13 LYME ST - BUILDING INSPECTION (3) t 4 .
IV
{ The Commonwealth of Massachusetts
Board ot"Building Regulations and Standards
CITY
Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
✓ Revised Juuu ry
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
Th' Section For Official Use Only
Building Permit Number: Date Applied: / /
Signature: �//j2
Building Commissioner/Insp torW Buildings Date -
SECTION 1: SITE INFORMATION
1.1 P gerty Pddress: G 1.2 Assessors Map& Parcel Numbers
1 ,Lc.I MG 2 1
I.1a 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(tl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided R�quircd Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O vner of Record:
/3 dy.,e—
s
Name(Print Address for Spervic�e]:,
O✓1�....�. 110—.792—.$'t✓.3 Z_
gnaturc Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
!/ �..(titucG fb•-G GI r's9 Lei
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S /
4. Mechanical (BVAC) S
List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
l.1� 6.Total Project Cost: S /Q�i'�. 00 ❑Paid in Full 0 Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Rxpimtion Date
Name of CSL-I]older List CSL Type(see below)
f Description
Address U (lnmstricteJ(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
1'dephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I C Company Name or f1IC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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
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 0-11 _ ,as Owner or Authorized Agent hereby declare
that the statemeni and information on the foregoing application are true and accurate,to the best of my knowledge and
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ehalf.
n atz�
Print Name / /�
Si ature of Own or Authorized Agent Date /—T
(Signed under the pains and Enaltics of r'u
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 nu.1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/at ics,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"
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CITY OF SALEM
PUBLIC PRO
PRER
T Y
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DEPARTM
kl'i ��.111\I, �sls�a
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construction Debris
I)Is posalion Mdworkjvit
1 all
in accorJ:ux:e with the sixth edition of the State Building Code, 780 CMR scetion 111.5
Debris. and the Provisions of MGL c 40. S 54;
is issued with the condition that the debris resulting m
Building Permit q licensed waste Disposal facility as defined by
This work shall be disposed of in a Properly
111. S 150A.
The debris will be transported by.
lame of hauler)
The debris will be disposed of in
(nansol aci tly .
(address of 11acdily/
�itnal of p.rn,il applicant
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CITY OF S.U.E.'Vi
PUBLIC PROPERTY
DEPARTMENT
IL11�u��GY N.4'�Y 1
VwraG 13e wwumme"STU=•sALAK MA=A04Lsens 0n970
7kL 975-715-9S" 9 FAx 97$-74e.9&4
HOMEOWNER LICENSE EXEMPTION
Ptew Print
Date
Job Locatias 13 X g rx-e. S
Home Owns Address 13 ,L.,r�c_ 5-
Home Owner Telephone 9 — 97 9—57 3 2
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 licens%provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons) who owns s parcal 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 dwellin& attached or detached
strumm 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 772WO*U. 1 _,
ements.
HOMEOWNERS SIGNATURE �p
.APPROVAL OF BUILDING NSPECTOR
See other side for state code
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