12 BARTON ST - BPA-13-618 MINOR INTERIOR UPDATES ^ * S
\yJ� The Commonwealth of Nlassachusetts
Board of Building Regulations and Standards CITY OF
J.' Massachusetts State Building Code, 780 CIN S
Revised Mar
Marar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For'Official Use Only
Building Permit Numbers' Daie�fhpphed;.
Building Official(print Name) . '5'gnature; Date
SECTION 1: SITE INFORMATION
L1 Property Address: 1.2 Assessors Map& Parcel Numbers
i2 &-krfion SFree=+ 3(0 040V
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 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public ❑ Private ❑ Municipal if yes❑ unicipal ElOn site disposal system ❑
SECTION2:,`PROPERTY'OWNERSHIPI'
2.1 Ownert of Record:
SgrcCh t• L0&)insc�r-) Salem NP 019-TO
Name(Print) City,State,ZIP
(2 Bo-ri-o,') S}rem{ #2 979-831m7ZS3 ShutCV)inson I0&0(G:)1Moj ,ccm
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) .'.
New Construction ❑ Existing Building ❑ Owner-Occupied Cl Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'.
M'inr�r ln-I-e-ricer t%eno�c�-h'�ns
v�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Rem Estimated Costs: Official Use Onl
Labor and Materials y`
I. Building $ l Building Permit Fee $ indicate how fee is determined:
o
❑.Standard.Ci /Town A" lication Fec
). Electrical $ - h' PP
❑Tota1 Project Cost',Qtem 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (iIVAC) S List:
5. Mechanical (Fire $
-Suppression) 'total All Pees: $
_ Check No. Check Amount: Cash Amount:
6, Total Project Cost: S Dov, 11 paid in Full ❑ Outstanding Balance Due:
SEC'TION5: CONSTRUCTION SERVICES
5.1 Constriction Supervisur License(CSL.)
License Number Expiration Date
Name of CSL Ilolder
List CSL Type(see below)
No. and Street Type Description
U Unrestricted Buildin s up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
City/Town, State, ZIP 11VI Niasonr
RC Roofing Covering
WS Window and Skiing
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Emait address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No. and Street Email address
City/ own, State, ZIP Tzle hone
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 will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... 11
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN .
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[, 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
_on arced iinit�hiQiss application,is true and accurate to the best of my knowledge and understanding.
P itrt wner's or r\ riz 's Nanuuc Signature) 2 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 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 LIIC Program can be found at
www.m;us ov%ilea Information on the Construction Supervisor License can be found at www.Inass.so�/dp_;
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;uea(sq. ft.) _ Habitable room count
Number of fireplaces_ Number of bedrooms
Number of bathrooms _ Number of haltibaths
fype of heating system -_--__ _ Number of decks/ porches ---- --
1'ypeofcoolingsyuem-- —_---_-- Enclosed--.—__----Open _
3. "Fotal Project 5qusre 1'00tage" way I e Sub,tituted for"l otal Project Cost"