50 FREEDOM HOLW - BUILDING INSPECTION (6)r
-_ - ---
j 7 TheC'onununtveuhhoFMussachuxus --
I y; Board ul'Buihling Regulations and Standards CITY OF
st ;, Massachusetts State Building Cudc.'730(AIR SALEXI
'L'-,•• li'd ri.edJ I hill 2011
Building Permit Application To Construct. Repair. Renovate Or Demolish u
One-or Tnu-Funtill' DtrvllitkV
This Section For 011'cial Use Onl
Building Permit Number: D fC,lpplicd:
Building Ol)icial(Print Marc) Signature 1)Ic�
SECTION I:SITE INFORMATION
I.I Property Address: 1.2 Assessors Map& Parcel Numbers
23 i ree.l.ov.. ik�il Un(4 #-z,01
1.1 a Is this an accepted street?ya no Nhtp Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed We Lot Arco(sit 11) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rcer Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§Sa) 1.7 Flood one Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munici el❑ On site Jis
Check fifes❑ P pusul system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: rY
�l i 5 CI'11,.1t+fj'L �cJ a,sv�`OSco l t !Vl {� G l�l o'
Name((I Prin not) City.State,ZIP
?� 5l7opa J A�� ��� sCJ� 7476 rsso-kSACoL cob•,
No.and Street Telephone &null Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ O III ner• III cupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : or1 �X1"shnn kit,
(Ja r
lJs , IZcwII—Iwo -Qx ,st -f\, ll RwhnroowvS i flew +i-^l-c-1 a✓cA
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs:
(Labor and.%laterials) OMCIIIl Use Only
1. Building S 34I QOG, 1. Building Permit Fee:S Indicate how fee is determined:
'_. Elocirical S C+/000, ❑Standard CitytTuwn Application Fee
❑Total Project Cost'(Item 6)x multiplier _..—_x
j 1. Plumbing S 2. Other Fees: S - -- —
a, \Ieeh.mic.Il III\.W) S List:- ----_ � �
3 \Iedcwical (Fire — —_—.-- --- — --
Cu„ression) S Tard .uFees: S_
Chock No, ( heck Anun ult: _ Cash \inounC o. Total Project Cast: S 1}�i(>LY) ❑paid in Full 0 Outstanding IlaLutce Due:
..
SECTION 5. CONS Rl f.fl(LN SERVI(TS
('onstrucliml Supervisor License(CSt.) sP,0� - 0(914S-( -
^p C S I innse Number Pvpiration mite
Nawcol'C 1 Holder l IsICSI. I)pc
C�,� �j LJ{j F.(L�_S I -_..-_—_ _.._.-._.-__.__ ,I'%pe Description
No, ad Strccl _ 1 L@
l Inrestrictcd(Ruildin�s ti In 15,020 cu. It.I
M
M� 01�`i'S R Reatricled I I'.uni1 Y Dttclli11
� r_. kc4 - -.. . .
Citti fall n,Alale.Lll' \I Slasun
RC Rlwlin Cutcrin
\SS N'indua',IoJ.tiiJin
-7u1- L3'It-107-4 _ �'" SF solid Fuel Burning Appliances
7r�1'LKA-Z (Z30 j) S�rAAC, CC1M I Insulation
1'cle hone hnlail address D Donotition
5,2 Registered Home Improvement Contractor(HIC) 8 Z 1'Z
116�e�
&el I IIC Registration Numhcr Ifspirnion Dale
I IIC Company N,mtc nr IIIC'Hcgistrunt Namu R-I-f S �d I-1Pt'G. CU)1
�741 �i'cicQ
rya. mtd S el '7 S3 I -�35 loi+( limail uddmss
Mcv- o�.� 1-ti4- a144j �s(-4�vZ-Iz3o
Ci !Town.State,ZIP fcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 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 ..........X No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERh11T
1,as Owner of the subject property,hereby authorize I y10W L( M, J LP Wb1
to act on my behalf,in all matters relative to work authorized by this building permit application.
Jt la Sc.It Ld AAI-7— � o)-
DJIC
Print Oaner's Nwne(Elcctronte Stgnulurv)
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 tru and accurate t It best of my knowledge and understanding.
I'rinl th+ncr's or:\udloriieJ Aga is N;une I nectrunw Slgnuure) Duce
NOTES:
L :\n Owner%Ocl obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(not registered in the Hurtle Improvement Cuntractur tHIC)Program),will nu have access to the arbitration
Program or guaranty fund under M.G.L.c. IJ_'A.Other important information on the HIC Program can be fund at
Information on the Construction Super isor License can be found at kt%%t, nl.ln+ �_ s ,II+,
\Then substantial work is planned,provide the iitl'unnation below:
rota) (lour area I sy. IT.) - I including garage. tinishcd basement attics.decks or porch)
Cirus living area I sy. 11.1 ___ Habitable roust count
� \lnuhcr of lircplaccs
Number of bedrooms
Number ol'hathrooms . . _ . . . \umi+crofhalfhaths -
1'\pc of heating S)'tcnl \umher of dccks. porches
Fnchascd
i
fv pe of 0101111g st'tell' - '
1, Total Project StItime Footage"nrn lie substituted lift 'I'otal Project Cost-
CITY OE S.1[. Nft AISSACHUSETTS
Jt;MDNG DEP.imm'sT
I_'0 W-U-4NGTON STRB$r, Vo FtOOit
rEL (978) 741-959S
K1313PRLBY DAM01.1 FAX(978) 140-44
MAYOR T)towa ST.PMAAS
D(RECroit OP Pl:BLiC PRaPBRTY/BLRDLNG CO.%011sslo.
siEjt
Is
Construction Debris Disposal At'tidavit
(required for sU demclition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CUR section 111.1
Debris, and the provisions of MGL o 40, S 34;
Building Permit 4 is issued with the condition that the dcbris resulting from
this work shall be disposed of in a properly licensed waste disposal racility as det3ncd by NIGL c
III. S 150A.
The debris will be transported by:
�1 �G cc�S C6^c�r�chc;�n 2 1�2vxoc�l�+
�uC
(name ut'hauter)
The debris will be disposed of in :
I s�v S"-O A — Mw S�k
(name a��l.)
(,ddrv„of r,,,t„y)
r-
udndmreafF--" trpphunt
2 Z� JIZ _
,:Lug
CI-I•Y OF S:\LEM. NWSACHUSETTS
• BUILDING DEPARTMENT
1 s i 120\'(/ASN6VGTON STREET, )'a FLOOR
T EL (918) 745-9595
F.'Le(978) 7.10-9846
<llt3ERLEY DRISCOLL I
TTio%w ST.PiERRE
'NL•1Y01 DIRECTOR OF PCOLIC PROPERTY/8U1 DING CO>L%IISSIONER
1Vorkers' Compensation Insurance Affidavit: builders/Cont rate tors/ElectriefansjPlumbers
koolleant Informatlnn T 1 1 Please Print Lea_iht-Yr-
VIIlni: IBusitk��UrWtmvatioe,lmlividu,tl): / off y�-C64$ �ASirud6fiA I O�-•'1r�� "�"C .
Address: (0 '� S'rree_
CityJStatc/Zip: i�\c'rblklu�at P.,Ar olcigS- phone tt: 76 `1 -(�39 - (01`( /781 - 4gL.- 1236
Are you an employer!Check the appropriate box: 'type of project(requlred):
I.ey I am a employer with 4. ❑ 1 un a general contractor and 1 6. ❑Now construction
antployem(full and/or part-time).• have hind the sub-contractors
2.C]
.❑ I airs a sole proprietor or partner-
listed on the attached sheaf. r• tmodeling
.hip and have no employees These sub-contractors have a, ❑ Demolition
working for me in any capacity. worken'comp.insurance. 9• ❑Building addition
[No workers'.comp. insurance S. ❑ We area corporation and its 10.0 Electrical repairs or additions
required.) offlcers have dtteraised their
3.❑ 1 ran a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.L\o workers'Gump. c. 152,$1(4),and we have no 12.❑ Roof repairs
insurance required.) r employees.LNoworkers' 13.❑Other
cump.insurance required.)
\ray applluun teat el0.ckshas/I must afyo ran out the seaim below showing their oaken'compemadun pulley inrormulion.
'I hvneuwaocs who whand this airdsvit indiwing they am doing all work and than hits ouni4e conitsct=must snbmir a now atrlasvil indicating each.
<'amrxten that chock this bear must attached m additiund shst'hawing the nano of the subaontmtots and their workers'camp.policy information.
1 um an rmpluyer that It providing worken'rumpenradon bhtaranee for my empluyeet. Below to flit policy and Job site
infanrrarion,Insurance Company Name: G�"Cii-.T q-ttiGUrctr-�G�.
Policy 4 or Self-ins. Lic.N:TOW C.. Zz'�f39 1 Elf irution Date:
lob Site Address: Sb ")"-�-�`�'�s"'� ,T�(laW City/stuteizip: SGLA-tM I lV 01 ?O
Altacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failuro to secure cuverage as required under Section 2SA of`IGL c. 132 can lead to the imposition ofcriminal penalties of a
fine up to 11.300.00 and/or one-year imprisnnmenq as well as civil penalties in the form of STOP WORK ORDER and a Ima
Of up to 52i0.0a I day against file violator. Ile advi,ted that a copy of this statement may be furwurdcd to Ilia Office of
lovcstigutiuns ol'the DIA I'or insurance coverage verification.
l rto h weby certify ruttier the paint and prnalrles of perjury that the infunrlurlan provided above iv True and carrect
ii • nrtd' Data: _.
I'hnrc 1'
Official nee wdy, Do not write ire this area,to be completed by niy of town ofJivial
C try or'I'own: --- -.-, 1'ermitil.lccme.4_-. -_-
tswing,\uthurity (circle one):
1. Iloard of Ilcalth '. Ituililln., Depurhncnt 1.Cilyi Town Clerk 4. Fleetrle.tl Inspector i. Phinthing Inspector
0. Otlter
.._—__----