10 PALFREY CT - BUILDING INSPECTION (2) The Commomsralth of Massachusetts —
F( )It
O + c 13uard of Budding Regulations and Standards 111 V Il ll' �I Il 1
t Massachusetts State Building Code. 780 (AIR. 7°i edition SI.
Building Pet nit Application To ('onstrurl. Repair. Kenu�atr Or Ihnloli,ll a
(Ate- or TIt o-h unite Do"Itilig
This Section For Official Use Only
Bmlding Permit No Date Applied: -- Lg 0- --- --
/ �O
':_unature: _
Budding Cum: u. 1 le u>pccs0r(It Moldings Dale
SECTION I: SITE INFORMA I"ION
LI P:'o ertr .% re.s• /� 1.2 Assessors Map & Parcel Numbers
, �L,p�\wnb�r I':u:.l .s
.un:hrr :
III I I.la Is This an accepted , et'. yes ou___..
:.J Property Uimenawus:
�Z—unwg Diaries Proposed Use Lot Area(sq li) Flowage I lh
1.5 Building Setbacks (ft)
j Front Yard Side Yards Rear 1'arJ
Required Pro,ided Reyuucd Pnrvided Raywred Pn„iJ`_
—1
I
1.6 Water Supply: t.M G I.c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone:' Municipal ❑ On site disposal S. strm ❑
Public ❑ Prirate❑ Check if yes❑ P I }.
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re•old: Y !,O
r— !f
\.w:c Prins Address for Service:
S:enzture Telephone
F ':ECTION 3: DESCRIPTION OF PROPOSED WORK=(cheek all that apply)
ur.wCnc:n:clh,u ❑ E.cistine BuilJin" o TGA,ner-Occupied ❑ Itepairstsl ❑ ,_lieruion(s) 'j7L AdJiu+"n ❑
I� �—
i rm 'c' t ---... G A�cesaury Bldg. ❑ Number of Umts � Other ❑
3rv_f i ry :Trion of Proposed
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: T— — Official Use Only
I I_ahor and Materials) _
1. Building i 3 oU v 1. Building Permit Fee: b Indicate how fee a detcrhnmrJ: j
❑ Standard City/Town Applicanon Fee
'. F.Iecttvcal 5 ,
- ❑To(al Project Ghat (Item G-) x multiplier s
7, Mechanic 5 2. Other Fees: S
3. 11echaniral IH�'AC) $ List: i
i. Mechunir:l (Fire
$ Total All Fees: s
suppression);
f-- --_.. Check No. __Cheek Amount: ('ash Amount. -
o Total Project Cost: 5 3 O 0 Q 0 Paid in Full 0 OutStandnhg B:d:mce Due:
SECTION 5: CONSTRUCTION SERVICES
5.I Licensed Construction Supervisor (C'SI,)
1_Iecnse Numher f`.spu,luou Dade
Nance u1 C'SI.- Ilo IJer
Lui('SI_ �h pe me hclua 1
Tv c Dcscn ,uon
JJress
t l ilrc,111, J clip hr ii,IN 10( U. I'l i
-- — R Resulctcd 1'' F.Imd, D„ellule —�
S1��n;u arc —�
St \Looms Unlr
l _ _ RC' RcaJenoal Kaoline Cu"Iin`
Flephunc wS Read,nnal Hcoda•., ,mJ liJuc __ ___
- SF Re.tJ.nu.d Solid Fuel l_i_wuinu V ,p1ph ul_hni.il l.11n ii
D Rcadenli.11 Urnwlnlou _____
5.2 Registered Ilome Improvement Contractor 0110
MC Company Naute or HIC Registrant Nance Registration Number
AJdres, E. —_ —
,pratiun 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. F duce to pnnide
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.
Sienaturr of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 7 e ^ \/Olv� as Owner or Authorized Agent hereby Jecklre
that the statements and information oiTI& foregoing application are true and accurate, to the best of my knowledge and
behalf. _�,c4
Pont Name
c
Signature of Owner or Ayrl oozed. t Date
(Si ned under the ams and en es of erju )
NOTES:
I. An Owner who obtains a building permit to do his/her own work.or an owner who hires an unregl,tered c,oluactOr
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to me arbiuvtion
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program ;md
Construction Supervisor Licensing (CSL)can be tirund in 780 CvIR Regulations I IO.R6 and 110.R5, respectncly.
' When ,ub>tanual work is planned, provide the information below
(including garage. finished hasemenUathcs. decks or porch,
Total tLurti area !Sy. Ft.) @ ," g
Gross living area (Sq. Ft.) Habitable room want ...
Number of tireplaces Number of hednann,
Number of bathrooms Number Of
I\pe Of healing system _ — Numher of decks/ porches
Tspe of cooling .}stem
1 "Toed Project Square Foolage" may be substituted tor 'total Protect Cost '
CITY OF SALEM
^ Owl-
PUBLIC PROPRERTY
DEPARTMENT
'.I :r I". \C wu�•..,,N s r::e r r ♦ S.\I r\t. \1.\;i.\i .I I :,:1'� '_
Construction Debris Disposal Affidavit
(required lbr all demolition and renovation work)
In accordance ww 11 the sixth edition of the State Building Code, 780 Ch1R section 111.5
Debris, and the provisions of b1GL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as detined by MGL c
I 11. S 150A.
The debris will be transported by:
B x�
(name of hauler)
The debris will be disposed of in
(name ul facility)
(address of tacilav)
-- _ signature of pen aN icant
date — -
CITY OF S.UYUM
PUBLIC PROPERTY
DEPARTMENT
MAVOR 130WASONGTONS REST•SAL6KNAZAaft-WM01970
TM-*976745-9S"A FAL 979-74&9&M
HOMEOWNER LICENSE EXEMFnON
Please Print
Date
Job Location 1 O 111-1--e zf
Home Owner Address
Home Owner Telephone 7 F— 74 /,- :�Z
Present Mailing Address s , o
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 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 requi is and that he/she
will comply with said procedures and requir ents.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code