8 BARTON STREET - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board ol'Buihfing Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
r Reviser/Jurnmry
Building Permit Application To Construct, Repair, Renovate Or Demolish a l• =t/ttiY
One-or Two-Family Dwelling
This Section For Official Use Only
Cv1 Building Permit umber: ol 4, Jgale-Apphed:
^ ^ Signature: /)/�V
1\�(J Building Commissi Inspect Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
V i 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(R)
From Yard Side Yards - Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O ner'of Record: / /
64.1
Name(Prim) Address for Service:
Signata Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Descript'on of Propose Work=:
v
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCIRl Use Only
Labor and Materials
1. Building S 1 I. 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 (FIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No. Check Amount: - Cash Amount:
6. Total Project Cost: S�D�,�� ❑Paid in Full ❑Outstanding Balance Due:
�^ �� •� �o�t o at-ri(v'
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
���/',on `��iJ ,,,(���"'— Licenx'Na.SSm//belr�— apirati`urn�Uate
Name of' 'L• Ilol(J�er I.ist CSL type(we below) /'v5
rs De Description
.4JJres U Unrestricted(up to 35.000 Cu. Ft.
Ct� R Restricted Idt2 Family Dwellints
Si nary ..g � M Masomy Only
II�/GGTTOD RC Residential Roofina Coverin
I"elephone WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 R iste�6e'Ed Hom Impro meat Contractor(HIC)
an/y�N a ur k C RegistName Reg ras'26,n Num
AJJre 5n?;/gJ 70 Lr'
7/ ����"LNf!(Ji7 Espirati n Date
Signatu Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 ISC(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 to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Sinned under the pains and penalties of 'u
NOTES:
1. 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 W 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 7110 CMR Regulations 1 IO.R6 and 1 IO.RS,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"