16-21 FREEDOM HOLLOW - BUILDING INSPECTION v
10 The Commonwealth of Massachusetts CITY
J� n Board of Building Regulations and Standards OFSALEM
u Massachusetts State Building Code, 780 CMR, 7th edition RevvisedJanuary
Building Permit Application To Construct, Repair, Renovate Or Demolish a I, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
i
Signature:
Building Corn i - oner spe r of Buildings Date -
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
FREFDOM HOLLOW 21-0241-814 ,8155, 816 817 , 81" 819
1.1 a Is this an accepted street?yes X no Map Number Parcel Number 8 2 0 2 8 2 1
1.3 Zoning Information: 1.4 Property Dimensions:
—nmnn D Zoningistrict 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
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici a On site dis osal s stem ❑
Public Private❑ Check if yes❑ p p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: 400 HIGHLAND AVENUE , SALEM MA
M AN At:FR
N Print)V L E A VIN .N SQUARE AditibfOrATNTUM TRUST II
978-741-2003
gn Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': oo replacement. clapboard , cornerboards
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1-. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee — /�f
2. Electrical $ Total Project Cost'(Item 6)x multiplier x�
3.Plumbing $ 2. Other Fees: $
4.Mechanical QIVAC) $ List: _
5.Mechanical (Fire $ Total All Fees: $
Suppression)
�r7 Check No. Check Amount: - Cash Amount:
6.Total Project Cost: $ �O(�� ❑paid in Full ❑Outstanding Balance Due:
1501LE F9Vr14vvt1'(_ Pav /-3� ��rnG�El�1iu� Wne FM.1 1O&UIVrX�
L SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 91942 01 /04/7011
MICHAEL MERCURIO License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
P .O . BOX 438
Type - Description
Address U Unrestricted(up to 35,000 Cu. Ft.
WAKEFIELD MA 01880 R Restricted l&2 Famil) Dwelling
Signature M Masonry Only
339-203-1556 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning A2pliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration 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 ........... 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 &2 C as Owner of the subject property hereby
auth ize to act on my behalf,in all matters
r a ' wor aut rized b this building permit application.
i n to of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION -
1 ,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
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
l. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"