1 LOWELL ST - BUILDING INSPECTION (2) �. t
/���/'� � -------- fheComnwmre:dthoFMassarhusc�ts _ _ _ _ __ -
v ' � 13u:ird uf Building Regula[ions and Standards CI'I'1'OF
� ��� Massachusctts Statc Duilding CoJe. 7S0 ChIR ti,�LL��I
'e,�•• Rrris��d.l hu�_'�ll l
13uilJing I'rrmit Applic;rtion To ConstrucL Repair. Renuvate Or Denwlish a
(hrt�-ur Tivn-Fumih U�r��llrn.e
This Srctiun For OI'ficial Use Onl
Uuilding Permit Number. Date;lpplieJ: w.�/L.., � .'
..�iGii�C�C_ L:It�Z�(�CGa,yS�' .
Duilding 011iciol(Prinl N;une) Siyml rc p���
SECTION I:SITE IIVFOR�IATIOIV
1.1 Property,��drese: 1.1,�ssessor �tilap& Pnrcel Numben
I t.,�r�,e�l 5�. � ��l �ew�, 1M�1 ,oa� .�
i.ia ls this an accepted street?yes no ti�nP Number Parccl Namlkr
I.J Zoning Informntton: n A I.d Pr�erty Dimenslona: �
i ���
Zoning District Propuacd Usc Lut A'rca(sy ttl I�ronlagu Ill)
I.S Buildfng Setbacks(R)
Front Y;vd Sidc YurJs k�y Y;v� �
Reyuired ProviJcd Reyuircd Provi�lcd Neyuired Pruvided
1.6�Vxter Supply:�M.G.I.c.J0,§5a) 1.7 Flood Zone Informatlon: 1.8 Sewage Diepoaal System:
Public❑ Private❑ Lone: _ Oulside Flood'Wne'? Munici al O On site Jis
Check if �esO P pusul s��stem ❑
SECTION 2: PROPERTY OWNERSHIP�
2.1 Owner�of Record:
�A IZlL 'M�]tL G Elv Sq I 81�. . Wt aV � I 9 `7LJ
N;un�IPrint) ` 1 U—/qt�SiutJc.�l.IP ' .
I Ld W P�� �{ `� /� !`t'F' ��"� VhM Q!'�1 P�Lu5 d .-L�n� 7 t.� S.C �5.v�
�`lu.anJ Strmt �fe�ephone F.inoil Addmss
SECTION J: DESCRIPTION OF PROPOSED WORK°(check ell that npply)
New Construction❑ Existing Building,($ OwnerOccupied ❑ Repairs�s) ❑ Alteration�s) Additiun O
� Demu�ition ❑ Accessory Bldg. ❑ Number of Units�_ Other ❑ Specily:
�ritf Description of Proposed \Vo1rk': ,
�1�'�f'Yl P�l^ CiL�c� 1 6�— ,
SECTIO�V �; F;STIDIATED CONSTRUCTION COSTS
���i�� Estimated Cosis: Officiul Use Onl
I Labur nnd .\I�trrialsl Y
I. Duilding $ � �. Building Permi�Fee: f I i�_Indicate haw fee is detennined:
'. [Icctrical g ❑Standard CiryiTo�vn Application Fee
❑Tolal Project Cost�(liem 6)x multip�ier ___x
� }. Plumhing S �� '. pther Fras: S ------
�
� 1. \lah;mical Ili\':\('1 5 —� LisC
. _._. ---���'----- --
i �. .Vr:hanic;d �Firc S
�----- --- ------- -
..-----_ ..
� tiu+ue>siunl Tulul ;\II FeeS: $
� ('hrcA Vu. ('heck :\m�umt: C;uh .lnunm�:
� i, Tutal Project CusC 5 b GO -- - ---- -
/ � ❑ P:iid in Full �Uutsr.mJing Il�l:mc� Dum:
t
, ,
SEC'1'ION S: ('ONS'fRUC'1'ION tiENVI('ES
5,1 <bnstruction Supen�isor Licc�ue(CSL� �
I.icense Numhcr----- --- I'�piro�ion Ume
---�------- ---�-----..__...._---------
N;mtt of l'SI. I luld¢f
I.isl Ctil.�i)�x V��hclowl___
-----�-------------- ------------ 'I'�pe Ucscripliun
No. :mJ Strcel
l I I inre�tricied I Duildin�5�i l0 15,U00 eu. II.)
�I -- — -------..._- R R¢strictcd I�C?Pumil � Decllin
Cilyifu��n..ti1;LLaLIP h1 �lu;un
RC R�w�in C�rccrin
_. WS R'inJuw;mdtiidin
SF SulidPu¢II)urningAppliancca
I In>ulatian
'fek hnno I(mail;iJdrcsa D Dcmolitiaa
g.2 RrgistcreJ Ilume Improvemenl Cuntr:ictor(f1IC)
IIIC Rcgistr;i�iun Numh¢r lispirntiun bwc
I IIC Compan> Nunu nr I IIC Itegi.lmnt N�nu
No. wiJ Sv�;et CI11U1�Y�IIfI`J9
Ci /Town, State,ZIP �felo hune
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.9 25C(6))
Workers Compensation Insurance affidavit must be completed and submined with this application. Failure to provide
this �tTidavit will result in ihe denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE CO�IPLETED WHEIV
OWNER'S ACENT OR CONTRACTOR APPLIES FOR BUILDIIVG PERMIT
I;as Owner of the subject property, hereby authorize
to act on my behelf,in all matten relative to work authorized by this building permit application.
I�'+�12,K� U✓i�c�N�i " I 0 I 7 2011
Print Owncr's Nwne lElcctrunic Signawm) DYIC
SECTION 7b:OWNER� OR AUTFIORIZED AGENT DECLAILITION
By entering my name belaw,I hereby attest under the pains and penalties of pery'ury that all of the in(ormation
contained in this application is true and acc rate to ihe best of my knowledge and understanding.
W�rrt2�. vk e �I�-�,J ���, r o 17 �zo11
Prini Owncr'.or,\whorircd��gcn�'s N;mic I lilac� nic.tiiyn:�uuc) Duw
NO'f ES:
I. :1n O�vner�vho obt�ins a building permit lo do his.her uwn work,or an o�vner who hires an unrcgistered cunlraetur
. �iwt rcgistered in tha Hume Improvement Cuntnctur�H IC) Programl.�vill no have access to Ihe orbitrmiun
program or gu�r:mty fund unJer�I.G.L.c. I�'_A.Other impunant infumia�ion on the HIC Program can ba liiwid o�
������ n�.r.. _•,�� ,�,.i hiformatiun un the Construction Supervisor License can be found at��>���.m:iss ����� J�L
? \1'htn subst�ntial��urk is planneJ, pro�ide�he infurmatiun below:
� Tn�al tluur arca Isy. R.1 -----I including garage. tinished basrment'attics.decks ur purchl
Gruss licing area�sy. il.l ---- - ---_- --__ _ H:�bii:�ble ruum cuunt . . --- --
I \�umbtr ul lirtpl�c.s.---_. . . ..- — -- Vtunber ul beJrounu
� --- - - �-� - �
--- � � ....__ _ . _ . _. .. _
� Vumherofh�ihruunu \'umbcru(h:df'boihs . .
-- _ .. . _ _. __. .- _
� I:�pa af hr,ning i�;t.in . . .. _ _ _. ._ Viunhcr ul dceks, pur.hrs I
I I\(�C ol COPIIIIL i)SICIIt . . . . _ . I�ItCIOSCJ .. _ __ __.�)���Il . . I
I 1. ''f��lal Projacl tiyu;trC PuolagC"m:q h¢>ub�tilulrJ fi�f.:f��l;d PrujtCl Cus�" �
CITY OFSMEM, L1L�SS,ICHC'SET[S
8L'ILDLNG OEP.%ATtE\T
120 W SHNGTON STAEST, 1iO FtOOA
Thi (973) 74--9599
K OEAt Y DRLSCOLL FAX(978) 7984
MAYOR MOAU ST.Plt UA
0I1=01t OP Pt SUC PROPEATY/OC QOLYG CoNallssroN EA
Construction Debris Disposal Atfidavit
(required for all demolition and renovation work)
fn accordance with the sixth edition of the State Building Code,
Debris, and the provisions of MCL c 40, S 34; 780 C, R section l If.J
Building Permit //
this work shall be disposed of in is issued with the condition that the debris resulting from
1, S I SOA. s properly licensed waste disposal facility as dcAncd by MGL c
11
The debris will be transported by;
(�++ma ut'hauler)
The debris will be disposed of in ;
�e.na(namaorfacdiry)
'/tuA H�O�iG.•rT�V y� , ��
( ddreu of fJ.(h(Y)
fiynJrure Of permit JpppC Jnf
CITY OF $.AL.E.NI
PUBLIC PROPERTY
DEPARTMENT
LI f0lLJir n�r.w� -
.HnrOa s4-aM%Wm0IS1rM01VV
TVL 9"9.7+5-9s"•f.AL 93.7169W
HOMEOWNER LICENSE EXEMPTION
PIeeN iMat
Date -�—
Job Lacarlos L C9
Home Owner Address I
Home Owner Telephone
Ptrssm Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage m individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) who owns a pared of land on which he/she residee or intends to reside, on
which there ia, of 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 OQleial,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"wume@ 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
..vi it comply with said procedures and requirements
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTO
Sce other side for state code