23 LEMON ST - BUILDING INSPECTION (7) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
IN,l Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 1011
One-or Two-Family Dwelling
This Section For Official eOnly
Building Permit Number: Date Agplied:
-Building Official(Print Name) Signature ✓ D e /
N o J SECTION 1:SITE INFORMATION
1.1 Property Address. 1.2 Assessors Map& Parcel Numbers
2s /—C;lI J -.0-
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
--------- --- _
Zoning llistrict Pruoscd Use .__..__._.___ _—.______ _
P Lot Area(sq fq - - Frontage(tl)
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?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner'of Record:
/'077&0,1 4,¢i411105k 1 — N
Name(Print) Qty,State,LIP
�7-'Cnl c m
No.and Street `Tale on G�3 l d
Telephone Limail Addre �0
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) CD
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Add®on
14
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: C
Brief Description of Proposed Work': ,$Teu24CGc ec-7j Jr
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑"Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (BVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees: $
6. Total Project Cost: $ 1 a Check No. Check Amount Cash Amount:
S .UD 0 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License 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
Citylrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date--
No.and Street Email address
City/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
I,as Owner of the subject property,hereby authorize
4o 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
c1
By entering my name below, 1 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.
Print 0 ner's or Aut prized AgenPs 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.eov/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 UE S.1�1 [ LbL1S
, S.ICHUSET'[S
13 G DEP.1MIE`:T
\�iaaY h, 120 WASHLNGTON STREET, 3W FLOOR
I'M (978) 745-9595
KIMBERLEY DRISCOLL F.'Lv(978) 7-10-984S
NLAYO;L Ir o.%tAs ST.PiERRs
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG COJL\IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition Of the State Building Coda, 780 CD�fR section l l
Debris, and the provisions Of iNfGL c 40, S 54; 15
Building Permit 1# is issued with the condition that the debris resulting from
11 work shall ba disposed
1
l 1, S I SOA. of in a properly licensed waste disposal facility as defined by *vfGL c
The debris will be transported by:
(n,tntc ut'hauler)
Che debris will be disposed of in
(narnc facility) o� r
(aJJress or titcility)
' cr<1 permitapplicant
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASFUNGTON STREET,310 FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOU
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location 23 1-5;4aU ST S? t iyp
Home Owner Address 93 LC—LaLj wig
Present Mailing Address a3 45-�u ST _5?Z0H H04
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
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SITE PLAN /
I scale: 1" = 8' '` / 247
4TT frontage
gq• LEMON . STREET -- -