12 BARSTOW ST - BPA-16-953 REPLACE 20 WINDOWS ,
The Commonwealth of Massachusetts
�— Board of BuildingRegulations and Standards F; -r CITY OF
µ, SALEM
Massachusetts State Building Code, 780.CM$ f �� tig\`I +
tiaf Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
1 ^ One-or Two-Family Dwelling Ha Ib AUG 2 S P 12: 19
This Section For Official Use Only
Building Permit Number: ate Applied: / /
_ 1 M / / ,
I Building Official(Print Name) SignatureV Date'
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Imo- t X61
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq m 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'
Owner'of Rrd:
IIIrA rl 1vP r Y1vC-*) N1
Name(Print) City,State,ZIP
�1 �TVLI � rSC�jl ) ��YPo �' _ ��h •���• 11�.� e MQ fYft �-:
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other I Specify:
f Descrippon of Proposed W rkz:
67() 4�cIOJ4:4 All
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. 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 $
Suppression) Total All Fees: $
_ Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ���' ❑Paid in Full ❑Outstanding Balance Due:
CYYf:�%LCg:-0 Ct Z
SECTION 5: CONSTRUCTION SERVICES
5.1/1 Construction Supervisor License(CSL)
L(_0!G G 7 - r�
4 G �����d 1� � License Number
1 Q! o 7� Expi tion ate
ame of CSL Holder n �n
List CSL Type(see below)
TS ��-'" 't `r1-f'-��� n I "t G Type Description
No.and Street
I U Unrestricted(Buildings up to 35,000 cu.ft)
'AA AA-i ( L �� (7��� R Restricted 1&2 FamilyDwelling
wn,wn, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
` SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
55.2 egistered Home Improvement Contractor,(HIC) I Q O �n3q a
(6 ' )( k e c) _D T �✓ l t�-� S � HIC Registration Number Ex rati n Date
C Company Name�or"HIC Registrant N�e �J A ^7
o and Street Email address �yyt
YL
Cit / own, State,ZIP 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 A
1, as Owner of the subject property,hereby authorize & U�1 � 4 � (� �� r. -
to act on my behalf, in all matters relative to work authorized by this building permit application�—
Pr t Ow is Name(Electronic Signature) Dat
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained ' is plication is true and ace to to the best of my knowledge and understanding.
mt Owner's o Au ori d g a (Electronic Signature) ate
NOTES:
L 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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.inass.gov/dps
2. When substantial w�rk is planned, provide the information below:
Total floor 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"