16 BARCELONA AVE - WOOD STOVE PERMIT The Commonwealth of Massachusetts
(� <µ Board of Building Regulations and Standards Town of
1 �\ k'; Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
1! One- or Tu o-Fu urfs Bme!(ing
.Q� This Sept'
For OlTicial se Only
�y Building Permit Numb :q Dik Appllted:
Signature: ^
Building Commissioner/ or of wilding ' 1 Date
SEC ON l:Bt INFORMATION
1.1 Property Addres : 1.2 Assessors Map& Parcel Numbers
a,2cea�vA
1.1 a 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 fl) Frontage(ft)
t.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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system E3Public❑ Private❑ Check ifyes13 P P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /
C! i2 ,T- �tdF)� S�/ // QR/1cP/W14 do-,yv£
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Workz:
Pea m,r SToyt� C P✓eOelSl iN5 �9//a /�rI'7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S j J/ f 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
r
• License Number Expiration Date
Name of CSL-lipkler List CSL Type(see below)
Address TypeZ
De i uon
U Unrestricted(u 30-3' ,000 Cu. Ft.)
Signature R I Restricted-l-&2 Family Dwelling
M I Masonfy Only
RC Residential Roofing Covering
TelephoneWS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
i
HIC Company Name or HIC Regis rant Name Regis re ton Number
Address
/ Expiration Date
Signature T Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6))
Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide
this affidavit will result in the denial a Issuance of the building permit.
Signed Affidavit Attached? Yes .......... 0 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.
Signature of Owner Date
TION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,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
fff behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I I O.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"
+ i
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KII�S�..w NwVl11
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SALaK StASA00.MTIS 01970
7pi 97L74S•9S"•FAX 97&74&96"
HOMEOWNER LICENSE EXEMMON
Please"Itt
Date p
Job Location f 6; &Il C e40wx
Home Owner Address
Home Owner Telephone c 4 ., r
Present Mailing Address I
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.
DEFINITION OF HOMEOWNER
Persons)who owns a parcel of land on which he/she resides or intends to reside, on
which them 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 fora 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 tr
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code