24 BARNES RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY Massachusetts State Building Code, 730 CNIR SALEM
UU Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family avelling
This Section For Official Use Only
Building Permit Number:'` Date Ap hed:
Building Official(Pont ame) .' Signature, :` ! .
SECTION 1: SITE INFORiVIATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Z4 BPoLrie5 R.oAa u,._ MA
1.1 a is this an accepted street?yes _ no Nfap 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 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 2c, PROPERTY OWNERSHIP:``.
2.1 Ownert of Record:
Kk,k^ i4o,n,v a ffige- run�S l r4 ra a �cLe n., 0 1
Name(Print) City, State,ZIP
zLf es 9-0 q?8z10-762j TO Sep A+.auoucrhon. �
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK='(check all that apply)
New Construction ❑ Existing Building CI Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:: Rn M� p oet (�i V Lthe
SECTION 4: ESTINUTED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only,.,
Labor and Materials
1. Building S C� (7t)O 1. Building Permit.Fee $ Indicate how fee is'determine d:
2. Electrical $ ❑ Standard City/Gown Application Fee..
❑ total Piolect Co at',(Item 6)x multiplier x
3. Plumbing S 2 Other Fees: $
4. Mechanical (IIVAC) S List: t l?S
5. [Mochanical (Fire
Su: ressioii Total All Fees: .$
Check No. Check Amount: Cash Amount:
6. l'otal Project Cost: S C t 0 0 0 Paid in Full 0 Outstanding Balance Duo___
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number E.epinnion Date
Name of CSL f!older
List CSL Type(see below)
No. and Street Type Description
U Unrestricted (Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwellin
City/Town, State, ZIP M Masonr
RC Roofing Covering
\VS Window and Siding,
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
MC Registration Number Expiration Date
FIIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, 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 BE COMPLETED WHEN .
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.
Print Owner's Name(Electronic Signature) Date I
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 understanding.
Print m"'s or r\uthorized:\gent's N;une(Electronic Signature) Dnte
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. I42A. Other important information on the FI[C Program can be found at
www.mass.00vioca Information on the Construction Supervisor License can be found at www.mass.lk iclL
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _(including garage, finished basement/attics, decks or porch)
Gross living area (sq. 11 _ Habitable room count
Number offreplace Number of bedrooms -- ----
'
Number of bathroom n
s Number f half/baths
I'ypc of heating systont -__-- _ Number of decks/ porches " -__--
Fypeof Cooling system -- Enclosed_--------__(Ipcn _
3. `'Folal Project Squu rr Footage" finny be sub�litutcd dor''Twt it Project Cott"
�Yf
,r CITY OF S.UZ f, .ALvL-1SSAcHUSETTS
�� ►N j �' BUILDIING DEPART76MiT
120%VASHLNGTON STREET, 3" Rooa
\ TEL (978) 745-9595
KIAffiERL EY DRISCOLL FAA(978) 740-9846
NLWOR THON"S ST.PIERAE
DIRECTOR OF PUBLIC PROPERTY/BUILDMG COSOIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit kt 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:
J'Z
(name of hauler
The debris will be disposed of in :
---
(name of facility) _
l L9 u (ts,4e n.. I Uy�4
(address of tacilay)
ignanire of permit aPPlicant
date
CITY OF S-U-EM
PUBLIC PROPERTY
DEPARTMENT
w.a. 1 b WADWNG OS lnasr•!LACK wsfAow MM 01911
M 9'L145•95"• F.Aa.975-746164
HOMEOWNER LICLNSS EXEM"TON
Plow filet
Job Loeaticn 2` l A
Home Owner Address_ C A
Home Owner Telephone Z o `? 6 $ 1
Present Mailing Address .
The current exempdon of Homeowners"was extended to include owner-occupied
dwellings of two Units or few and to allow such homeowners to engage so individual for
hire who.doe not possess a licaaso provided that the owner acts as supervisor.
DEFENMON OF H0NMOWNER
Persona) who owns a parcel of land on which he/she resides or Intends to reside6 on
which there is, or is intended to be,a one or two flintily dwelling, attached or detached
structure accessory to such use and/or farm structures A person who constructs more
chap one home in a two year period shall not be considered a homeowner. Such
--homeowner"shall submit to the Building Oilfcial,on a form acceptable to the Building
Official, that he/she be responsible for all such wort performed under the Building
Permit
The undersigned "homeowner'assunscs responsibility for compliance with the State
Building Code and other applicable bylavn and regulations,
The undenigned "homeowner^certifies that helshe undentands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
will comply with said procedures and requirements.
HOMEOWNERS SIGNAMW
APPROVAL OF BUILDING NSPECTO i
See other side far state code