6 BARNES CIR - BPA-17-1725 SHED 42
m — 1 L4 — I I I RECEIVED MCES
I�•� I"he Commonwealth of Massachusetts ImsFECTIUNFIL
CITY OF
NBoard of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR 3'� NI
g N1a OCt 30 Revised blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official-Use Only
Buiiding Permit Number: Date,Appliede L
J
k-- Building Official(Print Name). Signature- Date
SECTION 1:SITE INFORMATION
1.1 P operty Address:2 V_ 1.2 Assessors Map& Parcel Numbers
(1 ; rnS Cc C `•0
1.[a Is this an accepted street?yes no Nrap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(If)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ — Check if es❑ P p y
SECTION2: PROPERTY OWNERSHIP"
!$e
wnert of Record:
Geor e e�c� Ie55rrS �e-tevA EA 0Lcl'�O
(Print) City,Stale,ZIP
(p ��,. e5 cnclP g ��c41y41 rp�less�s � �ovv.c� s� n
No.and Street Telephone Lmail Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Des ription of Proposed\Vork-:
tC) x a6Wee S e P
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. 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 1" Qther Fees: S
i t. Mcchvtical (FIVAC) S List:��F
5. Mechanical (Fire 'Coral All Fees:S S
Su ression)
np Check No. Check Amount: Cash.\mount:
G. " tat Project Grst: .S (y t a00., ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
r + 0' QJ, License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
Type -- - Description
No. ❑nd Street
U Unrestricted Buildings tip to 35,000 cu. tt.) -
R Restricted 1&2 Family Dwelling
Cityffuwn,State,ZIP M Masonry
RC Rooting Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
II Insulation
Teie hone Enmil address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
fIIC Company Name or HIC Registrant Name
No. and Street Email address
City/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 CONTRACTORAPPLIES FOR 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By enten g my nam below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained it his a p ication is tr ad accurate-to the best of my knowledge and understanding.
nd 30. aorY
Print Owner's or AuthnrizeJ Agent's N;une(Electronic Signature) Date
NOTES:
I. A n 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 rrr�r have access to the arbitration
program or guarmtty fund under ivLQL.c. 142A.Other important information on the HIC Program can be found at
www.mass. •oL y;!OC71 Information On the Construction Supervisor License can be found at www.nass.rz0v 111M
� 2. When substantial work is plvuned, provide the information below: �i
"Fetal floor area(sq. tt.) .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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 "total Project Square Footage" may be substituted for"Total Project Cost"
PLAN OF LAND
IN v
R.W. REID R.L.S. LYNNFIELD, MA.
SCALE I"- 20 ' Jv(- V z, i9e6
�d rdo o� R p
WILLIAM
6 so
"KID
2.
L9422
�I T
�yNFB1 GTCa/�a
!. C. eo �^ 3 2 6 °s U Rai
62So S.F
-7 P-T
Iox2o
—a 1 certii y that the dwoNing is
located as shown and
con-formed to the zoning laws
6-0 ,de If* o o 1/�,- of the Df
0
AlukAle
when constructed.
/ scary
G
a �
Y
d ry
�6 C G
V
6 2. so
A& RN6.S c1lecc IS
I , hereby, certify to the best of my knowledge that the premises shown on this plan are
not located within a flood hazard area as delineated on the map of Community it 250102A
prepared by the Department of Housing and Urban Development or its successors dated 3//r/»
I further certify that this inspection was performed in accordance with the "Technical
Standards for Mortgage Loan Inspections" as adopted by the Massachusetts Association of Land
Surveyors and Civil Engineers , Inc.
Note : This plan was prepared from a tape survey and is intended for mortgage purposes only.
Offsets shown on, or scaled from this plan are approximate only, and should not be used to
determine property lines.
Bo Page Certi ficate Number g7o3 / 86- 778
QTY
OF SALEM, MASSACHLTSETTS
BUILDING DEPARTMENT
' 120 WASHINGTON STREET,31D FLOOR
�T* ' 7FL. (978) 745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal "p sal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edit
ion of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
eP�A t��� S he�tS
(name of hauler)
The debris will be disposed of in:
�A S V'-&9
(name of facility)
N �
(address of facility)
Signature ofapplicant
Opt _.3 a A-a r
Date
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHING"CONSTREET,3"FLOOR
yam* ' TEL. (978) 745-9595
EAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR Ti-iomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CON2 ISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date p- 3 b - ! '
Job Location
Home Owner Address Sr: rY
Present Mailing Address
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'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR