B-19-876 - 0013 BARTON SQUARE - Building Permit _18Z��
z The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR, MUNIUSEALITY
Building Permit Application To Construct,Repair,Renoyate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For,Official„ e Only,
(� Buildmg Permit Number: Date A h d. -',
r4 D
Building Official(Print Name) � - - Signatu e '
SECTION4:SITE INFORMATION
' 1.1 Property Address: 1.2 Assessors Map&Parcel Numbersti,
0 �V
Lla Is This an accepted street?yes no Map Number Parcel Number " 1 �
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft)y t Frontage(ft)
e
j
1.5 Building Setbacks(ft) 3>1
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provi
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❑ On site disposal system ❑
SECTION 2:-PROPERTY OWNERSHIP'
2.1 Owner'of Record:
"VIJCg �.d, I A/ O
Name( rint) City,State,ZIP
f 7t-:31Y-2fV3 W,f cam 0eOh9as7
No.and Street Telephone qrnail Address
SECTION 3:DESCRIPTION OF PROPOSED WORK•(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied ❑ Repairs(s) b Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work?:
SECTION 4:ESTIMATED.CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ O Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (14VAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
rncz\ -T-IC) Me7124"z i m A t- .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -
20
'— &A/ License Number Expitation bate
Name of eSL Holder
List CSL Type(see below)
12 661/Nf iZ S
No.and Street Type Description
2� CCUJ Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
t RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I<yoC c� w0, I Insulation
TW hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
J��TZ/ 7
HIC Registration Number 5xpiration Date '
HIC Company Name or HIC Registrant Name
No.and Street Email address
&5�: a22/gl4C Nil I've � 2�
City/Town,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 f 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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 br Authorized Agent's Name(Electronic Signature) 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
2. When substantial work 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"
t i
CITY OF Slu�I, 2vL-kSSACHUSETTS
• BUILDMG DEPARTS LNT
` 120 W ASHINGTON STREET,r FLOOR
TEL (978) 745-9595
FAX(978)740-9846
KM BEYL FY gRISCOLL
NMAYOR "I�-Io>�tAs ST.Pr> RRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO.LMIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlic;ant information Please Print Leeibly
NaMe(Busir>- ga WOrnizatioNlndividual): A4 E!f /1/66tJ(/!�
Address: /Z JJJ 4 KI i f2 S 7-
City/State/Zip: ME 1212/gliq C &IL 6&�Phone #:_ 21 -3
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ 1 a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
t loyees(full and/or part-time).' have hired the sub-contractors
2. 1 it'll a sole proprietor or partner- listed on the attached sheet.: ? ❑Remodeling
shill and have no employees These sub-contractors have S. ❑Demolition
woikin for me in an capacity. workers'comp.insurance.
g Y9. ❑Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 arin a homeowner doing all work right of exemption per MGL 1 i.❑Plumbing repairs or additions
myself No workers'comp. c. 152 '1 4 and we have no
Y: [ P ( )� 12.0 Roof repairs
insrrance required.)t employees. [No workers' 13.❑Other
comp. insurance required.)
•Any applic:nt that checks box#1 must also fill out the section below showing their workers'comperimion policy information,
t l Ganeownen who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Cuntractors.that cheek ibis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
1 am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and Job site
informadoiL
Insurance Company dame:
Policy#or Self-ins.Lic.M Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S 150.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Date: AE -/ -lam
P o #: . 977'— F /:I - 21Y 3�
Ojfcigl use only. Do not write in this area,to be completed by city or town oJjciaL
City otr'fown: Permit/License# _
issuing;Authority(circle one):
I. Board of llealth 2.Building Department 3.City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Othrr
Contatit Person: Phone#'
i
A �
r r CITY OF SALEM, MASSAGIUSE M
BUILDING DEPARTMENT
120 WASHINGTON STREET,3RD FLOOR
TEL.(978)745-9595
KDOERLEYDRISODLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING 0CMNIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition & renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris,
and the provisions of MGL c40,S54;Building Permit#
is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,S150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applic t
(today's date)