13 LINCOLN RD - BUILDING INSPECTION (4) The Conunom%ealth of Massachusells
t Board of Budding Regulations and Standards FOIL
t 1l:lssue11usrtts State Building Code. 7SO CNIR. 7"' rtlitiun
I. f
Building Permit Application To Construct. Rrpair, Rcnu\me Or Dcnu,lislt a Rrt t,r /lrunn,
fhu•- ur T11 o-kiugily lhrrllin,q L _rut,v
'['his Section For Official Use Only
V
13utlJing Permit Number. Dale ApplieJ:
— -"
13wIJm onunt..n.ned Inspector ul BuJJmgs Uat
SECTION I: SITE IN'FOR:NIA'HON
1.1 Property . ddr . ': 1.2 Assessors Map .'F Parcel Numhcrs
I.LI Is '. a.t n•_':r I I;7J >II'e c'.x. -t..
r-
1-3Apzoonin;; Information: 1.7 Property D neasi:
Luntng Di5toct Prnpu,eJ Use Lot Area iw tit_ Frontage t1U
1.5 Building Setbacks (ft.)
j Front Yard Side Yards Rear Yard -
! ReyuireJ Pnn idcd Reyu!red Provided RcywreJ Pru.rJrJ —a
—II I I
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood 'Lone Information: 1.8 Sewage Disposal System:
Zone: _ Outside I yes Zone? Municipal ❑ On site Jis wsal s stem ❑�
Public ❑ Private❑ Check if yes❑ P' I T.
SECTION 2: PROPERTY OWNERSHIP' j
-.'.r c !Prin / .'C''• �— Address
for
/Scrvice
�ll/�/L�C�J��
Telephone 7 --
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
"Jnat ucton ❑ Existing Building�aa Owner Occupied ❑ Repairs(l) ❑ Alteranon,$) ❑ r\ 'u oon ❑
P
Demolition ❑ Accessur BZJ ❑ Number of Units (. +rc: S e:�lv.�
scri lion of Proposed W xk
�'�'-rf. �
SEC•rION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Mate ials) Official Use Only
I. Building '5 2 I. Building Permit Fee: $__ Indicate hoe% fee a JctcrInowd-
—1 ❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost' (Item 6) x multiplier x -_
3. Plumbing _ S 2. Other Fees: S —.I�(��
1. Mechanical (HVAC) .S List: --
5. Mechanical (Fire S
Tor.J :\II Fees: S ------
Suppression)
Check No Check :\mount _ ('ashAniounr_ _ .
0 Total Project Cost: 5 3O� 0 Paid in Full 0 Outstanding 13al:ut.e Uue:
F, r
SECTION 5: CONSTRUCTION SERVICES
F
Licensed Construction Supervisor(CS1.)
Llce)iw Number F.\)nr.uaun Date
Name of('SL IIolder
Llel CSI_ '1\pe lseo hrluw l
r c Descrl Ilull __
\ddtes,
' l� l'nrt•atncled ,up to)5.1N10(L PI 1
--_ R Re,lrleted L@_' Famih D,kellun_e
]I_naulre \I \Luonrs Onls
—_ RC Ro'ldcnual Rooliug l o cillie
Telephone .'n plsn�s
11a1 \1 nd:nd.... .. >Idhl_ _
Re,Idnnul Solid flirt I3uuuna \pph.wc Re.ldenlyd Dcnwlllum
5.2 Registered Home Improvement Contractor 0110
HIC Company Name or IIIC Registrant Name Registration :N'uulhcr
1 Addre,s —
EvpoaWm Date
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 [his application. Failure to pnr.Ide
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 M act on my behalf, in all rttatters
relative to woi k authorized by this building permit application.
Si nature of Owner Dale ----- �_--__---___�
��Q/� /�)� e) /�SECTION 7b: OWp!—N1�ER[ OR AUTHORIZED AGENT DECLARATION
1. (ryJl(�K'7 J(�(k A WX/� , as Owner or Authorized Agem hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf \ip'� -- _
Pr' ameWorAwthonzed .Agen7
J.�OV
Sign•ture t Owner Date
(Signed under fife pains and penalties of er'u ')
NOTES: _
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an uniegi,tered contra.ulr1
(nut registered in the Flume Improvement Contractor (HIC) Program), will not have ;recess to me arhitralinn
program or guaranty fund under M.G.L. c. 142A. Other important information on the f-IIC Proer in and
Construction Supervisor Licensing (CSL)can be timnd in 780 CMR Regulations 1 I0.R6 :md 1 10.10. respecti
When substantial work is planned, provide the information below:
r,ral flours area ISq. Ft.) (Including garage. finished hasemenVuncs, decks nr purtihl
(iros.s living area ISy. Ft.) Habitable room count
Number of tlreplaces Number ut hednnnns
Number of bathrooms Number of h,Ilt/hash, _
fvpe of heating system -- Number(it deck,/ p„rchc,
Type ut cooling sy,lem _ Gnc ll,scd
i. "Total Project Square Footage' may be ,ubstnuted tor 'Folal Project Cost'
- y
CITY OF S.U.EM
PUBLIC PROPERTY
DEPARTMENT
- 130 WA9ONG110M STU=•SUA4 MAUMNLMM 01970
TFi 978-74S.9S"* FA7t 97&74&9/N
HOMEOWNER LICENSE EXEMPTION
Please Print
Date__ f�
Job Location 77 Q
Home Owner Address - -
Home Owner Telephone —
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 who.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 fora 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 wont 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 d requirements.
HOMEOWNERS SIGNAIL
APPROVAL OF BUILDING IN PE OR
See other side for state code
u
CITY OF SALEM
PUBLIC PROPRERTY
T* '+ DEPARTMENT
p''�bM:u^�
11\: .C!\$l!<CI'T � $.\I
l III: v-8--15-9595 ♦ FAN:9,8 74_9846
Construction Debris Disposal Affidavit
(required li)r al demolition and renovation work)
In accordance %kith the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
di
this work shall be sposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
(name of taethty)
(address of lacitity)
— - iena1ure of prrmit applicant
Z7
date ---