9-11 LUSSIER ST - BUILDING INSPECTION QThe Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tiro-Familt,Divelling
ection For Official Use Only
Building Permit Number: Date Applied:
Signature.
Buildin ommissioner/In Buildings Date p•�
SECTION 1: SITE INFORMATION
1.1 Property Address: S, n � F 1.2 Assessors Map& Parcel Numbers
J �
! // kraisir T t
Parcel Number
1.I a Is this an accepted street'?yes Map Number
no. ;.
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 Required Provided
1.6 Water Supply:(M.O.L C.40,234) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
�{ ❑ Zone: _ Outside Flood Zone? Municipal K(On site disposal system
YES ❑
Public Private Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ff-1
i1i�JJO
�ARk4t'y QRGf
e(Pnnq V Address for Service:
91e may/ayf�/
'Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
EConstruction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑olition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical 5 — ❑Total Project Cost'(Item 6).x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S Ltst. I '
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. (i Check Amount: Cash Amount:
6. Total Project Cost: S paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Super isor(CSL)
License Number Expiration Dale '
N4mc of CSL- Hyldrr List CSL Type(see below)
Address T Description
U ®Restricted
ed u to 35,000 Cu. Ft.)
Signature R 1&2 Famd DM Onl
RC l Roofin CoriTelephone WS l Window and SidinSF l Solid Fuel Burnin Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration 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 this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, , 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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under thepains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I 10.115, 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 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
I - PUBLIC PROPRERTY
l"Y DEPARTtiIENT
.\":1:V1.1111.\II \I. \l.\•�V •. I .• .I'I _
I I I 't'S V;.'):'tn I \\' 97S-'4.'tih
Construction Debris Disposal .affidavit
(required li)r all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of 1IGL c 40, S 54;
Building Permit ft is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal Iacility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name of hauler)
I lie debris will be disposed of in
(name ut'lac ility)
(address u1 facility)
�IL'Ilalnl l' of per�ut .ytphcant �
late
CITY OF SALElbi
PUBLIC PROPERTY
DEPARTMENT
IUIO��GY NMfIY
NAVOK 130 WMMNCTON STUB=9$AL9K M. A=A00.'SLM 01970
TU-979•715-9S"* FAX.978.74496"
HOMEOWNER LICENSE EXE.rIM'ION
Plem Print
Date &
Job Location
Home Owner Adikiiii X1 Xc /f
Home Owner Telephone - a
Preset Mailing Address /�, li 5h.'�.P .ST
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
Persons)who owns a parcel of land on which he/she reside@ or intends to reside, on
which there is, or is intended to be,a one or two family dwellin& 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 requirements.
HOMEOWNERS SIGNATI.
APPROVAL OF BUILDING INSPECTOR
See other side for state code