10 BARCELONA AVENUE - BUILDING JACKET I Esselte
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William H. Munroe I
One Salem Gi^een
745-0213 December 19, 1985
Mr. & Mrs. Andrew Mitchell
10 Barcelona Ave.
Salem, Ma.
RE: Beauty Salon, 10 Barcelona Ave.
Dear Mr. & Mrs. Mitchell,
Due to a discrepancy in our files the notice to cease and desist the.
operation of your Beauty Salon was in error.
Our files now reflect the decision of the Board of Appeals for a Special
Permit to operate a Beauty Salon on the premises.
we are sorry for any inconvenience this may have caused for you.
Resp ctfu yo s,
Edaquiki',
Asst. Building Inspector
EJP/hmc
c.c. Mr. Louis C. Mroz, Administrative Aide
Mrs. Josephine Fusco, City Clerk
Mr, Leonard Fr. O'Leary, Councillor
L�
LtII#tt XII PTft� ''1�[7�P c�T�TttPYtf
'%'���'`�� �LTTIaTYt$ �P�IiLTfT`IPYCf
William H. Munroe
One Salem Green
745-0213 December 17, 1985
Mr. & Mrs, Andrew Mitchell
10 Barcelona Ave.
Salem, Ma.
RE: Beauty Salon, 10 Barcelona Ave.
Dear Mr. & Mrs, Mitchell,
It has been brought to the attention of this Department that you are °
operating a business (Beauty Salon) in your home. This is in direct violation
of the Zoning Ordinance of the City of Salem, Section 5; A-1, not a "Permitted
Use" .
You are hereby ordered to cease and desist the operation of this business
and to remove the sign indicating such a business exists, -
If you desire relief of .this order }you may apply for same through the
Board of Appeals.
Respectful our ,
�h
EdgaPaquin
Asst. ding Spector
•EJP/hmc
c.c. Mr. Louis Mroz, Administrative Aide
Mrs. Josephine Fusco, City Clerk
Councillor, Leonard F. O'Leary
n
0 SENDER: Completc+kms 1,2,3 and 4.
o Put your address in the"RETURN TO"space on the
3 reverse side. Failure to do this will prevent this card from
W being returned to you.The return receipt fee will arovlda
you the name of the person delivered to and thadata of
delivery. For additional fees the following services are
available.Consult postmaster for fees and check box(es)
c
.Z for services)requested.
W
1. Show to whom,data and address of delivery.
2. ❑ Restricted Delivery.
3 Article Addressed to
Mr. & Mrs. Andrew Mitchell
10 Barcelona Ave.
Salem, Ma. 01970
5
4. Type of Service: Article Number C
N
❑ Registered ❑ Insured
® Certified ❑ COD P 154 217 419
❑ Express Mail
Always obtain signature of addresseeQagent and
DATE DELIVERED.
G 5 Signature—Addressee
3 X
y 6 Sgn2yure- A ant C,
7. to of Delivery /+
2 S Addressee's Addre70NLYf regwv a
m
v
H
UNITED STATES POSTAL SERVICE
OFMAL BUSINESS
PNM
SENDER INSTRUCTIONS &
your name,address,and ZIP Code in the
space below.
• Complete kerns 7,2,8,and 4 on the reverse.
• Attach to front of amide R Space permits, PENALTY FOR PRIVATE
otherwise affix to back of article. / usE mw
• EMlorasartide"Return Receipt Requested"
htl
,=article
number.
RETURN
TO Building Department t
(Neme of Sender) -
(lila Salam CraaTl
(No.and Street,Apt,Suite,P.O.Box or R.D. No.) `
Salem, Ma. 01970
(City,State,and ZIP Code)
P 154 217 419
i
RECEIPT FOR CERTIFIED MAIL
NO INSURANCE COVERAGE PROVIDED
NOT FOR INTERNATIONAL MAIL
(See Reverse)
a Sentto
1� Mr. & Mrs. Andrew Mitchel
a Street ad o.
10NBarcelona Ave.
P.O.,State and ZIP Code
O O
uSAlem, Ma
O Postage - $ 0
6 K
n
♦ Certified Fee 1.67
O
Special Delivery Fee �
Restricted Delivery Fee
C
N
Return Receipt Showing
to whom and Date Delivered
"W Return receipt showing to whom,
mDate,and Address of Delivery
oTOTAL Postage and Fees $1.67
LL
oPostmark or Date
E
December 17, 1985
0
ILL
:y
a
STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST-CLASS POSTAGE,
CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES.(see front)
1. If you want this receipt postmarked,stick the gummed stub on the lett portion of the address side of the article
leaving the receipt attached and present the article at a post office Service window or hand it to your rural carrier.
(no extra charge)
2. If you do not want this receipt postmarked,stick the gummed stub on the left portion of the address side of the
article,date,detach and retain the receipt,and mail the article.
3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,
Form 3811,and attach it to the front of the article by means of the gummed ends if space permits.Otherwise,affix
to back of article. Endorse front of article. RETURN RECEIPT REQUESTED adjacent to the number.
4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee, endorse
RESTRICTED DELIVERY on the front of the article.
5. Enter lees for the services requested in the appropriate spaces on the front of this receipt.If return receipt is re-
quested, check the applicable blocks in item 1 of Form 3811.
6.Save this receipt and present it if you make inquiry.
O1�I+
5
ofu1Pm, � � cl��zsz
q.
Public Properig Pepariment
Puilbing Peyartment
William H. Munroe
One Salem Green
745-0213 December 17, 1985
Mr, & Mrs. Andrew Mitchell
10 Barcelona Ave.
Salem, Ma.
RE: Beauty Salon, 10Barcelona Ave.
- - -
Dear Mr. & Mrs. Mitchell,
It has been brought to the attention of this Department that you are
operating a business (Beauty Salon) in your home. This is in direct violation
of the Zoning Ordinance of the City of Salem, Section 5; A-1, not a "Permitted
Use"
You are hereby ordered to cease and desist the operation of this business
and to remove the sign indicating such a business exists. -
If you desire relief of this order you may apply for same through the
Board of Appeals.
Respectful cur ,
Edga� . P,aquin�//
} Asst. .riding Spector
EJP/hmc
c.c. Mr. Louis Mroz, Administrative Aide
. Mrs. Josephine Fusco, City Clerk
Councillor, Leonard F. O'Leary
� 23�s � 5 � � 5
� The Commonwealth of Massachusetts
� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
r ' Revrsed Mar 2011
��� Building Permit Application To Construct, Repair, Renovate Or Demolish a
OOne- or Two-Family Dwelling
—' � � This Section For Official Use Only �
� BuildingPermitNumber: . Date pplied:
9 � , a ///,6
�
� Building Ot6cial(Print Name) Signature Da[e
� SECTION ]: SITE INFORMATION -
1 . 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
r 10 Barcelona Ave.
l.la Is this an accepted stree[?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Dishict Proposed Use Lot Area(sq It) I'rontage(ft)
LS Building Setbacks(ft) ,.,, _ _
Front Yard Sidc Yards Rear Yard �' m
Required Provided Required Provided Reyuired Prov �y
—rn
� Z
1.6 Water Supply: (M.G.L c.40,§54) tJ Flood Zone Information: 1.8 Sewage Disposal System: .0 � �
Public❑ Priva[e ❑ Zonc: Oulside Plood%one? Municipal ❑ On site disposal systMi ❑� 0 �
Cheek ifyesO �
� SECTION 2: PROPERTY OWNERSHIP' Q�
2.1 Owner of Record: ��
Fabio Ferreira Salem, MA 01970
Name(Print) City,State,`LIP
10 Barcelona Ave. 617-293-2582
No.and S[reel "felephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construc[ion ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other �Specify: Solar
BriefDescription ofProposed WorkZ: Install 9.88kw solar panels on roof. Will not exceed roof panel, but will add 6"
to roof height. 38 panels total.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials �
1. Building $ 3000 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ 31,000 �Standard City/Town Application Fee �
❑Total Project Cost'ptem 6)x multiplier x
3. Plumbing $ 2. Other Fees: $�
� 4. Mechanical (HVAC) $ List:-
, 5. Mechanical (Fire $
Su ression Total All Fees: $
34,000 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
103631 8/30/17
GrBgg LeCBSse License Number T'xpiration Date
Name of CSL Holder
ListCSL Type(see below) U
20 Patterson Brook Rd. Unit 10 � � I
No.and Street Type Desaiption I
W.Wareham, MA 02576 U Unrostricted(6uildin s u to 35,000 cu.ftJ I
R Restric[ed 1&.2 Famil Dwelling .
City/Towq State,ZlP M Masonry �!
RC Roofing Covering � �
WS Window and Sidin
S� Solid Fuel Buming Appliances
(508)291-0007 I Insulation
Tele honc Email address D Demolition
5.2 Registered Home Improvement Contractor(H1C)
170355 10/12/17
Gregg LaCasse/Triniry Solar HIC Registration Number Expiration Uate
HIC Company Name or MC Registran[Name
20 Patterson Brook Rd. Unit 10
No.and S[reet Email address
W.Wareham, MA 02576 (508)291-0007
Ci /Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this applicatioa 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 Gregg LaCasse
to ac[on my behalf, in all matters relative to work authorized by this building permit application.
Please see attached letter. 2/3/16
Print Owner's Name(Electronic Signature) Date
� � SECTION 76: 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
con[ai d in t ' ap i ation is true and accurate to the best of my knowledge and understanding.
1
�� 2/3/16
'rint Own 's-o �ut rize� AgenPs Name(Electronic Signa[ure) Date
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 informa[ion on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found a[www.mass.�ov/dns
2. When substantial work is planned,provide the informa[ion below:
Total floor area(sq. ft.) (including garage,finished basemenUattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of ba[hrooms Number of half/ba[hs
Type of hea[ing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project CosP'
Trinity Solar
20 Patterson Brook Road
Wareham, MA 02571
508-291-0007
Date: 1/27/16
I, Ferreira, Fabio —, do hereby grant Trinity Solar the right to sign on
(homeowners Nome)
my behalf in all matters regarding the permit applications through the township of
Salem for the installation of solar panels and all other
(Muoltipallty)
related work on my property at 10 Barcelona Ave. Please accept this
(Street Address)
document, with full signature, in place of all application signatures. Furthermore, should there
be any issues or discrepancies with the paperwork,please contact Danielle DeVito at Trinity Solar,
732-780-3779 ext. 9044 or danielle.devito@trinitysolarsystems.com.
Sincerely, Z4
10 Barcelona Ave.
;.Homeownerssigture Street Address
Ferreira, Fabio Salem MA 01970
Print name City,State,Zip Code
Phone Number
Optimize Engineering Co., LLC
P.O. Box 264•Farmville•VA 23901
Ph: 434.574.6138•E-mail: grichardpe@aol.com
Richard B. Gordon, P.E.
President
February 1, 2016
Salem Building Department
Salem, MA Re: Solar Panels Roof Structural Framing Support
To Whom It May Concern:
I hereby certify that I am a Licensed Professional Engineer in the State of Massachusetts. Please note the
following conclusions regarding framing structure, roof loading,and proposed site location of installation:
1. Existing roof framing: Conventional framing is 2x8 at 16" o.c.with 12'-4"span (horizontal rafter
projection). This existing structure is definitely capable to support all of the loads that are indicated
below for this photovoltaic project.
2. Roof Loading
• 4.33 psf dead load (modules plus all mounting hardware)
• 30 psf snow live load (50 psf ground snow live load reference)
• 4.5 psf dead load roof materials
• Exposure Category B, 95 mph wind uplift live load of 13.34 psf(wind resistance)
3. Address of proposed installation: Residence of Fabio Ferreira, 10 Barcelona Avenue, Salem, MA
This installation design will be in general conformance to the manufacturer's specifications,and is in
compliance with all applicable laws, codes, and ordinances,and specifically, International Residential Code/
IRC 2009, 2014 NEC,and 2012 ICC Energy Code. The spacing and fastening of the mounting brackets is to
have a maximum of 64" o.c. span along the rail between mounting brackets and secured using 5/16"x 31/2'
length corrosive resistant steel lag bolts. In order to evenly distribute the load across the roof rafters,there
shall be a minimum of 2 mounting brackets per rafter&min. 2" penetration of lag bolt per bracket,which is
adequate to resist all 95 mph wind live loads including wind shear. The mounting brackets shall alternate
between adjacent rafters between rail rows for better distribution of roof load. Penetration of anchors for
modules mounted within 18" of ridge and edges of roof is to be a minimum of 3".
Very truly yours,
Optimize Engineering Co., LLC
i
Richard Y!Gordon,P.E.
Massachusetts P.E. License No. 49993
MECHANICAL, ELECTRICAL, &CIVIL ENGINIrE
-0,OF MASSgc
�P tiL
y � RICHARD B
---777 CORDON m
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0 "0.49993 Ir
�FGIS'TE� G�
�O�SSIONN-�
Optimize Engineering Co., LLC
P.O. Box 264•Farmville•VA 23901
Ph: 434.574.6138•E-mail: grichardpe@aol.com
Richard B. Gordon, P.E.
President
February 1, 2016
Salem Building Department
Salem, MA Re: Solar Panels Roof Structural Framing Support
To Whom It May Concern:
I hereby certify that I am a Licensed Professional Engineer in the State of Massachusetts. Please note the
following conclusions regarding framing structure, roof loading, and proposed site location of installation:
1. Existing roof framing: Conventional framing is 2x8 at 16" o.c.with 12'-4"span (horizontal rafter
projection). This existing structure is definitely capable to support all of the loads that are indicated
below for this photovoltaic project.
2. Roof Loadinq
• 4.33 psf dead load (modules plus all mounting hardware)
• 30 psf snow live load (50 psf ground snow live load reference)
• 4.5 psf dead load roof materials
• Exposure Category B, 95 mph wind uplift live load of 13.34 psf(wind resistance)
3. Address of proposed installation: Residence of Fabio Ferreira, 10 Barcelona Avenue,Salem, MA
This installation design will be in general conformance to the manufacturer's specifications, and is in
compliance with all applicable laws, codes, and ordinances, and specifically, International Residential Code/
IRC 2009, 2014 NEC, and 2012 ICC Energy Code. The spacing and fastening of the mounting brackets is to
have a maximum of 64" o.c.span along the rail between mounting brackets and secured using 5/16"x 31/2'
length corrosive resistant steel lag bolts. In order to evenly distribute the load across the roof rafters,there
shall be a minimum of 2 mounting brackets per rafter&min. 2" penetration of lag bolt per bracket,which is
adequate to resist all 95 mph wind live loads including wind shear. The mounting brackets shall alternate
between adjacent rafters between rail rows for better distribution of roof load. Penetration of anchors for
modules mounted within 18" of ridge and edges of roof is to be a minimum of 3".
Very truly yours,
Optimize En, in @ringC
Richard B. Gordoh, P.E.
Massachusetts P.E. License No. 49993
MECHANICAL, ELECTRICAL, & CIVIL ENGINEERING
OF MASSgCy
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The Commonwealth of Massachusetts g ' RT�{�k SFS���
A Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR App R vise Mar 2011
Building Permit Application To Construct,Repair,Renovate Or'''mdlisH'� 2
One-or Two-Family Dwelling
�� • Ttus Section For Offictal Use Omiy ,' � �
Building Permit Number $' � Date'Apphed " " ' a
Bwldmg Official(Print Name) ,Signature y `Date
SECTIONI:SITE INFORMATION:``,':
1yQperty dress: 1.2 Assessors Map&Parcel Numbers
' 1.1 a 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 yes❑
SECTION 2: PROPERTY OWNERSHIP'`
7TIOwnerl ecord: I *,4 Q�� •��
a/me//(��Print) II City,State,ZIP
�(\ /U/ � C'tVLV(A7Nh 01W wf.)_93
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(¢heck all that apply)f,.
New
Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 0 Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : J 61,4 RtW. S W eS S
ptrw5.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:Labor and Materials Official Use Only"'>'
-
1.Building $ L Building Pemtit Fed:$ = indicate how fee is determined;
2.Electrical $ ❑Standard. City/T6wn,Application Fee
❑Total Project Costa(Item 6)x multiplier x'
3.Plumbing $ 2 Other Fees $
4.Mechanical (HVAC) $ .-List:,
ist �riS� J a� t
5.Mechanical (Fire
Su $ 'Total All Fees $
.{� ression "
Check No. Cheek Amount: Cash Amount:
6.Total Project Cost: $�t Sw ❑pfd in Full ❑Outstanding Balance Due:
u a 7Z) tyvz�s�
L,-at -�l,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction;t,gpgivisor License(CSL) '
License Number Expiration Date
Name of CSL Holder( ?u,x i 1:1
s List CSL Type(see below)
No.and Street Type Description
U I Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing 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
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /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 of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... ❑
SECTION?a: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.
�. 6� C 4el- o�i/2s/4
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my time 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 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
wlvw.mass. o Foca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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'
The Commonwealth of Massachusetts
t' Board of Building Regulations and Stardar�EEEIVED CITY OF
Massachusetts State Building Cod epi�7�8� HAL SERVICE Revi SALEM
ALE 4201!
Building Permit Application To Construct,Repair,Renovate Or Demololisb a5
One-or Two-FamilyDwellin N —
This Section For Official se Only
I^
Building Pemut Number: Date A lied:
Building Oficial(Print Name) Signature Date
SECTION 1:SITE INFORMATION
i \
r:strict
�f1 1.2 Assessors Map&Parcel Numbers
is an accepted street?yes t/ no Map Number Parcel Number
Zoning Information: 1.4 Property Dimensions:
g DiProposed Use Lo[Area(sq ft) Frontage(R)
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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner t of Recor
PR
W
XName(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPT)IONOF PROPOSED ORI{'(check all that apply)
New Construction❑ Existing Building MOwner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Wo]iz:
ix-tl cy, O
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1 Building Permit Fee:$ Indicate bow fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire
Suppression) $ Total All Fees:$
C�,y� Cheek No. Check Amount: Cash Amount:
X 6.Total Project Cost: $ o'W
13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
t
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street S Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing 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
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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.
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
X contained in this application is true and accurate to the best of my knowledge and understanding.
LeC,-hverlL R� tClcz (( `-e e 4�0-W, a (0
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.sov.'oca Information on the Construction Supervisor License can be found at www.mass. og v/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (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 halffbaths
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"