24 BARNES CIR - BPA-14-307 PELLET STOVE 30 'z5
,Zx The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
�I Massachusetts State Building Code, 780 CMR SALEPA
Revised.Liar•2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A plied: 12
�6
Building Official(Print Name). Si e- Date
SECTION 1:SITE INFORaV1ATION
L1, rupsyy Address: a 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes V no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provide)
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 ifyes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 caner of Rc
N me(Print) City,State,ZIP
8"J"s
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Vur -:
e_ e r-6 _I(of 1dO `1
SECTION 4: ESTIBIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 1. Other Fees: S
4. btcclianird (HVAC) S List:
5. Mechanical (Fire S
Su� ressiun) 'fond All Fees:S
Check No._Check Amount: Cash Amount:_
6. Tuhd Project Cost: S ) '7 0. ' ❑ paid in Full ❑Outstanding Balance Due:
MAID- hFoM� ov�2
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL [folder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings lip to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
CityfFown,State,ZIP NI Nfasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telc hone Email address D Uemolilion
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or[IIC Registrant Name - '
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MIG.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`
1,as Owner of the subject property,hereby authorize
t on it behalf, in all matters relative to work authorized by this building permit application.
o ( o6lT
Print O ner's Name(Electronic Sign lure) ale
SECTln? b: 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
+ „ stained' this application is true and accurate to the best of my knowledge and understanding
9 A
Print O vner's or Authorized Agent's ;one('lectronic 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[tome Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under NI.G.L.c. Id'2A.Other important information on the HIC Program can be found at
i"', ,as,
. ov:'oca Information on the Construction Supervisor License can be found at wtow.mass.eov/d ss
2. When substantial work is planned,provide the information below:
Total floor area(sq. It.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
ryPeorcoolingsystem Enclosed Open
3. Total Project Square Footage"may be substituted for"Total Project Cost"
I_,
CITY OF SA EM
PUBLIC PROPERTY
DEPART4NIENT
V I UWALjy fL.rU Y.
wrae
ML t'S.16 4S" •v.&r.a.?wjaW
HOMEOWNER LIMNSE E.1(E.m"jOrV
Aft" print
Dale d Q �
lob Coeadots
Horns Owmr Address �2N�
Horns Owner 7etapbooe 71 - z V 7 - z
PStsstt n�iliag Addatirs a� � Cr,�. may„
The current esempdon of"Homeownwe was extended go include ownw_oceupie
dweUinyo of two Units or leas send to am�S rash homeowners ���AnirAg�,{ ddtW far
hire who doa not paaaaas a Hceaar;provided that the owner acts as aupwW*W.
DEFINMON O/HOMEOV44M
Peison(s) who owns a psrael otLad on which hdsbe resides or Intersds to restdey on
which there 14 or is Intended to bon s ace or two &Wly dweWnS attached or detached atrucnud accessory to.Such use and/or firm strneturee. A person who constructs more
than one hams io a two year Padod 1ha18 not be considered a homeowner. Such
"homeowner"Shall submit to the Building OQlc'4 on a form acceptabls to the Building
Fermib hdshe be reryartaible for all ruck work performed under the Building
The undersigned "homeownd'uaumes responsibility for compliance with the State
Building Code and other applicable bylaws and re
The undenigned"homeownce certifta that hd s undentan a City of Salem Bwiding Oeparottent rnitimum inspecdo roc tun and t
.vill comply with Said Procedure usd f uir and that hdSha
HOMEOWNERS SIGMA MM —
.�PPROV,�LOF9UICDIVGI;ISPE 0
ice other stda far state cote
"r CITY OF SALEM, NLkSSACHUSETTS
BUILDCVG DEP.\RT\t&NT
!1 120 WASHNGTON STREET, 3AD FLOOR
TEL (978) 745-9595
Fmx(978) 740-9846
KI�tBERL.EY DRISCOLL
NfAYOR THosw ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUHMNG COSL\tISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting fromthis work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debri will be transported by:
� 7ly(�j
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit a cant
iU
date
Jcbrisait:dk