54 BARSTOW ST - BPA-16-594 REMOVE/REPLACE PORCH Lf
The Commonwealth of Massachusetts
Board of Building Regulations^. CITY OF
SALEMassachusetts State Building Code Off lf i Revisedd Marf20!!
Building Permit Application To Construct,` �Ve�s atee Or Demolish a a
One-or Two-Familylme 12
This Section For Official Use Only
Building Permit Number: Da pplied:
/4...
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Addre/s�s: 1.2 Assessors Map&Parcel Numbers
I� L la 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 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 yes13
SECTION 2: PROPERTY OWNERSHIP'
1 Owner'of
- G-Q ^t 11�f l J(1-10
Name(Print) City,State,ZIP 0
�-t
5410[nl , q7S)� 1 77 dci}�, OcRff('avmaI G vi
No.and Street Te ephone Email Address �—
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑T Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : _oy` .r � r ems'l�1 :9LJr-/4/
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials 60
1.Building $ $ 1. 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 $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Five $
Suppression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ g yj ❑Paid in Full ❑Outstanding Balance Due:
SEVJb G. � .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
G CCj .JLU
Ho "O 04? I—bv,nM License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
10 wo ce64-er Idi
No.and Street Type Description
Q� nY l,� �I q U Unrestricted(Buildings u to 35,000 cu.ft.
d� R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
9*$-yq1 _ yyq y��/ �0 � 7g;�, I 1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) «56 S z
/"(orta D� HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name /
No.anStreet Email
address
cr
ThowS9 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
I,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.
fi a�, �JPp I ��fsrAh A4 8016
Print Owner's NAnw(ElectronivS+gnaturej / Date
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 in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Ag ec mic rgna ur Date
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 can be found at
www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/dQs
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) 9S (including garage,finished basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfibaths
Type of heating system Number of decks/porches 1
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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