3 VARNEY ST - BUILDING INSPECTION a
f , The Commonwealth of Massachusctts
Board ol'Building Regulations and Standards CITY
� a OF SALEM Massachusetts State Building Cute, 7S0 C'MR, 7 edition
Rrviarr/Jonarov
Iuilding Permit Application To Construct. Repair, Renovate Or Demolish a
One-or rsvu-Faqssly Dwelling
This Sccliqfi F4r OlTicial Use On
Building Permit Num r. Dale Appli .
Signature: 0,7.i•-J —1/ d 3&
Building Cumminianer/Inpecwror Suildin Date
SECTION I SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map dt Parcel Numbers
I.1 a Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning lolormatlon: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq 11) Frontage(11)
WSign&
Building Setbacks(R)
Front Yard Side Yards Rest Yard
Provided Required Provided Required Provided
Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewsp Disposal System:
Private O Zone: _ Outside Flood Zane? Municipal O On site disposals stem O
Check if n0 y
SECTION 2: PROPERTY OWNERSHIP'
s of Record .
�
Address for Service:
Telephone
SECTION 1 DESCRIPTION OF PROPOSED WORK"(cbeck all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) ❑ AdditionJO
Demolition O Accessory Bldg. 0 Number of Units_ I Other O Specify:
Brief Description of Proposed Work':
Nw i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials OHlclal Use Only
I. Building Is 1 1. Building Permit Fee: S Indicate how lee is determined:
�. Electrical S O Standard City/Town Application Fee
O Total Project Costs(Item 6)x multiplier x
1. Plumbing S 1 2. Other Fees: S
4. Mechanical (iIVAC) $ List:
S. Mechanical (Fire S
Suppression) Total All Fen:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S a Q 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.iccnse Number lapimtiun Ihte
Name of CSL• I kidder IJA CSL type(see below)
f Ihscri ion
:%ddress U [In l0 31.000 Cu.Ft.
R Rcstricicdl&2 Family Dwelling
Siy"ature M M' Only
RC idential Roulin Coverin
felvp r WS Residential Window anJ Sidi"
SF Residential Sal(d Fuel A..in Appliance Installatiun
O Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Cum any Nam or IIIC Registrant N e� Registration Num
Address Es ' Lion Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. f 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 ..........0 No...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
p 1 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.
Si ure of owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
X1 ,as Owner or Authorized Agent hereby declare
that the s emenrs and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print =a
Signature of owtm or Authorized Agent Date
Si under the pains and (ties of 'u
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 gg 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 790 CMR Regulations I I O.R6 and 1 I O.RS.respectively.
When substantial work is planned,provide the information below:
Total Iloors 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
Typeofcoolingsystem Enclosed ()pen
). "Total Project Square Footage"maybe substituted for-Total Project Cost"
s
%off CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
dktl1 ! HI I.1'!'Rlx.I'•I I.
V`.lia+ 120 W.\il II\GIoNSrIt LET • SA I.M. MAiiAt.I It it I-liJ19
I LI: 978.74 i.9395 ♦ 1'Ax:978.74C-'t846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
—__ - Debris,-and tlte-provisions.of.MGL_c 40,_5-5.4;_._,
Building Permit if _ -
is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
1 l 1. S 150A.
The debris will be transported by:
Ineme of hauler)
The debris will be disposed of in
{address of facility)
slgy afore of Ixnult apphcant
V date
dcbri:al l.dot
CITY OF SM.Elf
PUBLIC PROPERTY
DEPARTtitENT
v.Ot,.fY 0.
VArw 130 wAwvdGrow sneer.11 m'1 r,N MAOe.'srrts OW0
M+7s•745•9sss•t..r r.s.»osw
HOMEOWNER LICENSE EXE.MMON
Pleaw hhit
Date CA-al - l0
Job Locedoet ',:�cfi\,Ah tilc o�0.Z O
Home Owns Address
HomeOwns?elephooe 5t2 —74 l4rS
Present Mailing Address Sam
The current exemption of"Homeowners"was extended to include owns-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who,does not possess a license`provided that the owns acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s)who owns a paeael 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
Pamir.
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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures Ir uirementL
HOMEOWNERS SIGNAMME
APPROVAL OF BUILDING CiSPECT R
See other side for state code