18 BARCELONA AVE - BUILDING INSPECTION (3) SERV(Qtgommonwealth of iblassachusetts CITY OF
8 Board of Building Regulations and Standards SALEM
4Y7 AIN�ssacllusetts State Building Code, 780 CMR Revised ANar 2011
�R
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For.Ofl;cial Use Only
Building Permit Number: Date plied:
Building Olticial(Print Name). Signature Date
SECTION 1:SITE INFORMATION:
1.1 Prop ddress: 1.2 Assessors Map St Parcel Numbers
�( A� L4 �l�VEIL
\ L l a is this an acce ted street? es X no Map Ntunber Parcel Number
1.3 'Zoning Information: IA Property Dimensions:
Zoning District - Proposed Use Lot Area(sq It) Frontage(R) - -
1.5 Building Setbacks(it)
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 oAdditlon
Public Private O. Zone: _ Outside Flood Zone? Municipal 13 On site diCheckif esO
SECTION2: PROPERTYOW2.1 wnertof Record:ImCity,State,ZIP
C172R�y�SD7 gl�No.and Strcel Telephone E AddSECTION 3: DESCRIPTION OF PROPOSED WORW(check all thatapply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) 1
Demolition ❑ 1 Accessory Bldg.13 Number of Units Other O Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS :
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S 2�QtherFees: S
4.ivIcehanical (I-IVAC) S List: Ol6 V V
5. Mechanical (Fire Suressiun) DD S 'fatal All Fees:S
Check No. Check Amount: Cash Amount:
6. Tutu Project Cust S ❑ paid in Full 13 Outstanding Balance Due:
M�\
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructimr Supervisor License(CSL)
License Numbers .1 'Expirati'un Date-
Name of CSL Holder
List CSL"type(see below) _
No. ;rod Street Type 7 - Description .
U Unrestricted DuilJin a l0 35 000 cu. Il.
R Restricted 1&2 Family Dwelling
Citylrown,State,ZIP M Masonry
RC Roolinit Covering
WS Window and Sidinx
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dade
I IIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.E�C.M§ 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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........13 No...........O
SECTION 7a:OWNER Al1TH0.RIZATION TO BE COMPLETED,WHEN,
OWNER'S ACENT Oti CONTRACT OR APPLIES FOIY BUILDING.PERMIT'
I,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.
� i
R
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.
o e 1
Print Owner's or Authorized Agent's Name(E ecuonic Signature) I 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 no_I have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A.Other lmpodiiii information on the HICYrogmm can be toun at
www.mass.cov'oca Information on the Construction Supervisor License can be found at www•.nmss..+ovlJos .
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. R.) N .(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
1. "Tom! Project Square Footage"may be substituted for"rut:d project Cost"
t CITY OF SALEM, MASSAC HUSETTS
3 , BLALDING DEPARTMENT
120 WASH NGTON STREET,3"D FLOOR
?zr TEL. (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/B LBLDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT-
3ILL_;,Date Q Qa r`Job Location l U F c-eII Ion 0- & ih-g b
( aC r-yCer J,
Home Owner Address r'1=� l a L0_ vy, q
Present Mailing Address I X Y'C__e_� 0-,V\ Ile— CL
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one=or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'SSIGNAT E L
APPROVAL OF BUILDING INSPECTOR