10 PALFREY CT - BUILDING INSPECTION The Commonwealth ut Massachusetts
Board of Building Regulations and Standards FI llt
4 '`1 d Massachusetts State Building Code. 7Sl) ('MR, 7 edition I SI:
Huilding Permit Application To Construct. Repair. Renovate Or Demolish a Krrtsr,l./lout u t
One- or Tiro-Fonuly Dncllin,g 'nnS
This Section For Official Use Only
Building Perer: Date Applied:
Sign44 ,
--
mmissioned Insper of Buildings Date
SECTION 1: SITE INFORMATION
1.1 P : ress: 1.2 Assessors Map & Parcel Numbers
l r4 T
L la Is this an acce ed street? yes nu_ Map Number Pawel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use ot Area Isq In —_ Frontage (it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: IM.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Systern:
Zone: Outside Flood Zone'?
Public ❑ _Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow re-of Rec
5 a G
Name (Prim Address for Service:
S , — _
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Buildings Owner-Occupied ❑ Repairs(s) Alteration(,) ❑ ,\dditinn ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Spccily: _
--- 1
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ O D I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Corr (Item 6) x multiplier x '
3. PlumbingS 2. �—
Other Fees: $
4. Mechanical (HVAC) $ List: !
i. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Chick Amount: Cash :\nnxun: _
j 0 Total Project Cost: $ d 0 1/) 0 Paid in Full 0 Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
License Number 1'.zpiration Date
Name of CSL- Ifolder
List CSI_ 'fypc(scr below) _
'I'• e Dcscri pion ,..'.
Wdrees
' C Unrestricted lu [o 35.lN10 Cu. Pl.r
R Restricted 1&2 Fanldl D%%clhne
Signuulrc " Musonry Only
RC Residrmial Kaoline Cowrurt
Telephone \VS Rcsidenual Window ;wd Snhn_
SF Resid_rnli:d Solid I'nel Bmmne \ >>liane: 111]LlllaI1I,1I
D Residential Demolition
5.2 Registered Hume Improvement Contractor(HIC)
HIC Company Name or FIIC Registrant Name Regisumion Numhcr --
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 .......... ❑ 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 mat[ers
relative to work authorized by this building permit application.
Signature of Owner _ --_— --- Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
2//z v��, /G_ , as Owner or Authorized Agent hereby declare
that the statements and infor ation on the foregoing application are true and accurate, to the best of my knowledge and
behalf. _
SC[
Print Name -
Signature of Owner or Authoriz Agent Date
(Si nod under the sins and a all 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
(nut registered in the Home Improvement Contractor(HIC) Program). will not 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 750 C'MR Regulations 110.116 and I I0.R5, respectively.
'. When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area ISq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt/baths
Fype of healing system Number of decks/ porches _
Type of cooling system Enclosed ___ Open _ _-_-
3. "Toad Project Square Footage" may be substituted for "Total Project Cost"
CITY OF SMY.M
PUBLIC PROPERTY
DEPART mENT
VAroa 130 WA24NGeoM S7faar•SMAK NAMAO11.'MM 01970
Te .9'.L745-9S"* FA)L 976-748.964
i
HOMEOWNER LICENSE EXEMPTION
Please Print
Datez_a�
Job Location 6 C
Home Owner Address
Home Owner Telephone -
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 license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person($) 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 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 D artment minimum inspection procedures and requirements and that he/she
will comply with said procedures and t
ents
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
s 'S CITY OF SALLM
-li ,_ PUBLIC: PROPRERTY
` DEPARTMENT
Construction Debris Disposal .affidavit
(rekluircd li,r all demolition and renovation work)
In accordance ith the sixth edition of the State Building Cade, 780 CNIR section 111.5
Dcbris, and (he provisions of''vIGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal I'acility as defined by VIGL c
l 11. S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
(name of facility)
(uddress of facility)
'lunature of pul '; r phcant
7 23 -0 _
late
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