24 BARNES CIR - BPA-16-1225 SOLAR, UPDATED W/OWNER INFO The Commonwealth of Massachusetts
`\J1 ` Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
t Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I Date Applied:
t\12u vYL P'P U WJI ( 022tZr O uD t.l e TZ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Pro erty Address- 1.2 Assessors Map&Parcel Numbers
2 �at
l.Ia 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(0)
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' Peyn°�o�e�ty Salem MA 01979
Name(Print) City,State,ZIP
24 barnes cir 9785678763 Rogsnrse55@yahoo.com
No,and Street - Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Constructi Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alterations) ❑ Addition ❑
Demolition Cl I Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief es ript on of Proposed Woik': '_0 2 w.. '
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $It,IZ�Z;IpC� 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $Cy ,3� ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
1 3, Check No._Check Amount: Cash Amount:_
6.Total Project Cost: $� I 0 Paid in Full 11 Outstanding Balance Due:
SECTION5: CONSTRUCTION SERVICES II ,I�1'I'1DG
5.1 Construction Uv Supervisor License(CSL) �o gor�
License Number Ezptmtion ate
N f. y
/q�j der 1 c n1
U� List CSL Type(see below)
No. g`treet UU /� n r Type Description
1: r� ! ('�t �,�1. �y 6�I'' U Unrestricted(Buildings u to 35.000 cu.ft.)
l (, t ' `t - R Restricted 1&2.Fami1 Dwelling
City/Town, ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Hom�eI pp-ro(x'ement Contractor(HIC)
-4-IIC R `�I HIC Registration Number Expiration DateHIC Company Nan r IIC R istr�lat'yn'[n�N,.am 1 r `Q,(i�
No.and Street(� 9 "•t" 1 �'�,V)n .
'1111A�ty V t 11.11. �4:fMI �1 L.170('nt+,)_C' Email address
City/Town,Statute,:ZIP ��-�I�(J lb l�Telephhonnee(�,L
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52.§ 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........_,15' No..............❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize ))rV}. t 0 hrr
to act on my behalf,in all matters relative to work authorized by this building permit application.
Kevin Doherty 11/3/16
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 understand' .
�t 6wene e . 8 1
Print Owlncr s or Authorized Agent' Name(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
(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.masssov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"