3 LYNN ST - BUILDING INSPECTION Crc
J
� 7 The C'onumonweallh of Ma55aclttlSCUS
y,,'i� Board of Building Regulations and St;mdards CITY OF
')'�U, Massachusetts State Building Code. 730 CNIR SALE,M
Building Permit Application To Construct, Repair. Renovate Or Demolish
�\ One-or Ttru-Finrtill'Duvllit.g
This Section For Official Use only
Building Permit Number: —_ Date Applied:
1 -
�t�l�tt><C.r
Building 011icial(Print N,une) , i a Oute
SECTION 1:SITE INFOR IATION
1.1 Propperty Address: 1.2 Assessors Alap& Parcel Numbers
1.I a Is this an accepted street?yes no Map Numhcr Parcel Number
1.3 Zonin¢Information: 1.4 Property D menslons: ,�1
Zoning District Proposed Use Lul Arcs(� I s Frontage I� IIJ
1.5 Building Setbacks(R)
Front Yard Side Yards Rcar Yard
Required Provided Reyuircd Provided Reyuircd Provided
1.6 Water Supply:( . I.c.40.§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check fife--
SECTION 2: PROPERTYOWNERSHIPt
2.1 Owner'of Record:
u 01 egq
N;ane(Rrrtu) Lily.Stain,ZIP
Evan sfrier�- g7a'7yyG�Y
mJ S net Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
NewConstruction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief DescriptionofProposed Work': 'e -move v iIo- i' L .ice
Geof/rr�' h rJcye fr�-w, � w0 yFo V s�v /i.1 e t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and %laterials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost' Item 6)x multiplier _ _ x
� 1. Plmnhing S 1 1 _ ------
_. Other Fees: S
4. Meclmnird (MAC) S List:
s. .\lechanic;d 0--ire - -- --
tiu„ression) S Toud :\I1 Fees: S -__ - --------- --------- -
o. Total Project Cost: S C'hcck .No. __Check :\mount: - _-__-- Cash:\mount:
�l7d0 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUcriON SERVICES
5.1 Construction Supervisor License(CSL)
License Number I \piralion Date
N:une al l'SI. Ilulder -- ---- -- -
I.ist CSI.I*k PC Isee below)
No. .mJ.tree!
--- ------- ---------- 'I)pe I scription
U 1�nrc5trieled uilJin-s ti to 15,d1)0 eu. Il.l
It It trice IRS I'wnil r Dttcllin
Citsi foan..Slate.LIP
RC R;w m Cuvcrin
\4'S Window and Siding
SF Solid fuel Burning Applivues
1 htsulamotion
Talc hone Itmuil;tJJress D Delition
5.2 Registered Home Improvement Contractor(HIC)
1IIC Rogistration Number Expiration Date
I IIC Cw nc npan) Name or I IIC' Registrant Name
No. and Street imail address
City/Town. State,ZIP rvie hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 2SC(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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is tr accurate to the best of my knowledge and understanding.
t Date
Prim Uwner's; :\uthurircJ.\gcnt's Nance Iblcetnnuc Signauncl
NOTES:
\n Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program),will noj have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at kk>s,;.m:,,<>
2. When substantial work is planned, pro%ide the information below:
Total flour area(st1. R.)_ ___._I including garage. finished bascntenCattics,decks or Porch)
GrossikingareaIsy. 11.) _ Habitable room count
Number of fireplaces ____ . .- — _ ...— Number of bedrooms
Number ofliall
ths
•
t r
peofheg Ntmheo(decks, porches
1) litsy>lem It , r
1. "food Project Square Footage' nrq he suhstituwd for-I'otal Project Cost-
CITY OF S.Umef
PUBLIC PROPERTY
DEPARTMENT
w.usasar�•�.•�
Vwrae i�s v�ourw�oN st7usr•su„w Vna�oR>erss ot•-o
rM 9 a-7J195" •FAX 978-7169e46
H0ME0WNER LICLNSE EXEINMION
Pleaw hint
Due i o /
Job Location L+//+✓+ 37 ,Sec1e,1344
Home Owner Address 23_ 1,�ej „
Home Owner Telepbone D
Present Mailing Address 13 ��
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license.provided that the owner acts as uWa visor.
DEFINMON OF HOMEOWNER
Pawn(s)who owns a parcol of land on which he/she resides or Intends to resider on
which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use mWor 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
Offici4 that he/she be responsible for all such wort performed under the Building
Permit
The undersigned"homeownere 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
xill comply with said procedures and requirements,
HOMEOWNERS SIGNATGRE
APPROVAL OF 9UILDING 17VSPECTOR
See other side for state code
CITY OF Smy...mj NWSACHUSETTS
BI:ItDNIO DEPARTN ENT
120 W imiLNGTON STREET, Y°FYOOR
TM (978) 7459595
K1JC3ERLEY DRMOLL FAX(978) 740-9846
MAYOR I}tosLU ST.PMUA
DIRELTOR OP pLaLIC PROPERTY/BL: DL-IG CONWISSIOVER
Construction Debris Disposal Attldavit
(required for all demolition and renovation work)
In accordance with 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 M is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility) '��---
(1ddress of facility)
an'r�P�r�Plicant
�atr