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9 BARNES CIR - BPA-13-1011 POOL a The Commonwealth of Massachusetts CITY OF �. Board of Building Regulations and Standards Massachusetts State Building Code;780 CMR SALEM S �If Revised Mar 201 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tsvo-Family Divelling / This Section For dfficial UsiAly. Building Permit Number:;'. Building Official(Print Name) Signatu D SECTION Ic SITE INFO ION _ 1.1 opertg Ages;: �/co © i r_ 1.2 Assessors Map& Parcel Numbers 1.la 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 Rcquired Provided Required Provided 1.6 Water Supply: (M.O.L c.40,§54) 1.1 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑" Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es❑ SECT[ONZ PROPERTIG'OWNERSHIPL_,, r!geRwec�orlie S -���i�l cl � ame(Print) City,Stata,ZIP y .� 21✓ e s C'le e �_F S5 �r ooso No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF.PROPOSED WORKV(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other 13 Specify: Brie escription of Proposed% orkr: SECTION 4: ESTILNLkTED CONSTRUCTION COSTS- Estimated Costs: [tern OfRclai Ust Only-... Labor and vlaterials 1. Building S 11 Building Permit Fee:S Ihdidate how fee is determined: 2. Electrical g ciStandaid.CityCPutvnApplicationFee. ❑'Cotal.PiojectCostr.(Item.6)xmultiplier x 3. Plumbing S 2, Other Fees: S 1. Mechanical (lIVAQ S List: i. \fech:mic.ii (Fire $ . Su > Hessian) _ Total:111 Fces:.i_ n- Check�Io. _Check Anmunt: __Cash anwunc r l'utnl !inject Cult S tQ't% O 0 Paid in Full 0 Outstanding Valance Ihto: r l SECTION 5: CONsfRUCrION SERVICES 5.1 Construction Supervisor License(CSL) License Number Cxpiration Date Name of CSL I[older List CSL'Type(see below) Type Description No. and Street U Unrestricted Building up to 33,000 cu. tt. R Restricted 1&2 Family Dwellin City/Town,State, ZIP VI Vlasonr RC Rootin Coverin \VS Window and Sidin SF Solid Fuel Burning Appliances I Insulation felt hunt Email address D Demolition 5.2 Registered Home Improvement Contractor(MC) FIIC Registration Number Expiration Date f TIC Company Name or FIIC Registrant Nant No.and Street Email address Ci /Tuwn,State ZIP Telephone 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 DE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date 7SECTION 71): OWNEW OR AUTHORIZED'AGENT DECLARATION enteringe below, I hereby attest under the pains and penalties of perjury that all of the information licatio 's true and accurate to the best of my knowledge and understanding. rited:\gcnt's Nantc(Electronic Signature) D;ut NOTES: I. 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 Hotne Improvement Contractor(HIC) Program),will!U have access to the arbitration program or guaranty find under ALU.L. c. 142A. Other important information on the HIC Program can be found at www glai .euy%ora Information on the Construction Supervisor Liccnse can be round at ttww.ntass.,,ovddi 2 When substantial work is planned,provide tht information below: Total floor area(sq. It.) _(including garage, finished hasonenVattics,decks or porch) Oros; living:rcl Oil. d.) ffabitablt room count _ Number of tircpl.lccs_,—__----- Number of bedrooms _. .---__-- Number ofbathrnums Number 'if ImIt'baths I'cpo of heating ;yitcut ._ ----,-- Number elf decki/porchci - -- I)paofolalin� ;yuclu .__..___ {. "lold1 l'rll:Ct 1t�lla l'd I'rntLI�C"IIIaY' he illb if ltl lt.',I t,tr..I ,LI� ICI IIICCt l'Uits