50 BARSTOW ST - BPA-14-775 DORMER ROOF & ADD BATH f�)- L �- 1 � 5
C -7q- 1 tqq � c ljj
'rhe Commonwealth of Massachusetts CITY OF
- Board of Building Regulations and Standards SALENI
Q01TV
Massachusetts State Building Code, 730 CNIR RevisedMar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dlvelling
This Section For Official Use Only
Building Permit Number: DateAp led:
Building Official(Print Name). Signatura Dal
t SECTION 1:SITE INFORMATION'
1.( D P�r �tit Su W SI 1.2 Assessors binp 3r Parcel Numbers
re
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Lot Area(s tt Frontage(It)
Zoning District Proposed Use 4 )
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.q0,§Sq) l.7 Flood Zone Information: L8 Sewage Disposal System:
,,C Zone: _ Outside Flood Zonal Municipal On site disposal system ❑
Public p� Private❑ Check if yespi
SECTION 2: PROPERTY OWNERSHIP! /
2.lAD wrier la(\Recgr�dy �e� �a�y (/1/IQ Ol9DU
I��111 (Print) r.( Imo— City,Slate,ZIP
7-f-f" et c
Nu.and Street f epho a L'tnail Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed 1Vork': wa C✓' o
y(L' w I i� {f, oow, I ` vOaC
SECTION d: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building $ Sd OrrTf I, Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical 5 L rr>r ❑Total Project Cost'(Item 6)x multiplier//�-----x
3. Plumbing .$ U-pTr 1. Other Fees: .$
t. Mechanical (FIVAC) S G� List:
i. :\fech.mical (Fire $ total All Fos:S
Su ression)
Check No._Check Amount: Cash :\mount:_
!. Total Project Cult: $
4. V-� 0 Paid in Full 0 Outstanding Balance Due:
r.
SECTIONS: CONSTRUCTION SERVICES
5.1 traction Supervisor License(CSL)
J/" License Number Expiration Date "
M i � }
Nat eol'CSLHulder ytr
- ` //' List CSL'fype(see below)
2:2 S Z�—" `��, ri
� � Type Description
No.;aid Street
U Unrestricted(Buildings tip to 35,000 Co. it.)
Restricted 1&2 FamilyDwelling
City7Envn,State,ZIP bl Masonry
IiC Rooting Covering
WS Window and Siding
Is ' lid Fuel Burning Appliances
1 Insulation I
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
city/town,State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.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 AGENTOR CONTRACTOR APPLIES 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 Maine(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I he/'ind
ains and penalties of perjury that all of the information
contained in this application is tru to th best of my knowledge and understanding.
`Z/
Print Owner's or Authorized Agcn ' nc( cuonic Signature) ate
NOTES:
1. Ain Owner who obtains ing permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the U14ae Improvement Contractor(If IC) Program),will nnf 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
www.nnass.eovoca Information on the Construction Supervisor License can be found at www.nlass.aOVAIL
�. When substantial work is planned,provide the information below:
total door area(sq. R.) (including garage, finished basemenUattics,decks or porch)
(cross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Numbcr of bathrooms Number of half/baths
l•ype of heating system Number of decks/porches
fypeofcoolingsyitem Enclosed Open..
1. • I'oial Project Square Footage"may be Substituted liar"fatal Project Cost"
i
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CITY OF SALE\ [, rtiL1SS:ICHUSETTS
13LIMLNG DEPART.NLE,NT
130 WASHLYGTON STREET 3t°
FLOOR
TEL (978) 743-9595
KIMBERLEY D2ISCOLL F.VX(978) 740-98M
NLAY01, Tiia sST.Ptum
DIRECTOR OF PUBLIC PROPERTY/HLILDLNG CO\B(ISSfONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CPAR section l l 1.5
Debris, and die provisions of,bfGL c 40, S 54;
Building Permit ik this work shall be is issued with the condition that the debris resulting From
l 11, S I SOA. disposed of in a properly licensed waste disposal racility as defined by �*vIGL c
The debris will be transported by:
t) L �t OSh
(name ofhauier)
The debris will he disposed of in :
— (name at facility)
-----(addrcssorfitcitily) f
signatur u'rper f applicant
CITY OF SAI.ENI, ANSSACHUSETTS
s BUILDING DEP1RTNUINT
120 W.�sHLNGTON STREET, 3w FLOOR
TEr- (978) 745 95 5
FAx(978) 740-9846
MfBERLEY DRISCOLL
MAYOR T'HORGIS ST.PIERAS
DIRECTOR-0F PUBLIC PROPERTY/BUMMIG CO'%WISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electri(!ians/Plumbers
Applicant Information Please Print Legibly
Name(Business OrganiiatiLiwindividujal�):/
Address: 27i Sft�T Tin �T
City/State/Zip: � �+ ale' Phone It q7f-S �`/oas�
Are you an employer?Check the appropriate box: Type of project(required):
1.99-f`am a employer with 4. ❑ 1 am a general contractor and 1 6. 1]New construction
employees(full and/or part-limo).' have hired the sub-contractors
2.❑ Irma sole proprietor or partner- listed on the attached sheet.I 7. 2E l cmodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. y, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL 11.❑ Plumbing repairs or additions
myself, [No workers'sump. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13.0 Other
comp. insurance required.)
-Any applimnt dun checks box el most also rill uui the amours below showing their worker'eumpensmiun policy nifiomation.
'I lomeowner+who nuhmit this anidavh indicating Ihry,arc doing all work and then hire outside contractors most submit a new arr?davil indicating such
;r'onucemrs thin check this box most onachcd an addiliunal dhect showing Ili name orthc sub•camnctors and their workin'comp.policy information.
I ant an employer that is providing workers'conlpeo radon insurance for my eatplaj ees. Below Is floe policy and Job site
inforntulion.
.Insurance Company Name: ___-.
Policy 4 or Self-ins. Lic. 0: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead Indic imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations al'the DIA for insurance coverage verification.
I do hereby ee if uncle he p t•mrJ eoahies of perjury that the infurnmtlon provided above is true and correct.
Data:
Offic•iul use only. Do not write in this area, ro be completed by city ur iown agirial
Ciry nr Town: _.__... .__ Permitfl.lcense N
Issuing Authority(circle one):
1. Board of Health 2,Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _.. .. _ Phone #:
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APPROVED
Subject to anY other
authority halPAag -
Fw.�'
PLANY APPRO ED SOLELY
TYPE AND LOCATION OF
ALL F,RC PROTECTION DEMCE_f=L•COpJET77 TO A
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