22 BARNES RD - BUILDING INSPECTION (3) $ 1 (01
REc YED
The Commonwealth of Massachusetts INSPECTIONA CITY OF
011�
Board of Building Regulations and Standards ^ S 4
Massachusetts State Building Code, 780 CMR IQ15 MAR 2 RAsei�lltlr toll
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number. Date Applied: '
Building Official(Print Name) Signature t✓/ � Date
SECTION 1:SITE INFORSIATION'
t 1.1 Propearrty Address: 1n ,, yp� 1.2 Assessors blap&Parcel Numbers
o��. YJd -rno5 r�
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Coning District Proposed Use Lot Arca(sq It) Frontage(II)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public Private❑ Check if es❑ p po y
SECTION2: PROPERTY OWNERSHIP!`
2.1 Owners of Record: ( 1 , ��e45
phi -.� -I. �„il0"V _I'tCS,
Rim (M-111tV City,State,ZIP
No.and Street Telephone Email Addnss
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction'3Existing Building Owner•OccupiedV I Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4: EST4NATED CONSTRUCTION COSTS
Item Estimated Costs: OfOcial Use Only
Labor and Materials)
I. Building $ o o I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ \ o o ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S \ Q Q 2`?.Qther Fees:
4.%Icchanical (FIVAC) S I cp List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount_
6.Total Project Cust: S ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
r f ; License Number Expiration Date
Name of CSL[folder
List CSL'fype(see below)
No.and Street Type Description
U Unrestricted(Buildings tip to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
City/fown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Sidina
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
INC Company Name or[IIC Registrant Name
No.and Street - Email address
___Ci /To3Yn,State.ZI_P __ 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 Is✓;uance of the building permit.
Signed Affidavit Attached? Yes ..........O No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN..
OWNER'S AGENT OR CONTRACTOILAPPLIES 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:OWNER'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 understanding.
�\
Print Owner's or liorizcd Agent's Name(Electronic Signature) Onto
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(rot registered in the Home Improvement Contractor(HIC)Program);will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
w-ww.nmss.eov:'oca Information on the Construction Supervisor License can be found at www.nass.tov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) 'A .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room coma
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. "folal Project Square Footage"miry be substituted for"Turd Project Cost"
QTY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
120 WASHINGTON STREET,3'm FLOOR
7i L(978)745-9595
KAMERL.EYDRISOOLL FAX(978)740-9846
MAYOR THOMAS STAERRE
DIRECTOR OF PUBUCPROPERTY/BUILDING 00MAgSSIONER
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 c40, S 54, Building Permit# is 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:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
4Sianat re of applicant
C�I7
ate
CITY OF SALEM MASSACHUSETTS
1 BUILDING DEPARTMENT
120 WASHINGTON STREET,3"°FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINMERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CON11 IISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 30,-? 1 15
Job Location Q 3— Li rnn.S AeL SnAL_m m 4
Home Owner Address t )Gl VYLP_
Present Mailing Address S(1 rQ1_
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. /n
HOMEOWNER'SSIGNATURE�J
APPROVAL OF BUILDING INSPECTOR
59 ; a
µ. .x
d
I
a
b^m I'
A,k^ P, _•v�P?Oi19mm° 23a a ....m k 1 ...-. —27
.,.,,... k
v b w r
2,37
MIA
'nms '1' dat rm ' t mn xa-:vye � �-rmM^r-^ r
s
KLV3 kA '�730 0AW430
si -n,.x��3
k
Wm
1 1 1
"",t .
r —
J
Is
i :. fir •' ,, }: 5:` .�.
a H
t � _ a
b:
x Q a AA7u � i 1�J1 f t � _ �,
t,� as q hnFS t L I
,
a, z r:_
p r��X :Aa Ai
xx F l •. t•� r.� y �{} $3q r
, r
A"`a^A&b sad Tay
`.tm }r s --I fi ,--
t €
sue. n
5
. .I
a
F' t i3 k
'preamTMnM Nmm�'4t M&Y.S.taiP'•v..rM.t!!r!^�„MNtt.T_eS nor n ��rv.e.nm+"j"m'r.ira �«.. u,.A.,.m.- � x �. sR m.i.m+ ..M •.. —•. .-.. a .. ....
.. i. a '. � ,...