1 LINCOLN RD - BUILDING INSPECTION r.
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'"edition Wilbraham
Y" Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Two-Family Dwellirr Ext 118
tkIq This Section For Off Use n
Building Permit Number: ' A at Rli
Signature: 7/ a a./0
Building Commissioner/Inspector orBuildink
SECTION 1: SITE NFORMATION
1 1
P7117 p117 Add less Rodd 1.2 Assessors Map& Parcel Numbers
0
L 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 R) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided RequiredProvided
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 Owners of Record:
krlSteu &<ricpdI I I /-INno/N Read ead
Name(Print) Address for Service:
of7S-7yy—A14QI
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ I Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units--L_ Other ❑ Specify:
Brief Description of Proposed Work': II II —}—
_ Q ,a 0 P na s1aake._.s,. CILu(� oN St PS /1J IY� ItlPI CPv�e Lj hnn vel
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:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No.
6. Total Project Cost: Check Amount: Cash Amount:
$
MOO 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES r
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry 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 Dale
Signature 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 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
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.
Pri ame
Signat of Owner or Authorized Agent Date
Si ned under the 2ains and penalties of perjury)
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
v
CITY OF SM-EM
PUBLIC PROPERTY
DEPARTMENT
mea M. &%A0MWns oi97o
TEL 978-74S-9S9S•FAX.978.740.9&16
HOMEOWNER LICENSE EXEMPTION
Pies" Print
Date `lra.a.joQ
Job Location I L Mro �nr Road -
Home Owner Address I 1-i meoW &and
Home Owner Telephone ot-n-7,i4- 4 i�I
Present Mailing Address I L j'u r o I u R d
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 who,does not possess a license,provided that the owner acts as supervisor.
DEFUMION OF HOMEOWNER
Persons) 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and req ' ements.
HOMEOWNERS SIGNATURE ` 2,
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALL'.M
PUBLIC PROPRERTY
' Y%^ DEPARTMENT
I
III 'i'S.'J;. :n.,: ♦ I
Construction Debris Disposal .-affidavit
(re\luired litr all den}UIitIUn and renovation \%oik)
In accordance \\ith the sixth edition of the State Building Code, 780 ChIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54:
Building Permit ft is issued with [tie condition that the debris resultinmg front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris Will be transported by:
Inantc oC hutltr)
the debris will be disposed ofin
(name of f.nlhty)
laddre.. of I]cJnvl
.Ignatwc of piluut apphcaut
' ,IaIC