28 BARNES RD - BUILDING INSPECTION The Commonwealth of Massachusetts
� Hoard of Building Regulations and Standards CITY
�u rll Massachusetts State Building Code, 780 CMR, 7ib edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate (Demolish a /, '008
One-or Two-F roily Dwelling
This Sect/on tor Official Use 094
Building Permit Num r.�f Di4ylApplie .
Signature: r/�IT;h / 113p,
Building Commissioner/Inspector of Buil ' s Date
/ SECTI N 1: ITE INFORMATION
X 1.1 a Prope Address:� 1.2 Assessors Map& Parcel Numbers
uR Qd -
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
7_oning District Proposed Use Lot Area(sq 11) Frontage(tl)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal[3On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
?iefa�d f3don9/io a8 des Ra/
Name(Print) —� Address for Service:
Signatu e7 I/V Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
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 S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Su ression
4 Check No._Check Amount: Cash Amount:
5'
6.Total Project Cost: S U a(� ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
4
License Number Expiration Date
Name of CSL-I lulder
List CSL'I'rpe(see below)
Address ti
Description
li Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&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)
I 11 Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
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
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
X I, 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 I 10.116 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"
CITY OF SALE.%vi
PUBLIC PROPERTY
DEPARTMENT
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ra.971 74$.9S"•F.%x r.t7+o.nw
HOMEOWNER LICENSE EXEMPTION
Flew trlrat
Date
Job Location fScr�dtes R d
Home Owner Address Same-
Home
ameHome Owner Telephone 9 79 479 3 30 3
Present Mailing Address Same-
no
SamP_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
Persons) who owns a parcel of land on which he/she resides or intends to redid@, 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 O®cid,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 bylaws 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 requirements.
HOMEOWNERS SIGNATLRE A;k
APPROVAL OF BUILDING INSPECTOR u�
See other side for state code
CITY OF S�U.&NI, NL-kssACHCSETTS
l3UMDLNG DEP\RT.%i&NT
' 130 WASHNGTON STXM.Y°FLOOR
TEL (978)745-9595
FAX(978) 740.9846
g I.%(BE RY DRLSCOLL
2MAYOR THO.ues ST.Ptt M
DIRECTOR OF PCBLIc PROPERTY/Kamt::tG CMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5
Debris, and the provisions of MGL c 40, 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 disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(ass of facility)
a � _
siga re f permit applicant
date
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