24 FRANCIS RD - BUILDING INSPECTION The Commonwealth of Massachusetts
' I � .� Guard of Building Regulations and Standards CITY
r Massachusetts State Building Code. 780 CMR. 7"edition OF SALEM
RvvurJJuneun•
Iuilding Permit Application To Construct, Repair, Renovate Or Demolish a /. :MAY
One-or Two-Family Dwelling
This Section FqpWicid Use Only
Building Permit Num r. Daile Applied:
Signature:
C /O
Huilding 4 Pelor of Buildi ga e
SECTION . SI FORMATION
1.1 Pro rty Address: 1.2 Assessors Map di Pared Numbers
�e r?
I.la Is this an accepted street?yes no L111 Map Number Parcel Number
1..) Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq R) Frontage(11)
1.5 Building Setbacks(R)
00wnerl
ont Yard Side Yards Rear Yard
Provided Required Provided Required Provided
ly:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
vae❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal D On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
/ ecord: k
q t�i2 j9/iC cS
Name(Print) Address fw Service:
9 T -- 79a-a ?al
Signa Telephonic
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check aR that apply)
JMcchmnical
Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alterstion(s) O Addition ❑
lition ❑ Accessory Bldg.❑ Number of Units Other ❑ Speciry:
Description of Proposed Work':
Y�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: ORlcld Use Only
(Labor/and Materials y
ding S 760Q 6 1. Building Permit Fee:S Indicate how fee is determined:
trical S ❑Standard City/Town Application Fee
�`� ❑Total Project Cost'(Item 6)x multiplier x
bing S 2. Other Fees: S7—&�
anical (HVAC) S List: (,f�anical (Fire S
sion Total All Fees:S
Check No. Check Amount: Cash Amount:
l Protect CosC S OQ.d 6 0 Paid in Full 13 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
S.1 Licensed Construction Supervisor(CSL)
L wane Number lispiratiun l}ale
Name of CSI." I holder List CSL fype(see below)
f Ihscri ion
Address U I1"mincled u to 35.000 Cu.Ft.
R Restricted IA2 Famil Dwelli"11
Signature M M Only
RC Residential RoutineCovering
I'elepMurs WS ResiJrnlial Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Horne Improvement Contractor(HIC)
I IIC Company Name ur lIIC Registrant Name Registration Number
Address Espiraaion Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2.f 2SC(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..........0 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 ��✓��S [ L-,r Ti as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building pe it application.
Si ner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si under the aim 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 rig have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found ire 790 CMR Regulations I I0.R6 and I MRS.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.Ff.) habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage-may be substituted for"Total Project Cost"
CITY OF S.U.E-N1
PUBLIC PROPERTY
DEPARTmNiENT
K110F11iY fvwv
MAYM 130 WADUNGTON STUM 9 SALM MAMA0U.'SEM 019'0
TEL 9'.L71SAS"• FAU.978.74&9L4
HOMEOWNER LICENSE EXE.r1PTION
Please Print
Date '7l�VI,2010
Job Location c ' ley l�
Home Owner Addrras r=
Home Owner Telephone a a 3
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 posseaa a license,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 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
APPROVAL OF BUILDING I;•i ECTOlt r v
See other side for state code
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