitration
program or guaranty fund under IvI.G.L.c. 142A.Other important information on the HIC Program can be found at
g ww.nia�s.cov_oea Information on the Construction Supervisor License can be found at��'tca_mnss.yov_dL
2. When substantial work is planned,provide the intonnation below:
Total Floor 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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open —
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
i
CITY OF SALEM, LovLkSSACHUSETTS
BUILDING DEPARTNLE.NT
120 WASHNGTON STREET, 34D FLOOR
` TEL (978)745-9595
Rut:(978) 740-9846
KI.NBF.RLF-Y DRISCOLL
,MAYOR T Homa ST.Pmaxn
DIRECTOR OF PUBLIC PROPERTY/BUILDLYG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit All 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 MGL c
111, S 150A.
The debris will be transported by:
M -CIWff-C f
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
nature of permit applicant
date
Icbnvi(J�:
CITY OF smxL Nf
PUBLIC PROPERTY
DEPARTMENT
UfOWaY^�r•w•
`�A1Oe 136WAwss,Tonsnmsr•WAK V%asasasaanetre
HOMEOWNER LICENSE EXE.MMON
Mass Print
Dan 6- J
Home Owner Address s
Home owner Telephone 78.74 S 2 7 i�:
Prcamt MaillaR Address 4 A m£
The current aempdon of"Homeowners"was extended to inchtde owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner sets as supervisor
DEFINMON OF HOhMOWNEA
Person(a) who owns a pared of land on which be/she resides or Wends to rmide, on
which there is6 or Is intended to bs6 a one or two finally dwellinS attsehed or detached.
structures accessory to such use and/or furor structures. A pagan who constructs more
than one home in a two year period shall not be considered a homeowner. Such
'?nomeowner'shall submit to the Building OfIIciat 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 Cods and other applicable by4swo and regulations.
The undenignned "homeowner'certiffa that he/she understand@ the City o[Salem
Building Department minimum impaction procedures and requirements and that he/she
will comply with said procedures and requ' emennnts.
HOMEOWNERS SIGNATI.'RE vim_
.APPROVAL OF BUILDING INSPECTOR
See other side for state code