7 BARNES RD - BUILDING INSPECTION FCJC�s The Commonwealth of Massachusetts— Board of Building Regulations and Standardsmemo
Town of
Massachusetts State Building Code, 780 CMR, 7`"edition Building Dept
✓� J Building Permit Application To Construct, Repair, Renovate Or Demolish a �
One-or Two-Familt Dwelling
This Section For Official Use Only
Building Permit Num Date Applied:
Signature:
Building Commissioner/inspector of Buildings Date
SECTION 1:SITE INFORMATION
! 1.1 Property Address: j�� 1.2 Assessors Map& Parcel Numbers
.-2
1.I s 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 a Provided
1.6 Water Supply:(M.G.L c.40,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public Private❑ — Municipal On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1,.,Ownert of Reco d:
A'!_1/'L/ P rlNb LEIS �9T J �
Name(Print) p Address for Service: �y
Signature V ���—�--� Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction V0 Existing Building Owncr-Occupied Repairs(s) ❑ I Alteration(s) ❑ Addition
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': —=G _Li 619
;k-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlchd Use Only
Labor and Materials)
1. Building b G S 0�, r?U I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost)(Item b)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
S. .Mechanical (Fire S
Suppression) Total All Fees: S
Check No. _Check Amount: Cash Amount:
5. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due!
7
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
• Lernsc Number Expiration Date
Ngme of CSL- Hp Wer List CSL Type(see below)
T Description
Address
U Unrestricted tup to 35,000 Cu. Ft.)
Signature R Restricted 1&2 Family Dwelling
M Masonry Only
RCResidential Roofin 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. 152.1 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 ..........O 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
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
� i
as Owner or Authorized Agent hereby declare
that the statem is and i 6 formation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Prim Name
Signature of Owner or Authorized Agent Date
Signed under the pains and enalties of perjury)
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 I I O.R6 and 110.115, respectively.
2. When substantial work is planned, provide the information below: j
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" �
1
'M
} MM�nT-d
I I
a
-1b M
all
i
S
a
N
Q3 N;
i
r
`i
,i
I
l
I
� 1 t
0
-74
ZF D$FF�J23 rk
CITY OF SALEM
y
r ( PUBLIC PROPRERTY
DEPARTMENT
II I' '/'N '49.ISVS ♦ I %C: 'i'8 '4_'6L,
Construction Debris Disposal Affidavit
(rc(luired lirr all demolition and renovation work)
In accurdance %Kith the sixth edition ofthe State Building Code, 780 CNIR section 111.5
Debris, and the provisions of fb1GL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
/y
(name of hauiler)
Ilse debris will be disposed of in
(name of facility)
(address u(facilily)
i�naiwc of panru�t .yiphrant
,Isle
CITY OF S UE.M
PUBLIC PROPERTY
DEPARTMENT
K, y fy rvwvv i
%IAVM QD Wwuru"TON STREET•SuFx M. ASLU34LssnS 01970
TEL V..L745-9S"0 F.%X.970.740.9&W
HOMEOWNER LICENSE EXEIMMON
Please Print
Date — 1- 6-7
Job Location 7 0.5' S_ Ed , Sc� jam r Q
Home Owner Address '2 Pxn-r15---is RA S c he rn sq
Home Owner Telephone
Proud Mailing Address '7 P)a r+� a /o , , ✓�
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
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 requir ents.
HOMEOWNERS SIGNAMW %
APPROVAL OF BUILDING NSPECTOR
See other side for state code
i