7 BARNES RD - BUILDING INSPECTION (2) I i I ✓ --- I'lie Commonwealth of Massachuselts
Y 1: Board of Building Regulations and Standards Cl IN OF
PPPP lt. btassachusclls Slate Building Cudd. 7S0 C NIR SALEM
'L•�•• rr,•ri,,d la,r�nrr
Building Permit Application To Construct. Repair, Renovate Demoli- a
rhrv- or rwr14l:mill' D% cllio,
This Section For 011icial Use O I
Building Permit Number. _— Oata Ap •d•
Building Otiicial(Print Nwnc) Sign are Dole
SECTION I: SITE INF'RA A
I.I Property Address: 1.2 A e rs a di Parcel Numbers
I.la Is this an acce it street? 'a l`no \Inp Nunnher Parcel Number
I.J Zoning Information: 1.4 Property Dimensions:
Loniny District I'ropuxd Uw Lul Amu(sy It) Fronluga(III
1.5 Building Setbacks(It)
Front Yard Side Yards Rest Yard
Required Provided Required Provided Reyuind Provided
1.6 Water Supply:(M.GA.u.y0.§Sy) 1.7 Flood Zone Informallon: 1.3 Sewage Disposal System:
1lrblle❑ Prtvote❑ Zone: _ Outside Flood Zone?
Check if �s❑ Municipal❑ On site disposal s)stun ❑
SECTION]: PROPERTY OWNERSHIP'
2.1��vnern of Recor t—
✓�rL x,oi wiz -5/71ull a, �y?0
Me of •(Print) Uq,State,I.IP
7 15,*trA1 E:� 21
Nu.and street relephone hmad Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction(3 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Allerotton(s) ❑ Addition ❑
Demolition ❑ accessory Bldg. ❑ Number of Units_ Other ❑ Speciry:
Brief Description of Proposed Work":
SECTION 4: ESTIMATED CONSTRUCTION COSTS
hens Es,!,, led Costs:
(Laburund.\I;neriah) OMclal Use Only
I. Building S e�vo 0&;7 I. Building Permit Fee: S Indicate how fee is determined:
'. lAwrical S Cl Standard CiryiTussn Application Fee
I 1 I'IuniMng S ❑Tutol Project Cost'(Item 6)s multiplier
_. Other Fecs: S
J. \lech.miCal II\' \('1 i Lisl:
Check No. _— --( Ileck:\nwuut: C.uh \mouul:
n Tufall'rnjcctCust i frU _.___..
! /Q� ❑P.6d in Full 0 Outstanding Bal.unce Due:
si:( HON is ONS MUCHON SERVICF-S
\111ralion Mile
Nmlie a1L SI. I loldcr I I it CS I. 1'%PC(1ec 1'e"I%I)
I P1: Description
�J J5 it,
.111isirccl —Mulldings tip it)35,110
R .........
%ill.S1.1tv. RC R,x)lill Csii,vrin
S mj Sidin
SF Solid I:ugl Burning Appliallc9s
Insulation
Demolition
l'elc hams
11.2 Registered Ilume Improvement Contractor(IIIL)
E\11irillion Wig
I IK:Itelibiration NutnWr
I 11C C0111pall) Name Or I IIC Itcgistraml Nuala
Email address
U.;old Street
C it 111'awn State ZIP role hone (M.G.L.C. 151. 1 2SC(6))
SECTION 6:WORKERS,COMPENSATION INSURANCE AFFIDAVIT
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.
Yes ..........C3 No...........
Signed Affidavit Attached?
9
3L%.Kluill7a: ON�IqERAUTIJ�()IUZATIONTOB CONIPLETEDWHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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,
Date
Print
cr,s Nanic tElccurunic Sianuture)
SECTION 7b:OWNER' ORAUTHORIZED AGENTDECLARATION
By entering try name below.I hereby attest under the pains and penalties or perjury that all of the information
s tf -Z,
ue and accurate to the best of my knowledge and understanding.
Y6 -.onlaired in this application gi _
Wile
it'i'NaIng
NOW '
I.
.\it dmici %%hu obtains a building permit to do his her awn work,or an owner who hires an unregistered contractor
not registered in the Hume Improvement Contrictur(HIC) Program).will LU) have access to the arbitration
program urguiranly I'und under M.G.L.I:. Other important informaflon on the HIC Prograll,can be lound at
-\ .1p,
I information on the Construction Supervisor License call be found at ��i
2. ki,lien substantial%i,ork is planned,provide the Ilit!itrinatiun below:
I including garage, finished basement.1ttIcs.
decks or ritirdi)
rotal ,lien area(stl tI I -- Habitable roan!cOtilit
Gross living area liti. 11.1 Number of b%:drowns
till 11,er ol,lirvllhcvs -
I s Ilk:ol heating is Stoll .01'ell
s Ile ol,ioohilq s,tQlll i
1. I i,1,11 prolvo Square Fool-19c
CITY OF sm-E.m
PUBLIC PROPERTY
DEPAIMMEN'T
u.uuur o•aaau
wvwe ULU4 4Aonow earn ottr-s
HOMEOWNER LICLNSS EXE.1 MON
Model Mat
Dam (;-1 la
lob Locadw
Home Owner Addreas
Home Owner Tolepboae
Ptesone Mailing Address
The current exempdon of"Homeownae war extended to include owner-occupied
dwellings of me Units or few and to allow such homeowners to engage an individual for
him who does not poaew a licens%provided that the owner sets as supervisor.
DE INMON Of HOMEOWNER
Penon(s) who owns a parcel offend on which holshe resides or intends to reside. on
which then is, or is intended to be,a one or two family dwelling attached or detached
structttrea sccasory to such use and/or farm structures A person who constructs more
thaw one home in a two year period shall not be considered a homeowner. Such
"horneowner'shall submit to the Building 00164 on a form acceptable to the Building
Officiai, that her/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"asruma responsibility for compliance with the State
Building Code and other applicable bylaws and regulations.
no undersigned "homeowner"certifta that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.will comply with said procedure and requirements.� /
HOMEOWNERS SIGNATh'RB �t;p ((// ��/j
APPROVAL OF BUILDING INSPECTOR
See other side far itato code
CITY OF S UI ENI, ii'LNsSACHUSETrS
• BUILDL\G DEPAR-11MENT
N 130 WASHINGTON STREET, 3nD FLOOR
TEL (978) 745-9595
F&X(978) 740-9846
KIJtBERLBY DRISCOLL
MAYOR DIRECTOR
ST.PIERItB
DIRECTOR OF PUBLIC PROPERTY/BU IMNG COMMISSIONER
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 111.5
Debris, and the provisions of MGL c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
-IkoYl7 D 25
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
•.kbrisall:dux