12 LEE ST - BUILDING INSPECTION (3) a The Commonwealth of Massachusetts
;► Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 780 CMR, 7'" edition
\ r RrvisrdJunnurs•
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. MAI
+(� One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: 7 7//J
Building Commissioner/InspeciWof Buildings Date
SECTION I:SITE INFORMATION
1.1 / erly pEF .hT n �A 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes /�/y no Map Number Parcel Number
1-3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lol Area(sq 11) Frontage(B)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zom?
Public❑ Private❑ Check if yes[] Municipal❑ On site disposal syste103
SECTION 2: PROPERTY OWNERSHIP'
2.1 ner'of Reeord: CA^/d 5/�CF /Y/
Name I nni) Address for Service:
Signalum Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building s I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing s 2. Other Fees: S �(
4. Mechanical (11VAC) S List: r (/
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S o e 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor fCSL)
License Number I:xpimtion lyate
Name of CSI-- 11older 1.ist C'SL Type flee below)
rs De I Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC I Residential Roofing Covering
felephone WS Residential Window and Siding
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address
Expiration Date
Signuture Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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�1'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
✓ 1, AOigFA A C( IIYI f L 10 as Owner of the subject property hereby
authorize 5-d A JE to act on my behalf, in all matters
relative t work authorized by this building permit application.
02 ,2-0 o9 5- . ?Q/0-
nce 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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will ffg have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.115.respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementiattics,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"
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
u�otitsV om
wroa i 3p wmwu�ow Snrrr•swat VwaAoasWrn a19'0
rM rs-715.9s"•F.uL 978-740.964
HOMEOWNER LICENSE EXE.MMON
Faint
Date
!ob ��` �!!^� �� SAS Fd) m 4 0/9,>'o
Ham i Owner Address .S M/ F
Ho Own Telephone 97f�. 7/i S• ?7/�/
Presort er Mailing Address --!U9!n E
The current exemption of"Homeowners"was extended to include owner-0ccupied
dwellings of two Units or lea and to allow such homeowners to engage an individual for
hire who.does not possess a license,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 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
Pentti"1
The unoersigned "homeowner"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 CISPECTOR
i
See other side for state code
i
CITY OF SALEM
... r .;, PUBLIC PROPRERTY
DEPARTMENT
I_'C \C Nq Ih,.. !.S I'3 L IT • SAI I V, \1.bi.\I iI'.
Trl: V,8-N;:r;a5 ♦ FAN: 978 J3;!9844,
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 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it _ 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
I It, S 150A.
The debris will be transported by:
(name of hauler)
'I lie debris will be disposed of in
1SrE2 5714T'A/
(name of facility)
, sat�9MQ5��17 Qom. Sr?�CA,
� taddress u(lacility)
signature of permit applicant
date -- —
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