16 BARSTOW ST - BPA-13-659 SHED =� The Commonwealth of Massachusetts
a ° OF
Board of Building Regulations and Standards CITY SALEM
Revised Mar
Massachusetts State Building Code, 780 CNIR Revised
2011
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 pplied:`
lC �
Building Official(Print Name) V Stgna Ere - Date
SECTION 1: SITE INFORtNIATION
` 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map 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 2., PROPERTY OWNERSHIP'
2.1 Owner'of Record:
,,A�O J rLl's
Name(Print) City,State,ZIP
'<'A-M �e
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': /tPIAIo✓ a 'Tids7ALL1 S';e /6 S/)aGQ
:> e;y
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only"
Labor and Materials yY'
I. Building 1 Building Permit Fee. $ Indiiiate how fee is determined:
❑ Standard City/Town Application Fee.
2. Electrical $
❑Total Project Costs,(Item 6)x multiplier. x
3. Plumbing S 2. Other Fees: $. .
J. Nlechanical (FIV:AC) S Lisi:�
5. Mechanical (Fire $
Su> ression) Total All Fees: ,S
Check No. Check Amount: Cash r\mount:
( Tutnl Project Cost �S aSpp, pp 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 COliStrnl'ti011 Supervisor Liecnse (CSL,)
License Number Expiration Date
Name ofCSL Holder
List CSL Type(see below)
No. and Street — Type. _ Description
U Unrestricted Buildin s up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town, State, ZIP Nt Masonry
RC Roofing Coverin
WS Window and Siding
Sr Solid IF Burning Appliances
I Insulation
relz hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IiIC)
HIC Registration Number Expiration Date
HIC Company Name or I11C Registrant Name
No. and Street Email address
City/Town,State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. e. 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
I, 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
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 Aullwrized:\gent's Name(Electronic 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 Hmne Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under bLG.L. c. I42A. Other important information on the HIC Program can be found at
www.mass.<,ov/oca Information on the Construction Supervisor License can be found at NvwNv,mass.�ro JL_i
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 of fireplaces_ Number of bedrooms _ --_--
Number of bathrooms Number of half/baths _
Type of heating system _ Number of decks/porches
I'gpe of cooling system —-- Enclosed
("3_ "I'otal Project Squ:u-0 Foomgr" inay be. substituted Cnr"I'otal Project Co,I" --_ -
CITY OF Sm-mof
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNSE EXLMMOX
P1arw Mot
Date
Job Location
Home Owner Address SA.n
il!ome Owner Telepboae 44/ova
Present Mailing Address /lam Bi9�S� uJ
The current exemption of"Homeownars"was extended to include owner-occupied
dwellings o[two Units or teas and to allow such homeowners to engages ast individual for
hire who does not possess a license provided that that owner acts is supervisor.
DFyiN ION OF HOMEOWNER
Person(s) who owns a posed o/land on which hdshe resides or intends to reside.on
which than h6 or is intended to bs,a one or two family dweWng, attached or daubed
structures accessory to such use and/or farm structures. A parson who constructs more
than one home in a two year period shag not be considered a homeowner. Such
"homeown s"sW submit to the Building Official, on a form acceptable to the Building
Official, that hdshe be responsible for all such wort performed under the Building
Permit
The undersigned "homeowner^assumes responsibility for compliance with the State
Building Code arsd other applicable by-laws and regulations
The undersigned "homeowner"certifies that hdshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdahe
Will comply with said procedures and requirements
HOMEOWNERS SIGNATLW � o
APPROVAL OF SUILDNG INSPECTOR '
See other side for state code