1 LEMON STREET CT - BUILDING INSPECTION (2) w �/os.o , �'l �,/
. ,
y� � The Commonwealth of Massachusetts
��° � Board of Building Regulations and Standards�'���'�L���'14`� �� CITY OF
%" �\V�f/� MassacSusetts State Building Code, 78,�a$°���� " evised Mar�2011
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' �'��' Building Permit Application To Construct, Repair, Reno�a�$e Ot�Ds�olj�li� ' '
One- or Two-Family Dwelling , b 1U� �
M This Section For Official Use Only
�`� Building Peimit Number: Date Applied:
� l
, � � � 7
��, Building Official(Prin Name) Si ature �
� SECTTON 1: S,ITE I FORMATION
1
L1 Pro ert Address:
l Assessors Ma & Parcel Numbers
P Y � p
� � � o,�-fo�.f- S% l'�/ _ �(�t=(�14_`� -(�
� � 1.l a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning lnformation: 1.4 Property Dimensions:
�z� ��Ql'reS
Zoning District Proposed Use Lot Area(sq ft) � 2 Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rcar Yard
Required Provided Required Provided Required Provided
1.6 Water upply: (M.G.L c.4Q§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
"Lone: Ou[side Flood Zone?
Public Private❑ Check iPyesO Municipal �'6n site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qayner�pf Reco� � C /1� /"C� C��"'
Q'�A'd � iC�L�9 .� �
Name(Print) ' City, State,ZIP
/ 1�,�� �j�' �s ? - �i��63L n� �;��, �����;/ ���y
No.and Stree[ Telephone �`7 Email Addres
SECT[ON 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑ Existing Building C� Owner-Occupied Q� Repairs(s) ❑ Alteration(s) Addition ❑
Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Descrip[ion of Proposed Work2:
'' �� ----- -----
SECTION 4: ESTIMATED CONSTRUCTION COSTS
[tem Estimated Costs Offieial Use Only
Labor and Materials
l. Building $ I. Building Permit Fee: $ Indicate how fee is detennined:
2. Electrical $ ❑ Standard CiTy/Town Application Fee
❑Total Project Cost (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. TotaE Project Cost $ ' DDU- �� �Paid in Full ❑ Outstanding Balance Due:
M���-� l � 1
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
NLicense Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town, State,ZIP Telephone
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) Date
SECTION 7b: OWNEW 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 ' s applicatio 's true and accurate to the best of my knowledge and understanding.
-
Pnnt Ow er's or Aut o iYd Agent's Name(Electronic Signature) 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 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 can be found at
www.mass. ovR /oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned, provide the information 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 half/baths
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"
CITY OF SALEM, MASSAC HUSE TTS
1 N BUILDING DEPARTMENT`
i 120 WASHINGTONSTREET,3"D FLOOR
TEL. (978)745-9595
FAX AX(978)740-9846
MAYOR THoMAS STYIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMvUSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.,
Date to/Z7 t 4
Job Location I p k a..` Si
Home Owner Address_ S kw r a Lf
Present Mailing Address
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 hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION 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
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner' certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CnyoFSALEK MmAchm m
BummDBrArrr
120W MS"=T,Y1DRO a
T��➢78 74x9595.
Fi►x 740.9&16
%II�ERIBYDRiS�IZ
AUYCR 7}ioar�SSTPBrrntB
DBSCrMcFptm11CP TY/BuumyG
Construction Debris DisposaiAffldavit
(required forall 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 c40, S 54; Building Permit N is Issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
,pz ,�
Signa re /of, applicant
/Z7//G
Date