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78-86 FREEDOM HOLW - BUILDING INSPECTION - wa i' The Commonwealth of Massachusetts CITY Board of Building Regulations and Standards Massachusetts State Building Code,780 CMR,7a'edition OF SALEM - Revised January Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling jlitsSfi4ntbflct... ebly .ar Bui1¢tng Perinitt"Inm1Y " ate;4letd: Buil;iingCbtpmtss<onerl It`e, � d t *°��a� ,. 1.1 Pro dress //P// .2 Assessors Map&Parcel Numbers 13 7 1,--56 l.la Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District, Proposed Use - Lot Area(sq ft) - Frontage(R) 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 Sysi:em: Zone: _, Outside Flood Zone? Municipal❑ On site disrwsal system ❑ Public❑ Private❑ Check if yes❑ ; -.. $ L TTON Z: PRQI 4}�N2SHl 2.1 Owner'yf Record: 1/,`- C� __ e ?/'r/n , "-" Name(Print) Address for Service: 7 GG Sign Telephone w SECTIdN3 b,E CRiP >ON(SI Rn pSEDs'VOIW 4000*11 that aPply) New Construction❑ Existidg Building❑ Owner-Occupied ❑ Renaits(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1Accessory Bldg. ❑ Number of Units _ I Other O Specify: Brief Description of Proposed Work-: %�/� _ per --�c,a ° K - SECTION 4ewSTEMATRIKOFIS!W—YICTION.COSTS TLa stimaiigd Costs: pfticiahUse only Item b(,tzd Materials1.Buildin 1 Bmi ! lyermif Fee $ Indicate how€ee is determined: d CtLy/Tc Wfi ApplloationTee g ;�--- "'�tStP7tdN 2.Electrical ®T©tTPrbj€t)t`CR¢13;(Ifem b)xmultiplier x 3.Plumbing $ Aq _ 4.Mechanical (H,AC) $-------------- R 5.Mechanical (Fire $ Total11)=)ges Y " Su ression "h )10; O�eck Amount: Cash Amount: 6.Total Project Cost: $ a o (f V ;,p Patd m i ull ',0 Outstanding Balance Due: .. lel . Lt r " SECTIbN=5�r2b1VyS't��1'Gix�0�1� EA�!ICES , 5.1 Licensed Construction Supervisor(CSL) /1� L License Number Expiration Date Name off CSL-Holder V�- List CSL Type(see below) V Address ° U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwellin Signature - p� M MTs-onry Onl RC - Residential Roofing Coverin Telephone WS. Residential Window and Sidin SF Residential Solid Fuel Buming Appliance Installation D Residential Demolition 5.2 Re 'stere H e I provement ContractortIC) jD �_ HIC Coryrgan Name or C Red t me G. Registration Number Address c-� Q G ` ,7 ` `. J _ c .f(r�12 Expiration Date Signature .Y �G+�--e-,' Telephone SECTION 6 WORKERS'COMPENSATIOIN IIIIRANCE 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 No .. 0 jSECTION 7i-,O N1 ER AUTHU ATIOI±1 BE( RL DtWHEN , :; �ON')!FER'S=AGENT.OR C�N')"RAGTOR I1I'P�iI�SfFOR BUI�nDIN`is PER1�I' . as Owner of the subject property hereby authorize ."`�F—� .�� to act on my behalf,in all matters relative to wor authorizeo)�y is building permit application. y_ Sign re of r Date . SETI©N 76,O�VNERy Q„ < O �AC Fl<JT IIECLARATION as Owner or Authorized Agent hereby declare that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and behalf. c� l Print Name ///fin i L z"t Signature of O—`caner or Authorized Agent Dale - Si ned under the pains and penalnes of er u ... NO'�ES 77 1. An Owner who obtains a building permit w 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 I10.R6 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (inclhding 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 i= 3. "Total Project Square Footage"maybe substituted for"Total Project Cost"