406 JEFFERSON AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�y Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
'n Building O�cia1(Print Name) Signature Date
U I SECTION 1:SITE INFORMATION
1.1 Pro a Add 1.2 Assessors Map&Parcel Numbers
L410(n T� SON AVE'
L la 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 tt) Frontage(It)
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.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Rec
l��ol+N �q(rotnJS 0/?70
Name(Pri-nt)t)�� City,State,ZIP ry a
Z�D\JcEf soN A)P 9��;3 �/�/
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: ,4 ✓tlV
P !y!!pj o C134 rtr -C,
B— cti✓�✓ACC aL
2 DAR i A¢
SECTION 4:ESTIMATfD CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ S j6 "�=' 1. Building Permit Fee:$ Indicate bow fee is determined:
2.Electrical $ 20CX0 0 ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ U t List:
5.Mechanical (Fire
Supp,ression) $ Total All Fees:$
6.Total Project Cast: i
00 Check No. Check Amount: Cash Amount:
$ '—
❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date ;� ,
Name of CSL Holder
List CSL Type(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)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant 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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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.) 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"maybe substituted for"Total Project Cost"
CITY OF SALEM, MASSAC IUSETT_S
BUILDING DEPARTMENT
120 WASHNGTON STREET,31D FLOOR \`
TEL. (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location q0(-, :,_4erG,,U Ake A4j4
Home Owner Address 410b �,J 4er5Obd ,4w 9>'Q1ew .*74
Present Mailing Address qo(o \7e,`7 15,OAA& 5�E"" y*
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official,on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE i r
APPROVAL OF BUILDING INSPECTOR `IilP!(4L
CITY OF SALEM, MASSAChI SE M
BLQLDiNGDEFARTMENT
120 WASFIINGTONSUEET,3'mFLOOR
nL.(978)745-9595
K1MERLEYDRISOOLL FAX(978)740.9846
MAYOR THOMBS ST.PIERRE
DIRECTOR OF FUBLICPROFERTY/BumDING O[)IsuSSIONER
Construction Debris Disposa/Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL 00, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
wn �AiyS-Kr^
(name of facility)
OJA��6�"'IL �17
(address of facility)
ignature of applicant
�o -c2
Date
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Commonwealth of Massachusetts
Citv of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 a5641
nuae n°
Return card to Building Division for Certificate of Occupancy -
Permit No. B-15-132
FEE PAID: $245.00 P EFIr Msm I T T 0 RL3h U I L D
DATE ISSUED: 212 412 01 5
This certifies that BARROWS JOHN J MICHALSKI JANINE D
has permission to erect, alter, or demolish a building -^a_ 406 JEFFERSON AVENUE Map/Lot: 310091-0
as follows: Renovation FINISH BASEMENT (PLANS ON FILE) IN A SINGLE-FAMILY HOME.
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Contractor Name: j�
PETERJ. BARBAGALL0
DBA:
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Contractor License No: cs-060149
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a 6i4r 2/24/2015
r 0' BU'Idino-Official , k `�`� + fi Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request: " ,y
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
$ pitr
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same.
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The Certificate of Occupancy will not be issued until all,applicable signatures by the Building and Fire Officials are provided on this permit.
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H IC#; 165538 'Persons contracting with unregistered contractorsrs do
not have access to the guaranty fund"(as set forth in MGL c.142A).
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Restrictions: ° a 17
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Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.