19 BARSTOW ST - BPA-10-756 REROOF ^ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building j Code, 780 CMR, 7ih edition OF SALEM'wsi Revised Januury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numb/r: Date Applied: /T�
Signature: (. �� l0
Building Commissioner/lospector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro a ddress: 1.2 Assessors Map&Parcel Numbers
1.l 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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wate4,�Lupply:(M.G.L e.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 Re ord.
Name((Pfinl) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other, ❑ Specify:
Brief Description o Pro V✓
posed/W+Work': ?L
�v'nt s D` 62 ,�,..fir rT6 '
E
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofticiel Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
!, ❑W Check No. Check Amount: Cash Amount:_
6.Total Project Cost: S ✓ l�lJ�v Paid in Full 13 Outstanding Balance Due:
,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Cons ruc on Supervisor(CSL) C,
b/J��2 7,. License Number lispiml' n Uate
Na�m[/,e'u�'f.4if I lul r 9 /���y List CSL Type(%"below)
-/U 'f Description
Add� U Unrestricted(up to 35,000 Cu.Ft.
- R Restricted I&2 Family Dwelling
Signatur, M Masonry Only
RC Residential Rouding Covering
Te ephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 �teg tered Horgg 1 rove�mentt Contractor(HIC)
111C Com C HIC Registrant N Registralio Number
D, P. r 1% o/pie 1i l/o
AdJ , -/j' P
Es iration Date
Signs ore Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
��{ $ - f'GI,kS /�'�` as Owner of the subject property hereby
authorize 24v�� l to act on my behalf, in all matters
relative to work authorized by this building permit application.
�`�41�
Signature of Owner Date
SECTION 7b,:: OWNNEW OOR AUTHORIZED AGENT DECLARATION
661 L ,as Owner or Authorized Agent hereby declare
that the statements and information o the foregoing application are true and accurate,to the best of my knowledge and
behalf
Print N=
e
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
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. "Total Project Square Footage"may be substituted for"Total Project Cost"
i_