1 BARNES CIR - BPA-544 SHED The Coin inomvealth of Massachusetts
1\U1 7 Board of Building Regulations and Standards CITY OF
NlassachusettS State Building Code, 730 CNIR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dtibelling
This Section For Official Use Only
Building Permit Number: / Date App red3
t�%Nsb.f(:(, 'TYL zl Elfob
Building Official(Print Name) I Date
SECTION f: SITE INFORNIATION -
1. ropert ddress: 1.2 Assessors Map & P el Numbers
1.l 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-
2 MO nert,o7fRefOrd:
ild ?2^11-
Name Lett) — City,State,ZIP
No.d11U 3LIUM Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ N nits_ Other ❑ Specify:
Brief Description of Proposed Work: / �1 n
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only,
Labor and Materials y`
1. Building $ I Building Permit Fee. $' Indicate how fee is determined:
❑ Standard City/"fown Application Fee
2. Electrical $ ❑Total Project Cost'',(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Mechanical (Fire
-Suppression) Total All Fees: $
Check No. Check Amount: _Cash Amount:
6, Total Project Cost: S 0 Paid in Full 0 Outstandin
— ------ -- —=---F�'�c'u--- ---- — --- . Balance Due=---=_-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL I-folder
List CSL Type(see below)
No. and Street — Type Description
U Unrestricted Buildings up to 35,000 cu. ft.
R Restricted I&2 Family Dwelling
City/Town, State, ZIP VI Nlasonr
RC Roofing Covering
WS Window and Siding
SF Solid FucI Burning Appliances
l Insulation
"relz hone Email address D Demolition
5.2 Registered Hone 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. 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATIONTO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize P d�
to act on my behalf, in all matters relative to work authorized by this buildin permit application.
V2
mt Owner's i laine(E lectron ick'ignature) Da
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 or Authorized Agent's Nance(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
(nut 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.111asS Dov oea Information on the Construction Supervisor License can be found at wwu<mass.-' dors
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_ Numberofbedrooms _ --
Number of bathrooms _ Number of halt baths _
fypeorheating.iystmn _ _ Number ofdacks/ Porches
I'ype of cooling system-- Ellclosetl----. .-----Open
3. "focal Project Square Footage' utay be sub;titut,�J Project Cost"
CITY OF SALEM, i%LXSSACHUSETTS
BUILONG DEP.ART.%tENT
120 WASHLNGTON STREET, 3i° FLOOR
TEL (978) 745-9595
F.+s(978) 740-9846
KI\QiERLF-Y DRISCOLL
AtkYOR THo.%w ST.Pivas
DIRECTOR OF PUBLIC PROPERTY/BCILI)DIG CONNISSIONER
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit M 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
I 11, S 150A.
The debris will be transported by:
cx �L
(name of Hauler)
The debris will be disposed of in :
-- (name of facility)_
---(address of facility) _
s' >iJturo of ermit plicant
a/
date
Abn.aiY J•w
"�D _. � CITY OF SM.ENf
PUBLIC PROPERTY
DEPARTMENT
wauur OUSA"
Vwrae 13evxww.UM.trua• U M VwoAowsumOlt-*
ML 9-9-745.95" •V.%L V8,740.964
HOMEOWNER LIMNSB EXEM"10M
Pin" Tr1r. ` /
Data'L�/ (/
Job Locadois Pr rc/
Home Owner Add:easAfr
Home Owns Telephone
Presaot Mailing Address Gc�
The current exemption o["Homeownere was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who does not possess a licenser provided that the owner acts as supervisor.
DEFiNMON OF HOMEOWNER
Petson(s) who owns a pe cd of tend an which he/she resides or Intends to resider on
which there i; or is intended to ber a one or two i3tmily 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 0mei4 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 bylaws and regulations.
The undersigned "homeowner'certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Mill comply with said procedures and requirErr� ter.
HOMEOWNERS SIGNATLRE
.kPPROVAL OF BUILDING INSPECTOR
See other side for state code