1 BARNES CIR - BPA-15-22 INSULATION r
The Commonwealth of Massachusetts RECEI SERV CES
Board of Building Regulations and Stagr�rCj�t]NAL CITY OF
Massachusetts State Building Code,78tld�1�G]KF LSALEM
As
Building Permit Application To Construct Repair, Renov ed Mar 1011
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One-or Two Family Dwelling
This Section For Official Use Only .
Building Permit Number: Date pplied:
Building Official(Print Name) _ Signature _ _ Date
SECTION 1:SITE INFORMATION
1.1 Propertryv Address: / 1.2 Assessors Map&Parcel Numbers
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1.1 a Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zooing Distnct 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
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1.6 Water Supply:(M G.L c.40,§54) 1.71 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? 'i
Munc ❑ Onsite disposal 1 Check if yes❑ system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of ecord
t.,7 Legere. 5;tk*'-7 {�9
Name(Pont) ! City,State,ZIP
I Y31C� �ii r. � (017- ��97yG9
No.and Street Telephone Email Address
SECTION 3:DESCRH;TION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑, Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.[3 Number of Units_ Other Specify: *E
Brief Description of Propos W rk2: i
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SECTION 4 ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials y
1.Building $ a _ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical13Standard City/Town Application Fee
$ ' ❑Total Project Cost'(Item6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ ! List; j
5.Mechanical (Fire
Suppression) $ Total All Fees:$ .
6.Total Project Cost: $ Check No. Check Amount: Cash Amount:
oL�Q(M ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) S -71-7-7
y 3
Name of CSL Holder License Number Expiration Date
Eric W. 1:,I Ill List CSL Type(see below)
No.and Street Type Description
Salem MA 01970 U Unrestricted Buildin up to 35,000 cu.R)
Gtyll own,State,ZIP R Restricted 1&2 F—q Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
=Telep -,�,y. SF Solid Fuel Burning Appliances
IInsulation
Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
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AdimllC WeA7p at�nn�T T HIC Registration Number Expiration Date
HIC Company Name or HI ft a Name me Avenue
No.and Street Ul Salem 1A 01970 Email address
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 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
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I,as Owner of the subject property,hereby authorize C.ri-C 9 /M
to act on my behalf,in all matters relative to work authorized by this building permit application.
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Print Print Owner's Name Mectronic 3ignature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contained in this applicat[[[i'''o is
trueand ccurate t0 the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
w 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.L1,c. 142A.Other important information on the HIC Program can be found at
kvww.ntass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eovrdos
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"
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