3 FREEMAN RD - BUILDING INSPECTION (3) C)
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
/ Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For icial Use Only
Building Permit Number: ate Applied:
Building Official(Print Name) Signa Dale
SECTION 1:SITE INFORMATIO
1.1 PFperty.Ad re�s�A� 1 ��j 1.2 Assessors Map&Parcel Numbers
Lia is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District 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 a 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❑
s SECTION 2: PROPERTY OWNERSHIP'
2.1 Own of Record:
Name(Print) <- \ > ity,State,ZIP
No.and Street ,� ` a i - Telephone Email Address
I SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Rxisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify: •.
Brief Description of Proposed t7tT
B � G its
U
0,
SECTION 4:ESTIMATED CONSTRUCTI N COSTS 4.
Item Estimated Costs: Official Use Only
La r and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Stanrdard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (BVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$ ,
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $�]��,{j jjO 0 Paid in Full 0 Outstanding Balance Due:
' SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Xr,,�-f3 3
IM! !t 1 1 lY)re L it License Nuaber Expi lion Date
me of CSL Holder
List CSL Type(see below)
4/, ,de k4
No.and Street A (} ` a Type Description
�7 tK'L', U Unrestricted(Buildingsu to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
G�9'6G.-0931 Jo r)uA I x �Y4 SF Solid Fuel Burning Appliances
/1,pp r Ld/v1 I Insulation I
Telephone Email address D Demolition
5.2 Pe2istered Ho_mel Improvement Contractor(HIC) / / 0 5 p'a61
��j'Cap�['yD1V 5 7 /Z.IIC ! O arNe h H16 C(aRegistration Number Exp' lion Date
1 Tp�}'Y!
No.and Strugtr,, Email address
City/Town,State,ZIP 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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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.
Print Owner's Name(Electronic Signature) Date
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 true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/des
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
CITY OE S.l -&Nr, NEMACHUSETTS
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UJtBFAL&Y ORLSCtJLL FAX(973) 11Q9&W
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Construction Debris Disposal Atfidavit
(required for all demolition and renovation work)
fn accordance with the sixth edition orthe State Building Code, 730 CMR section 1 I I.1
Debris, and the provisions of,MGL a 40, S 14;
Building Permit At is issued with the condition that the debris resulting from
this work shall be
S 110A. disposed of in a properly licemed wrote disposal facility as donned by ,XIGL o
1 11,
The debris will be transported by:
(nume of hauler)
The debris will be disposed of in :
(nuns of daluy)
44-1(Jddrta of rJrilty)
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'ue
`�. C['[Y OF S,U-F-,,[I NWSACHUSEITS
BUILDING DEP. RrMENT
rl') ,�ti `� r�•� 120 W.SSHLNGTON STREET, 3ta FLOUR
FLIC(97,9) 7$0.99't6
:<jN((JEIiLEY DRISCOLL
A'AYO'Z DIONN3ST.PIFURAZ
DIRECTOROtr PULIC PROPERTY/312RD(NG COSISIISSIONER
Workers' Compensation fnsurance AITTdavit: Builders/ContractorvJElectricians/Plumbers
Ii f Meant Inform-Ann lcaxe Print Leaibf
V(Ilnd tnllrllle,Yt)rgaaNlllenrintflrllhlal)• y NGe � 6'
Address: !:X 12� !//le PAQ3r ng
CitylStatc/Zip: / PhoneN:791 ZZO Sf� g
Are you in umployer:r Check the appropriate bait [:a
prnjact(required):
Ii(1] I aft a amployerwith 4, ❑ I arrl a general contractor and I
employees(R,u,„d/or part-time).• have hired the subcontractorsow construction
2.Cl I am a gala proprietor or partner• listed on the attaehed ahect t emodeling
.:hip and have no employees Thew sub-contractors have emolitionworking forma in anycapacity. warkdrs'camp,ira inns, iiding addition(No workers'comp,insurance j• ❑ We ate a enrrnriltian and itsnyuircJ.J officers have exercised their eelrical 'paits or additions1aIn a homeowner doing all work right orexdtnptiun per MGC mbing repairs or uddiliensmyself. (No workers'sump, c. 132, 11(4),and we hil no of ropairainsurance requited.) t empluyeet.[No workers' her
cutup. insurance requited.)
;.\Ire applh:en dW dhriiiYr bos of mwl 31W all out the weliva bufew showins(hair eaYm'carnprnudud polity mOnlveaem.
I hrneuwlwv who.ulrndl this rlitdsvit indtcatne ihry,are Jaime nit,wre and Ihm hire tw4ide eanlreerme mtul rohmil a new alnJaril indfaine wok:r•-mnvlun ihsf chuiCk this box mull anachW ift.Idailivrra.h.1'huwine the nwnu a(rho mkr'entrreture and Ihafr,warkm'wrnp,pellty inrarrruaen.
/urn an anpluyrr that pruvlJ/nX workdn'cumpenmNun Inxwunu�ar my rmpluydrt: Maw Is lhlpo//ry and fob lire
irr�urnru!lnrr,
In.ururnc Company Name: b ,r'�__�.t!/-j
Policy 4 or Selr-ins. Lio; d: Expirution Data:
Jub Sild Address: , �?rse�1,�>7 R� Cilyi State/2ip: �l ��"w ZO
.\nacb s copy of the workdn'coin pentatlaa pulley de 'It"Ilid„page(Showing the Polley number and sipinllon data).
Failuru to wcurc coverage as required under.Section 21.\or.VGL c. 152 can i.ad to the imposition of criminal penalties era
tine ip to i I,5C0.00 und/ur one-year imprisnnmcnt, as well as civil penillius in this torrn of a STOP WORK ORDER and a fine
,!(till to S210.00 a Jay itJainsl dte violator. He advised that a copy of this alafemvni may be furwar&J to the Oflicd of
Ll rr.ligaliUnsof the nL\ for infunnCe atvernge vcniicatiun.
/Ile lrrrrby verti/y under dlr pubis and prnulNe.r,1perjury thus the injuroo1UNarr provided UGuvd it rru!•IrrJ a'U//eCC
<'.LIhir...
tl//resin u,e wily. /l,r ter writs in rhLr urro, to'r runryldbed by Lily Ur tUron"JI1,r'U!
City or ibvn: __.. .. .__ i'crmitil.lca'nse 1
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