17 BARTON ST - BPA-14-992 REDO KITCHEN, BATH & DECK K
�1 The Commonwealth of Massachusetts
Board of Building Regulations and Standar'OECEIVEQ CITY OF
Massachusetts Slate BuildingCode,
MONAL SERVICES SALEM
Building Permit Application To Construct, Repair, Renovate Or 3 mi lis(La2
One-or Tivo-Family Dwellin A � — P [[
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Date
SECTION l:SITE INFORMATION
L, Pro ert ddr ss: 1.2 Assessors Map& Parcel Numbers
--i .
1.1 a Is this an accepted street?yes—XL no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
L6 Water Supply:(M.G.L,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood%one?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1„Owner�of Record: S /. c �
( D '� (
Name(Pri City, State,ZIP
I St
No.and Street "telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied WJ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of nits Other ❑ Spccily:
Brief Description of Proposed WorkZ: ,� r"�L ko= .,-e.✓
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ Ooc),Do I. Building Permit Fee: $ Indicate how fee is determined:
O _ ❑Standard Cityrrown Application Fee
Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. plumbing $ (� , 2. Other Fees: $
4. Mechanical (IIVAQ $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No.__Check Amount: Cash Amount:
G. "Dotal Pro,iect Cost: $ � �S(], c� 'D ❑ Paid in Pull ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
17.)JA License Number Expiration Date
Name of CSL Holder r
List CSL'Cype(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition _
5.2 Registered Home Improvement Contractor(HIC)
tIIC Registration Number Expiration Date
kIIC Company Name or I IIC kcgistrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
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...........❑
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: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
cont e e in this ap Iication is true atitd acc t to the best of my knowledge and understanding.
r✓L
Pri -wner's or Authorized i 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 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 FIIC Program can be found at
www.ntass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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. ft.) I-labitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms_ Number of half/baths
Type of heating system_ _ Number of decks/porches_
Type ofcooling system Enclosed Open_
3. "Total project Square Footage" may be substituted for"Total Project Cost"