10 PALFREY CT - BUILDING INSPECTION (4) The Commonwealth of Massachusetts —
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised.liar 2011
Building Permit Application To Construct, Repair. Renovate Or Demolish a
DOne-or Two-Family Dwell/ng
This S •lion For Official Use 9111y
Building Perm i umber: Date Appl• _
72 /5/ /
Building OlTicial(Print Nmne) ignature I Date
StCT&6N .SI INFORMATION
1.1 Prop yy Q dress: G� .2 Assessors iViap& Parcel Numbers
1.1 a Is this an accep ed street?yes__z no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use of Area(sy It) Fronlage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if ycs❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
— Owner'of R cord: �// dl,�&
Sca� drti cd Sti�Pm /,
Name(Print) —� City.State,ZIP
0 97 '7 .956 s�a{� 'octi m�;� 6'
No.and Street Telep one 'm• Jdn
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Cl Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bidg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-:_ 0& -e_�<
SECTION 0: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier._x
3. Plumbing 2. Otea. Mechanical (IIV:\C') $ Lista_.!L'� T5 7 /
5. :Mechanical (Fire $
/ Suppression) Total :111 Fees: $
r� Check No. Check Amount: Cash Amount:
G. Total Project Cost: $ 0 Od 0 Paid in Full 13 Outstanding Balance Due:
c '
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Number Iicpir:Lion Date
Nutnc ol'C'SL Ifolder
List CSL"f)pe(see below)
No. mid Street Type Description
U Ihtrestricted Buildings u' l0 35,000 cu. 11.)
R Restricted M2 FamilyDwellin
Cot)✓fotvn,State,ZIP M Masonry
RC Roofing C'ovcrin
W'S Window and Sidon
SF Solid Fuel Burning Appliances
I Insulation
'I cic hone hmail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Expiration Date
I IIC Company Name or I IIC' Itcgislrunt Name
No. and Street Email address
City/Town,State, ZIP 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
I,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 Signatum) 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
ontained i is applic on i e and accurate to the best of my knowledge and understanding.
Print O(s ner's one uhoriz ,lgent's c(Electronic Signature) Dale
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 can be found at
o)vo.nt;i.". ;O% 0ca Information on the Construction Supervisor License can be found at gg��.m:(_r.Leo ,lpp
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) 1 including garage, finished basement'attics,decks or porch)
Gross living area(sq. 11.) Habitable room count _
Number of fireplaces _ Number of bedrooms
Number of bathrooms _ __ __ Number ofhalfbaths
1)pc of heating system ---- _ --- -- dumber of decks, porches --
1)peofcoolingsystent-- -. -----__-_-- Enclosed Open
i. 'Total Project Square Footage-may be substituted fix,,Total Project Cost-
r
CITY OF SAI.EIM
PUBLIC PROPERTY
DEPARTMENT
Wroa t]O vAaant.wn gnat•sMAW N jM0ft Wren OI1'e
rtL rs-715-9s" 978-74&9aee
HOMEOWNER LICENSE EXEMPTION
Pltaw hbt
Data 22t(Tk W i l �/
Job Location l U f �l e Sc P
Home Owner Addre n io ti moo,._ Gr- _f,,Aa,.
Homs Owner Telephone _ -
preseni Mailing Addraw LD
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 lieenae6 provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Persons)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 snucturm 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 O®cial,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 SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF S'UY.4 I, NL-kSSACHUSETTS
Bt;(I.DLNG DEPARTNONT
130 WASHLYGTON STRM' Yo FLOOR
TEL (978) 743-9595
FAX(978) 740-9W
Ki\BERIEY DRISCOLL
MAYOR THowu ST.PrElttta
DIRECTOt OF PLBLtc PROPERTY/at.=LNG CO\OIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit tl 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 MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
ti S P G r facility)
61(namahf facility) (/
(address of facility)
signature of p app ant
2 �Tt7 ✓
date
dabn»If,l,w .