13 FREEMAN RD - BUILDING INSPECTION / f r
^� a The Commonwealth of Massachusetts
!bard of Building Regulations and Standards CITY
�g+ OF SALEM
Massachusetts State Building Code, 730 CMR, 7'h edition
Revised Januury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 2008
One-or Too-Family Drvel(ing
This SectA For Otlicial UW,Onl
Building Perm Number: Date A ted:
j
Signature:
Building Commissio r/Inspector of Bw di' Date
SECTION�I:$ITE INFORMATION
LI Prop�y Ad s.%ate 1.2 Assessors Map& Parcel Numbers
L l a 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(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required 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❑ Onsite disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
/ 2.1 Owner ,Retold: , f�� n l� ('s ( //jl /0
I/ ,l gra 13 Fre e wta s P J( >�..�p : /�T
Name(Print) Address for Service:
0/m
Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description ofProposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OITieial Use Only
(Labor and Materials
I. Building .S I. Building Permit Fee:S Indicate how tee is determined:
�. Electrical S
C3 Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S 1. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Total All Fees: S
Suppression)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S O�(� ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Numher Expiration Date
Name of CSL- I]older
List CSL 1*ype(see below)
1'e Descri lion
Address 11 t Inres ie eJ a l0 35A00 C'u. Pt.l
it I RKIricted 1&2 Family Dweflin
Signature N Masunry Only
RC Residential Roofing Cbverin
.1 e ephone \VS Residential Window and Sidin
SF Residential Solid Fuel Burning A Iiance Installation
D Residential Demolition
5,2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or IIIC Registrant 'in Registration Number
Address —
Expirat un 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 matters
relative to work author zed-by-this-building ed-by-this building permit application.
Signature of Owner Date
t / SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
S
V I, �� e ')C 1 S s( 161 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name L -
QU,A-AA UT
Signature of Owner or Aulh rized Agent Uate
(Signed under the pains and penalties ofperjury)
NOTES:
1. 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 11 IC Program and
Construe . Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I I0.R5, respectively.
2. When substantia k isplanned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitabie 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 he substituted fir"Total Project Cost"
CITY OF SAI.E.N(
PUBLIC PROPERTY
DEPAMiENT
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HOMEOWNER LICE.rSE EXE.MPTION
Ptew filet
pale
Job Loeadois 1 3 Ffee;•.l, 2J Sa�
Home Ownes Address wen e
Homs Owner Telephone
prewar Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage m individual for
hire who does not possess a license,provided that the ownar acts as supervisor.
DEFINITION OF HOMEOWNER
person(s)who owns a parcel of Led on which helshe reside or intends to resider on
which there i; or is intended to ber a one or two family dweWng attached or detached
saucttum 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
'4tomeowner"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
•.viii comply with said procedures and requirements.
�
HOMEOWNERS SIGNATURE
APPROVAL OF 9UILDING NSPECTOR
See other side for state code