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13 BARR ST - BPA-13-698 INSULATION n The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM / Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a One- or Two-Family Dwelling "tx This Se fi F600fficial Use:Or ly Building Permit Number Date:A hed - S,ignature ?•` Date Buddingofacial;.(Pnnt Nam e) y ' SECTION 1 SITE I 0.ORMATIO, 1.1 Property Address 1.2 Assessors Map& Parcel Numbers Map Number Parcel Number I.Ia Is this an accepted street? yes_ no_ 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 q Re( Provided Required Provided Required Provided uired 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 yes❑ :..., SECTION 2Y'PROPERTY.OWNERSHIP' 2 O nert of Rec rd:/ / M �Cit a e,ZIP Name(Print) 7 0� -3i ear 978 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WOW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief DescriRtion of Propo ed Work': SECTION Q: ESTIA4ATEIXCONSTRUCTION COSTS Estimated Costs: Official Use Only [tern Labor and Materials ' 1. Building $ Ot �a 1 Building Permit Fee $ In sate how fee is;determined;, ❑ Standard Ctry/Town Apphcatton Fez 2. Electrical $ ❑Totalitolect Cost'(Item 6)xmultipher x . 3. Plumbing $ 2 Other Fees::$ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: S. Suppression Check No. Check Amount Cash Amount',- 6. Total Project Cost: $ 6 2 CI Paid in Full ❑ Outstanding 13a1mtce:Diie: / a�` C SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ©Oa�� /y 0 Q License Number Expiration Date Name o/f(CSL -folder 1 . 4 f e / n v List CSL Type(see below) y- �J S No and Street [ ' /'r Type Description: ( O U Unrestricted Butldin s u to 35,000 cu. ft. M YJ R Restricted I&I FamilyDwellin Cit /Tow fate ZIP q y M Masonr RC Rootin Coverin WS Window and0" S Solid Fuel Burning Appliances , I Insulation "Cole one Email address D Demolition /5.2 'R,egistered Home Improvement Contractor(HIC) 14, kv; die " Q h �-5 HIC Registration Number /Expirazion Date HIC Com nX.Nat I�e or HIC R istra Name N and Street O/ Email address t /To State, ZIP 4 Telephone I I� 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 wilt result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... Cf 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—)j/—/Z,(yyJ d-e a q/ Q to act on my behalf, in all matters relative to work authorized by this building permit appl ati � ro 10- l / Prmt 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 I licatign is true and accurate to the best of my knowledge and understanding. - A �"2r Co/(ema h : /o?A3 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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 %_vww.mtus.,,ov%oca Information on the Construction Supervisor License can be found at www.mass �-,ov.(Ims 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. R) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number ofdecks/porches _ Type of cooling system Enclosed _Open �d_ "fotal Project Syuare Footage" may be substituted for"Total Project Coat"