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1 FREEDOM HOLW - BUILDING INSPECTION (2)r � : T�-i � -��� s �� �. 2� � . � 9 � The Commonweaith of Massachusetts " Boazd of Building Regulations and Standazds CITY ' � � � Massachusetts State Building Code, 780 CMR, 7�'edition OF SALEM Revised Janttary Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 � One-or Two-Family Dwelling " This Section For Officiat Use Oniy - � Building Perm.itNumber. Daie Applied: m cn � � -o \ Signature: �'t9'M"b � . . !/II7/l y Z c7 o —+ � Buitding Comm�ssioned Tnspect f Buildings Da[� e p � � SECTION 1: SITE INFORMATION � m � I.l P operty Address: .D rn � ��p (+��� � , ' ,.` � 1.2 Assessors Map&Parcel Numbers p 2L1S21d'L, 1 \�Q Yl'l l.la Is this an accepted sReet?yes_ no Map i�7umber Parcei�Number •• 1.3 Zoninglntormation: 1.4 PropertyDimensions: o� Zoning District Proposed Use Lot Aree(sq ft) Frontage{ft) 1,5 Buiiding Setbacks(ft) Front Yard Side Yazds Rear Yard Required Provided Requirzd provided Required Provided 1.6 Wate�Supply:(M.G.L c.40,§54) 1.7 Flood Zone Iuformation: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside ftood Zone? Check if ves0 Municipal O On site disposal system ❑ � SECTION 2: PROPERTY OWNERSHIP' �I �O�wnQerj�oi�',R, ecord• ` l f �v � � �/1 P 3 r'V�_]�L'�i� C1 � C�\�,Vin Name(Print) Addmss for Sernce: � G�� • �'-1 c � S ��' ,: S�gpa TeLephone SECTION 3: DESCRIPT[ON OF PROPOSED WORK'(c6eck all that appty) New Constrvcfion� Existing Buitding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Additiou ❑ Demolition O Accessory Bldg.❑ Number of Units Other ❑ Specify: Bnef Description of Proposed Work': F��;t,p1,���1 /1 ,n i';N �{�, (1 � �i �y Sr�10,S�r 'r�w u�{- �_.�ivi Ck."1vS - �ia �n� � �I Q n� ra � �� ��r_Q 0 � �/'�.���r�p,r,�Yi+— � � S3-r tr vv� rl s.,,�' . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Offcial Use Onl Labor and Materials y 1.Building $ i. Building Permit Fee: $ Indicate how fee is determined: �.Electrical g ❑ Standard CitylTown Application Fee ❑Total Project Cost�(Item 6)x multiplier x 3.Plumbing � 2. Other Fees: $ ��� 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire � � Su ression 'I�otal All Fees: $ Check No. Check Amount: � Cash Amount: 6.Totai Project Cost: � �c6 q � �� �paid in Full ❑Outstanding Balance Due: G�'l�L� Lt � .U • I� l �� . r. SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) C� �) P License Number Expiration ate Name of CSL.Holder List CSL Type(see below) l , Y y� i_to aA r Q L'YIY\ Type Description Ad U Unrestricted u to 35 000 Cu.F[.) R Restricted 1&2 Family Dwelling 91 Lure M Mason. Only `k 1 «�- 9 y RC Residential Roofing Coveting Telephone WS Residential Window and Siding SF Residential Solid Fuel Burriing Appliance Installation D Residential Demolition 5.2 Registered ( ' JlbU7611Home Improvpment Cont clot(HIC) I a 3 .�� \ l � � S1n1YJt C Com an Name or HIm C R strant Nae Registration Number `11� K�1 cg a u ExphtinrilDate Signa re - 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 ..........t1 No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 1".JLX.X. h,(A (i ,l VW as Owner of the subject property hereby authorize ti L (^i to act on my behalf,in all matters relative� ork authorized b his building permit application— N -- Signature of Owner Date D aLI SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION T I U r ll✓✓fas Owner or Authorized Agent hereby declare that the statements and information A the foregoing application are true and accurate,to the best of my knowledge and behalf. — [� rJ 'ice. Print N /elm i ley Si ature of Ownor Au FAgent Dale (Signed under the 2ains and nalfies of nary) 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. 132A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and I10.R5,respectively. 27 When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/aRics,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"maybe substituted for"Total Project Cost' r f "`�':"",a��s«`3 • , :.�x"at.�'.yK,..� cs�ti'µ"^;. C"'�`-'� is V'F'C+ &OW Ttrrfce r - y .o +r f}3'fice of Cou"mer f fTstirs etc !3usiat=,Ae kiov t a T OME IMPROVEMENT CONTRACTOR Tegistrati©n, 128634 Type: r,AExpiraftn; 502015 DBA ED BYRNE W NDOW 00 E DWLiND BY#?NE 756 WESTERN AVE � y LYNN, MA 01902 Undcrucretary v I i ia 0; ('1) iq, I Fil i.. I,!, qy 4;. if III fit 13� fit 73 (y 0. Ck (6, 0 fill ol ii, to yy C, Ij cl C, 0 f/I NJ to P C7 tit 11 -1 1., 1Y to P-o Iij ii; as rn Cl (0 fq ID V, III tj y tl t, ITI flfl fit fit to t I of «7 tJ cp 0 rij Ip :T if[ A, 0) Ill 7� fit ci :it 40 fit It of cs 00 Iv ol C A, (Yl p1 The Commonwealth of Massachusetts Department oflndustrual Accidents Office of Investigations 600 Washington Street x Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Al➢palicajmt Inl6roatioa- __-_ _ Please Print T e0biv d _ _N3.L"S.�_(BLstagssiorgaanizationlindividual):. ,) yLX:�(1, - t _- dd-ress:'��l city/stat/zip: L�1 n vl If1ilW 1) 1 `f DS Phone t: Sr I SCI C2 Are you an empDoyer?theck the appropriate boa: Type of project(required): - i am a employer with�_ 4. ❑ I as a general conuactor and I employees(frill and/or part-time). have hired the sub-eoatiaator 5: ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet T ❑ Remodeling ship and have no employees t These sub-contractors have g. 0 Demolition employees and have workers' working forme in any capacity. Y o -, Coin.. . nstrance., ❑ budding additlOIl [1V0 WOFkei�' COii�1D. m52Lrange P - 9 -_ `] 5. ❑ We are a corporation and its 10-I I Electicai repairs or additioy re u;iec. oTcers have exercised their o 3.❑ I am a bomeowner doing all work 1 I. .lumbine repairs or additions myself f. o workers' comp. _ right of exemption per MGL 2.❑ Rootrepais insur-ice required.]7 c. 152, §1(4), and we have no employees: [No workers' 13 O1erY_f�/ OglXeo 't comp. insurance regvied] L<J;rlW13olr- `Aay applicant that cbec:s box ml must also ill out the section below showing their workers'compensation policy u-or=_toe - tiomeocrp "5 who submit this andavit indicating they are doing ail wom and then h6-outside conn,ctors must submit a new amdavit indicating such. '-Coutactots that check this box mini attached an additional sheet showing the name of the subcoavactors and state whether or act those ent es have employees, li the sub-conracrors have employes,they mut provide their workers'comp.policy number. - - -1 am an ear>ployer tha:is p rovidinn workers'compensation insurance Jor rny erTI*yees. Below is the poaey and job side .. inJarsnation. _._ Insurance company Nave: / / Y! - { �/zc �� /h l&4 GiiL.E'_n ( -__ __.__ t'olicy orSel= a_Licpp #; hll�' �bU -�D��1LAG -a�13 Expira`ionDate: a -6 1 Li _ . J,ob Site Address 1 Yv'r� D bl� to 6N.) Cii-y/State lip: sk �i}l 1 Y �q- ,ftat§a cepy of the r>orLyers' compensation policy decRoraSon page(sraocsing the polncy 1MdM6—_c and e pirataon date3. tailor e to ser7re coverage as required, under Section 25a of MG1 c, 152 can lead to the imposition of criminal penalties of a i7ane up to S 1,500.00 acrd/or one-year .iprsonment :s well as civil penalties in toe form of a S I OP vV0?l�ORDER and a fixe of up to$250.0:a d_y against the violator. Be advised that a copy of is statement ma-y beiorwardeo to the O=+C e OF Lnvesagations of 1he DLA for insurance coverage verification. I do>3erei-Y ce , index tire palms a ciadpepsttd'zc'er o3 ferjsy sha the ip4rormwe aopprovkied above is d�yae cage coarorg, _ Si�attr - - Date: ®,fj-zcial use only. Do not writ in this area, to be completed by city or town official City or Tows: P@rmit/License Issuing Authority(circle one): y. - 1.Board of Health-1 Building Department-3-City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: " Phone