3 FREEMAN RD - BUILDING INSPECTIONr
w
the Commonwealth of Massachusetts JNSPECTIONAL ERV ySOF
Board of Building Regulations and Standar s SALEM
Massachusetts State Building Code, 780 CMR R eV qir 2011
Building Permit Application To Construct, Repair, Renovate r mo ish a
One-or Tivo-Family Dwelling
This Section For Offi ial Use Only
Building Permit Number: Date Applied.
Building 0111cial(Print Name) Sipature - Date
SECTION 1:SITE INFORtNIAT10N
I.I. Property Address: 1.2 Assessors plop&Parcel Numbers
Frc / M I L__02Qt()
I.I a Is this an accepted street?yes no Map Number Parcel Numlxr
1.3 Zoning Information: I.J Property Dimensions.
Zuning District Propose)Use Lot Area(sq R) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
X
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: I.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Public❑ Private Check if es❑ P y
SECTION2: PROPERTY OWNERSHIP!
2.1 Ownert of Record:
1 n e,-Ain I ewe� 1✓� A d 19��
N meme—�t) City,State,ZIP - l
No and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildinglfl Owner-Occupied OafRepairs(.) O Altemtion(s) ❑ Addition (3
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building SU
i. Building Permit Fee:$ Indicate how fee is determined:
�.Electrical $ 2, �zJU, ❑Standard City/Town Application Fee
- ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing $ J,U 2`s Qther Fees: $
4.61cchanical (IIVAC) $ &Va r= List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
�. Check No._Check Amount: Caslt Amount:
6.'rutal Project Cost: rLIKO-0 — ❑Paid in Full ❑Outstanding Balance Due:
CIA
C{ L� L—(EE:O LA) tLL V) , U .
SECTION 5: CONS'rRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
- License Number Expiration Date
Name ofCSL Mulder
- List CSL'rype(see below)
No.and Street TYpr ; 'j Description
U Unrestricted(Buildings tip-to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Imasomy
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.mid Street Email address
-City./Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.i 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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7u:OWNER AUTHORIZATION,TO BE COMPLETED WHEN'
OWNERIS AGENTOR CONTRACTORAPPLIES FOR BUILDING PERMIT`
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nance(Electronic Signature) Date
SECTION 7b:OWNERI ORAUTHORIZED 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.
/f- 9-/s
Print Owner's or Aulhonzed Agent's Name(Electronic Signature) Dale
NOTES:
I. 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 NI.G.L.c. 1 d2A.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 ivww.nlass.eov:'dus
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. R.) � .(including garage,finished basementtattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
rypeofcoolingsystem Enclosed Open
1. "Total Project Square Footage'may be substituted tor-rotai Project Cost"
,/ub
°k CITY OF SALEM, MASSAaiUSETTS
R.
BUILDING DEPARTMENT
120 WASHINGTON STREET,311D FLOOR
�'rtvso TEL. (978) 745-9595
FAX(978) 740-9846
KIN BERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOROF PUBLIC PROPERTY/BUILDING COMbIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date April `I'I't-� DrwlS \
Job Location 3 fY W%G-n Q 1� ySg�znw� c (�m
Home Owner Address { CV`2e.Y�V\ `°� �nI '>A �41M /V ,*4 D lc'7r)
Present Mailing Address JQ Vg_ A-,-, Ab,mQ .
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner' shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
QTY OF SALEM, MASSAmUSE M
BUIIDINGDEPARTMENT
\ _ 120WASHNGTONSTREET,3'0FLOOR
nL.(978)745-9595
KH&ERLEYDRISWU FAX(978)740-9846
MAYOR THomm ST PIERRB
DIRECTOR OF PUBIJCPROPERTY/BUIIDING OCAWSSIONM
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 MR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit#
is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
� S
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
ignature of applicant
��f s
Date