8 FRIEND ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham
Building Dept
Building Permit A lication Construct, Repair, Renovate Or Demolish a 413-596-2800
ne-or Tit -Family Divelling Ext 118
T ' Sec ion For Offici 1 Use Only
Building Permit r: Da pplied: (/
Signature: ItY.1C D
Bw n Commissioner/I for of B ngs Date
--SECTION 1:SITE INFORMATION
LI PropY Ad; : 1.2 Assessors Map& Parcel Numbers
I.1 a Its 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(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 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❑
SECTION 2: PROPERTY OWNERSHIP'
1 ,0^w/ner,ofReco dG� lR �aCPel�✓�/ B4 S`lc.ry M.40/970
Na/ (Print) Address for Service:
i/9717ys 1/3 Y L/
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed WorkZ: Pd L. AWD R-e ic4V
(�RM�IG-c2 f�L�,nr�lvG S>/v�K- r� )Ll.lrtis
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder
' List CSL Type(sec below)
Address Type Description
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted IA.2 Family Dwelling
Signature M Masonry Only _
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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 .
as Owner of the subject proacrty hereby
authorize to act on my behalf, in all matters
relative t ork authorized by this
this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name _
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury) _
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 M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations t IO.R6 and I IO.RS, 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"may be substituted for"Total Project Cost"
CITY OF SALE.LI
PUBLIC PROPERTY
DEPARTMENT
Vwroa 13t1 WAwlraT(W S VX=•S.uFx S/wnAart:stM 01970
TEL 97}74S.9S" 0 FAL 976-7.104&M
HOMEOWNER LICENSE EXEMPTION
Please Print
Data �-16-0 - -
Job Location l/ jr,
Home Owner Address �`2 e S C�^�/ _ p2_ g Lpiy A14
Home Owner Telephone 1 9 7d 7VI 'f3 y N c-1/1 j 7j-a u o a /y
Present Mailing Address
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 who,does not possess a license,provided that the owner acts as supervisor.
DEFINMON 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 dwellin& 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requireplVnts.
HOMEOWNERS SIGNATUME
APPROVAL OF BUILDING DiSPECTOR --
See other side for state code
CITY OF SALEM
PUBLIC. PROPRERTY
DEPAIZ"I'MENT
III 'I'\.'{i. 144� I \\'. 'i79.`J_ ';i41,
Construction Debris Disposal Affidavit
(required for all demolition and work)
Tate Building Code, 7SO C NIR section 1 1 1.5
In accordance
\%ill' the sixth edition of the J b
Dcbi is, and the provisions of MGL e 40, S 54;
Building Hermit it is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debr' Will be transported by:
Inamc of hauler)
I he debris will be disposed of in
t nulnr of taeilny)
I�Iddrr�s ur I�cllitvl
aenatwc �>Y prnnit upphe unt
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