27 FRANKLIN ST - BUILDING INSPECTIONr
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The Commonwealth of Massachuw- LI`� ';tv
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Cade 78LEM
�� T ' l A �evi ed SAMar 20//
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A ied: I
6
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
27 Franklin Street 27-0469-0
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
R2 Single Family 4250 SF 50'
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
15, 20' 10, 17' 30' 32'
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 f Private❑ Check if yes0 Municipal f On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Jonathan Wells Salem, MA 01960
Name(Print) City,State,ZIP
27 Franklin Street 978-360-6804 jfalconerwells@hotmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building IX Owner-Occupied ❑ 1 Repairs(s) IX Alterations) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': Minor repairs to exterior shingles and trim where rotten(none near the electrical
service.Repair or replace two exterior doors. Repair or replace 3 exterior windows.
Install new kitchen cabinets and tiles in the kitchen. Re-shingle a portion of the front of the house(beyond minor repairs)
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $14,250 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ 5900 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 4000 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
24,150 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
City/Town,State,ZIP 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 .......... U 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 authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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
contained in this application is true and accurate to the best of my knowledge and understanding.
Jonathan F.Wells PV , 1 7_tat
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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
www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.gov.'dps
2. When substantial work is planned,provide the information below:
Total floor 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
QTY OF SALEM, MASSACHUSEM
r,
BUILDING DEPARTMENT
120 WASHINGTON STREET,31D FLOOR
TEL. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: 10-17-Zol4
JOB LOCATION
HOME OWNER ADDRESS:
PRESENT MAILING ADDRESS:_ 5wft /� / �,,At
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two(2)units or less and to
allow such homeowners to engage an individual for hire that does not possess a license, provided that the owner acts as
supervisor.
Definition of Homeowner:
Person(s)who own 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 the responsibility for compliance with the State Building Code and other applicable
by-laws and regulations.
The undersigned "homeowner"certifies that he/she understand the City of Salem Building Department minimum inspection
procedures and requirements and that he/she will comply with such procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY OF SM E:M, iMASSACHLSETTS
BUUMNG DEP\R'I-.MNT
` 120 WASHINGTON STREET,3-FLOOR
TEL (978)745-9595
F.A.'t(978)740-9946
K1\tBERLEY DRISCOLL
MAYOR THOMAS ST.PMRRE
DIRECTOR OF PUBLIC PROPERTY/BL'1LDING COMNUSSIONER
Workers' Compensation Insurance Affidavit: Builders/ContractorsiEiectricians/Plumbers
Applicant Information Please Print Legibly
Nalne(BusirnSsOrganizatioNlndividual): —sawn"
Y wok s
— t
Address: 21 {-rah 4'itt SE*w
City/State/Zip: ell MA, fluto Phone#: 97Y' 360• tvtretyt
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).` have hired the sub-
contractors
2-0 1 am a sole proprietor or partner- listed on the attached sheet 7• []Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9, ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
squired.] officers have exercised their 10.❑Electrical repairs or additions
3.�am a homeowner doing all work right of exemption per MOL HE Plumbing repairs or additions
myself[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13 ❑Other
comp insurance required.]
*Any applicant that checks box AI most also till cut the section below stowing their worked compenwion policy infurmation.
'I Imneowneo who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicting such
ConlraYon that chuck this Iwx must attached an addidatul chest stowing the name of if,cub�,n and their wurkere'comp,policy inroon su".
l am an employer that it providing workers'eompensadon insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy 4 or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a rite
of up to S250.00 a day against the violator. He advised that a copy of this statement may be forwarded to the Office of
Investigmions of the DIA for insurance coverage verification.
l do hereby certify i tde lie pains and penalties of perjury that the information provided above is true and correct
t ue Date: �0 � �T Za�G
P on th VJ/ 17ir-3G0- (ib oy
Official use only. Do not write in this area,lobe completed by city or town oJfciat
City or TOW n: PermitfLicense# _
Issuing Aulhority(circle one):
1. Board of Ilealth 2.Building department 3.Cityrrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _._ _ Phone#: