4 FRANCIS RD - BUILDING INSPECTION ql
The Commonwealth of Massachusetts
I Board of Building Regulations and Standards CITY
t h State Building Code, 780 CMR, T"edition OF SALEM
7 / Massachusetts Revia'edJwwun•
111 yy" Building Permit Application To Construct, Repair, Renovate Or Demolish a 1• =t�11Y
One-or Two-Fafrri4v Dwelling
This Section or Official Use Only
Building Permit Number: , Date Applied: � D
I
Signature: =A=16 \
Build@g C iss ncr/ ns of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro pp,erty Address: 1.2 Assessors Map At Parcel Numbers
y J- n r 0)
L l a Is this an accepted street?yes_ no Map Number Parcel Number
IJ Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided !I
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if es❑ P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
'G9cenee 2d
Name/�f nnf�] Address for Service:
�l Cm 47e -7V55-
Sioatun Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: E O 3�K /o r x fO r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List: !
5. Mechanical (Fire 'L /y al
Su ression) S Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S /.� O'9O r L. ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of C'SI.• I IolJer
List C'SL'fype(sec below)
Address Ts Pe I Description
IJ I tJmrslricled(up to 35,000 Cu. Ft.
R I Restricted I&2 Family Dwelling
Signature M I Masonry Only
RC Residential RootingC'overin
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
U I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 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...........O f
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, t1l ,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
behal_.
oavtne nssoh
Print N e
17 h 2G
Signatu of( ner or Authorized Agent Dale
(Signed under the pains and penalties of 'u
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 Mo 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 780 CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable 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
J. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.ULE.N1
PUBLIC PROPERTY
DEPARTMENT
K
NAV08 130 wAauN[.ON MMU 9 S '6-,%W&4C lLSWM 01970
TVL 973•7454S"• Fnx.979•7469"
HOMEOWNER LICENSE EXEMPTION
Please Print
Dam ':Y�ne 2, 90/0
Job Location `/ Fr¢ncr'r led
Home Owner Address .Sa m e
Home Owner Telephone q-7 8- 7`/6- YS -9�
Present Mailing Address scr m e_
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 requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE Uri¢ob
APPROVAL OF BUILDING [,INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1 V�
I'.,I: FIf1 •'MIV „11 I,C ,1dII]L.\4V�1M kJT 1.\I1)1. fit.\\{\I 1IIH I•\•14
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construction
llDebris nDisposal i Aon ffidavit
(requiredfor
In accordaune with the sixth edition of the State building Code, 730 CMR section I I I.S
Debris, and the provisions of MGL c 40, S s4;
is issued with the condition that the debris resulting from
building Permit N_�- rl licensed waste disposal facility as defined by MGL c
This work shall he disposed of in a prOVc Y
t 11. S 150A.
The debris will be transported by.
proms of hauler)
1-he debris will be disposed of in :
(owns ul acl Ily
I;�dr,rrf of 1'Jcdity)
.1 alYre of(wrmiJ Jpplieank
Jate