B-17-305 - 0014 BARR STREET - Building Permit r ,by
The Commonwealth of Massachusetts 'VIL
Board of Building Regulations an CITY CITY OF
Massachusetts State Building Cod , �✓ � SALEM
P 5 I; Revised Mar 2011
Building Permit Application To Construct;Repair,Renovate Or Demolish a
n One-or Two-Family Dwelling
U 1 <This Sect►oii F6eamctai Ilse Onl s
Building Permit Number Date A t d
B ST
u ial aldmg Offic (Pent Name) Signature
I ate
SECTION 1 SITE"INFORMATID�i ,
1.1 P perty Address: 1.2 sessors Map&Parcel Numbers
►q4 13P t o s+
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 oning Information: 1.4 operty 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 yes❑
SECTION 2: PROPERTX QWNERSI�Pt
2.1 O er'of Record:
tJJ•llHuh. i+ '� r�rar„ ItZ Sgl,I,, ry0S<, 6 ► J
Name(Print) City,State,ZIP
L) I�)ArY �j} -MS1rS l21I NC-�'
No.and Street Telephone Email Address
SECTION 3:,DESCRIPTION.OF PR:POSED.WORK (checkall that apply)'
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ElAlteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
.�� Brief Description of Proposed Work2: / YV f Ck )Ct,.. !fir pyr% ij Pool
SECTION 4;.ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use O nIy
Labor and Materials
1.Building $ 1 Building Permit Fee $ r Indicate how fee is determuied
2.Electrical $ ❑Standard City/I own Application Fee'
Q Total Protect Costa(Item 6)x cnultipher x
3.Plumbing $ .2. Other Fees:"$
4.Mechanical (HVAC) $ List
5.Mechanical (Fire
Su ression $ Total All Fees:
Check No. Check Amount ` . Cash Amount
6.T tal Project Cost: $a S d Q u ❑paid in Full ❑Outstandmg Balance.Due. .
s 3 rf
° i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Licetts.e(CSL)
License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
Type Description .
No.paid Street >
U Unrestricted(Buildings tip to 35,000 cu. tt.
R Restricted t&2 Farnily Dwelling
City/town,State,ZIP NI h4asonry
RC Roolinst Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFF!DAV!T(M:G,L:.c.151. 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 Istuance of the building permit.
Signed Affidavit Attached? Yes..........❑ No...........C3
SECTION 70-.OWNER AUTHORIViTION TO B&COMPLETED.WHEN."
OWNER'S AGENT OR CONTRACTOR APPLIES:FOR'BUILDING.PERNII'i'
1,as Owner of the subject property,hereby authorize -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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.
�r IAt� i�t�rnat`>
Print Owner's Dat
r � i
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 nut have access to the arbitration
program or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
w%Yw.mass.eov;'oca Information on the Construction Supervisor License can be found at+w%v w.mass.sov/dns .
2. When substantial work is planned,provide the information below:
"rota) fluor area(sq. ft.) .(including garage,finished basement/attics,decks or porch)
Gross living area(sq.11.) 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. "I'otal Project Square Footage"may be substituted for"Total Project Cost"