93-98 FREEDOM HOLW - BUILDING INSPECTION 1� The Commonwealth of Massachusetts
1 Board of Building Regulations and Standards CITY
000 Massachusetts State Building Code,780 CMR, 7a edition OF SALEM
Revised nuary
Building Permit Application To Construct,Repair,Renovate Or Dem ' h a 1, 008
One-or 71vo-Family Dwelling
. ;, •' � "`l"k)>Ss-a�cHo�!`��r 0�9�.., $�,C?djY
L;nrldrnghgrru Numbed; batC
Stgnature
Bwldmg Ccjinmrssronerl Tns}fegto7of vilest � "n`` a to
1.1 P% A bras: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes__c_,,,�no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District. Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
% SECIQl ;$ P 3RSIi(Pt;
2.1 Owner'-of Record: r
z t/ /7> �� —%t� C CCNcisc//GGGJ
Name(Prior) iA dress for Service:
Signature Telephone
S1 T10N 3s DE RIP k)l x P>*x. mO m.S)8 ?Wdi�iz?(c)tet)c alt 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':
SECTION 4:ESIIIIIAT: ONS {IJl TIQ1V BUSTS
Estimated Costs:
Item Labor and Materials
1.Building $ 1 B4rlclmg knppr it Pee $ . —Indicate how fee is determined:
2.Electrical $ iI Staprlard CttyfFoivn"Applib non,$ee
4 To"ta P olecEKst3,(s1tc 6j$tlthplrar� �x
3.Plumbing
4.Mechanical (HVAC) $ tat + w
5.Mechanical (Fire n
Suppression $ Tota�A. Fees
6.Total Project Cost: $
CheckP Check Amolurt: Cash Amount:
6 ��• p P.atdya Frlll, ❑ Outs(anding$alance Due:
r
77
_ 9W11C{>Nu ti 5m aLIt G S
5.1 Licensed Construction Supervisor(CSL)
M ( , P L �\�s°�� License Number Expiration Date
Name of CSL-Holder _ List CSL Type(see below)
ltid Y Vd7 l�DUd A I)`e05
Address r+ - -U- Unrestricted u to 35,000 Cu.Ft.
� ` R Restricted 1&2 Family Dwelling
Signature r7n� M Masonry Only
13 - - RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burninp Appliance Installation
D Residential Demolition
5.2 Re 'stein 1 H e I tprovement Contragt�(FIIC) �D
HIC Copan /Name or C Red nt me G. G' Registration Number
Address - `7 — -SS/D
G./"JI 0 L �� 7�. ,�T3(2 Expiration Date
Signature / Telephone
SECIt7N6 WORT{ERS7QIVIPNSgTY 1�1, ?1}L1�TC" AFFIDAIT(M.G.L• .e.152.Q25C(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...........❑
5Et`TI()N'7a U�t GER AI) H{F"'i''C A -
OWNER'S:AGENT,:O1f CONT1?;i�CT R'APP�S,3br01E T?!FsIt1yI17'�,* •'
I '�9 4^5 Ca S 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.
Si nature of Owner Date
S CTION771 ,171 t l r+f Z, i k1 I ltl DE t�R 1 ,'kION'.
C lzw p p 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.
L �
Print Name Aqw
Signature of Owner or Authorized Agent Date
Sied under the Sand enalties
C N,OT
I An Owner who obtains a buildingpermit to do his/her own work,
p 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 importantinformation on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I l0.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"maybe substituted for"Total Project Cost"