54 BARSTOW ST - BPA-15-985 INSULATION Ct' u
V) The Commonwealth of Massachusetts
60 Board of Building Regulations and SKdpZWEd CITY OF
SSALEM
Massachusetts State Building izOrLIVIA. S-Z d+CE edAhjr 2011
Building Permit Application To Construct, Repair, Renovate Or getp j� a
n One-or Tivo-Family Dr zkE? I S FF
J This Section For Official Use Only
Building Permit Numberr, Date Appl' dr
_
Date
Building 017i ml(Print Name). signature
SECTION L•SITE'INFORh1AT10N'
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
S y BA�S7ool s
fl 1.1 a Is this an accepted street9 yes no Map Number Parcel Number
9 1.3 'Zoning Information: 1.4 Properly Dimensions:
Lot Mca(s 11 Frontage it
Zoning District Proposed Use 9 ) g ( )
r � � 1.5 Building Setbacks(R)
From Yard Side Yams Rear Yard
M-
Requiwd Provided Required Provided Required Provided
fA
JA 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
`l Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
.f Public❑ Private❑ Check if yesO
SECTION2. PROPERTYOWNERSHIP"
f 2.1 Owner t of Record:
K to SrlLfm� Mi4 1Si97D
J �hme(Print) City,State,ZIP
SY RARs>ocO r7 &2-47,9-.2073�
No.and Street Telephone Email Address
J SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
M -Z
New Construction❑ Existing Building 02/ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other Specify: UXALMM 17QT/bAl
Brief Description of Proposed Work:
TAJSOLA7E 1111f 4, F)(rLP16A WAILS wlrq &aWAI CtlLOLQSE —
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 00 I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2, Electrical S ❑Total Project Cosh(item 6)x multiplier x
3. Plumbing $ 2' ether Fees: S
4.Mcclimical (HVAC) S List:
i.,\feehanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S�TSS�Jo ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES +
5.1 Construction Supervisor License(CSL) C 1667s8
/M NAMM _ License Number Expiration Uate
Name of CSL Holder list CSL'rype(see below)
�. ' IMA10Aj. QD Type. . - Description
No. ;md Street s
i U Unrestricted(Buildings u -to 35,000 cu. tl.
E > �� W fff) R Restricted l&2 FamilyDwelling
Cityam".State,'ZIP M Masonry
RC Rooting Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
6�7 591-A819 1 I Insulation
Telephone. Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) 1/0
STI CCAi ('CWI CO - HIC Registration Number Expiration Date
IIIC Comp:my Nmne ur IIfC Registrant Name
376 2Sh"('J'TON �
No. and Street Email address
T Mdibn) MA.
�a��-s91-6s19
City/Town. State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.QL.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 ..........O/ No...........O
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 S71CCA fONTR• CD
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
riot OwncCi Nhme(Electronic Signature) Dale
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.
Pr nt Owner's or Authorized Agent's Name(Electronic Signature) Dale
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 nut have access to the arbitration
program or guaranty fund under I.G.L.c. I42A.Other important information on the HIC Program can be found at
aww mass.eov'oea Information on the Construction Supervisor License can be found at w+v�!dns
2. When substantial work is planned,provide the information below:
'rota) floor 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 ofcoolingsystem Enclosed Open
3. 'Total Project Square Footage"may be substituted tor-Total Project Cost"