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2 BARNES AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts V UJ I Board of Building Regulations and Standards CITY OF SALEM Massachusetts State Bolding Code,780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date A Building Official(Print Name) Date SECTION 1:SITE INFORMATION 1.1 Properly Address: 1.2 Assessors Map&Parcel Numbers LIn 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 Regduued Provided Required Provided - 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Priyate❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner?of Reco d: ' l�flt� 15yt.$7aa/ S AGEk" 141a C? ! 97d Nana(Print) City,State,ZIP p A)q"zA'm' C �_• No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building o Owner-Occupied ❑ Repairs(s) P I Alteratio t(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work: Yna SECTION 4:ESTIMATED C014STRUCTION COSTS Item Estimated Costs:(Labor and Materials Official Use Only 1.Building $��i O 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost?(Item 6)x multiplier x i 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Construction,upervisor License(CSL) stfpE� n �.. oo CIV�-s r►,Sa�.(�S Licen��se Number Expiration Date Name of CSL Holder List CSL Type(see below) (J No.and Streeyt�a > Type - Description{-l✓� © 1 9 Unrestricted itii u to cu.ft Restricted 1&2-Famamil Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering - WS Window and Siding SF Solid Fuel Burning Appliances - roY I Insulation Telephone Email address D Demolition 5.2Registered Home Improvement Contractor(HIC) j' I,e A*7 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name I f?AC:2C aa(=a LIS M, wr.. C.,Wh f N and��reet [r Email dress 1�61't3c���s i-r/3 [hr9AO 97�a T�39a Cityrrown,State ZIP Tel 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 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 C' 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: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. PHLC I�or4� »✓ /a- 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 www.mass.poi. v/oca Information on the Construction Supervisor License can be found at wivw.mass.sovidos 2. When substantial work is planned,provide the information below: Total floor area(sq.R) (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 coaling system Enclosed Open 3 Total Project Square Footage"maybe substituted for"Total Project Cost" ;l i CITY OF S�-1 XNM, 1.fASSACHUSETTS BuILDING DEnItTSELNT 1 120 W ASHINGTON STREET,3"FLOOR. TV- (978)745-9595 FAX(978)740-9M6 KIMBERLEY IMSCOLL MAYOR THO�t 4S St.PtFARB DIRECPoR OF PUBLIC PROPERTY/Bt:t DLNG,LOJL%CWIONER Workers' Compensation Insurance Affidavit: Builders!Contractors/ElectriclawwPlumbers APPllcant Information Please Print Legibly Name(Business:Organintiorvindividmi): C r7 'S7'ef JC LrOA.1 Address: a I I�UCr4lYo.v��S t n City/State/Zip: 1?IA/30A V A)KI O r4f 0Phone#:_ .928 —Are-s-- 939P Are yya as employer?Cheek the appropriate host Type of projtxL(required): 1. 1 am a employer with 4. 0 1 am a general contractor and 1 6. 0 New comvtruction employees(fall and/or Part-time).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheeL: 7. 0 Remodeling ship and have no employees These subcontractors have 11. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition (No workers comp.insurance S. 0 We are a corporation and its 10 Electrical repairs or additions required.) officers have exercised their 3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' 13.0 Other comp.insurance required.] *Any appliam chat ehmi a box nl must alms Ca wt the sectim below showing their women•cmapensadon Policy information. I rameuwtxts who submit this Affidavit indicating lhcy ate doing WI wodr and then hire ounideeomtoemn must submit a new affidavit indicating sulb. :Conimcton that cheek this box mute anasbs9 an Alditlorgl ahrtt showing thc.aame a±!� di=cx aticau E and A.&workars'on ap.policy iafam ation. 1 am an employer that is providing workers'compensation Jasurancefor my employees. Below is the policy and Job sits information Insurance Company Name: Policy#or Self-ins.Lic.#: 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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 penatles ofperJury that the hirormudon provided above is true and correaY. Si mat ire• Date: Phone#: 978- 5 C.<- 9s 4 OfAcial use only. Do not write in dtis area to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): - 1.Board of liealth 2.Building Department 3.Cilyfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Conflict Persan: _ -_-- Phonefb Fl CITY OF S�U.E.NI, NL-kSSACHUSETTS BUILDING DEP1,RTNEAT • 130 WASHLNGTON STREET, 3i°FLOOR T FL (978) 745-9595 FAX(978) 740-9M KIJfBERLEY DRISCOLL ,MAYOR TTtoAt s ST.PtEm DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMNUSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in !3 FL (name of facility) 54 J��it3o fl (address of facility) sig re of permit applica date dcbriulTdce