5 VARNEY ST - BUILDING INSPECTION (2) �.
y
y� The Commonwealth of Massachusetts
CITY OF
I� �'" - Board of Building Regulations and Standards
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 Appli d:
Building Official(Print Name) Signafure Date
SECTION 1: SITE INFORMATION
1.1 Pro ty Address: 1.2 Assessors Map& Parcel Numbers
z_ riote 4-,�_
1.1 a Is this an accepted Street?yes no Map Number Parcel Number ,.
1.3 Zoning Information: 1.4 Property Dimensions:
'h
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks (ft)
iF
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.46, §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 Own of of Reco d: f�
RI &h Ard gOusol So je r1 )L'a •
Name(Pri t) City,State,ZIP
Srne!isL o ► ,� o -�c�S-5-3Y3
No. and St elephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': CeIIVIOSe / ' 'Sea-ling
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1. Building $ 10 0 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ - ❑Paid in Full ❑Outstanding Balance Due:
. 0
boll 7 0 reh//4C-41
4Ae'I RQlrlW11
i CITY OF SAL&N1, iNL--kSSACHUSETTS
BuumING DEPART.Nm%4'T
• A 120 WASHINGTON STREET, 3" FLOOR
�B.0 off` T EL. ()78) 745-9595
FAX(978) 740-9846
KiJfBERLEY DRISCOLL
MAYOR T HOhiAS ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LNUSSIO iER
Construction Debris Disposal 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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by: �y
6ZPL 5 t,21 ✓ o 6T625 Tn2 C /
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
AnKir f ermi pplicant
date
�chriuif.diw
° CITY OF &U.ENI, 1t'L-kSSACHLSETTS
BL'1LDING DEP ARTSLNT
120 WASHiNGTON STREET,3'a FLOOR
TEL (978)745-9595
FAx(978)740-9846
KISIBERLEY DRISCOLL
MAYOR THoNusST.PmRAE
DIR.EGTOIt OF PUBLIC PROPERTY/BUIIDLNG COSMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� 1 y �) Please)Print Le ibly
Name(Busimx OrganizatioNlndividual): �¢It �/�yt�t. //y,�AJC'CO .Vj Ulep a/
Address: 40 '&n is '8 .5
City/State/Zip: �.t�44 OIC,Oy Phone #: �Bi —S�C4`r�(57D
Are you an employer?Check the appropriate box: Type of project(required):
I. I am.a employer with ::1 _ 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the stab-contractors
2_❑ I am a sole proprietor or panncr- listed on the attached sheet. I 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp.insurance. g, ❑ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised thew
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself(No workers'comp, c. 132, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13, ier '
comp.insurance required.]
'Any applicam that chocks box BI must also fill out the Eeatioa below showing their worktms'compensation policy information.
r I bxneowner,who submit this affidavit indicating they am doing all work and then hire outside cmunittces man submit a new affidavit imtiating such.
=Co,stmvtan that cheek this box must rtbched sn aaditiwul ah:rt stowing iho name o(ths sub-eomm uto;and,heir workers'comp,policy inrmmvtion.
I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
informwiom
Insurance Company Name:_ C VNC A i( S /
Policy 4 or Self-ins. Lic.#:_0 S61 Vja Expiration Date:._/Z,
Job Site Address: Y Q . 7' A I' t City/State/Zip: Q/e&
\flash a copy of the workers'compensation policy declaration page(showing the policy cumber and expiration slate).
Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a
fine up to S t,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against die violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations ol'tlte DIA for insurance coverage verification.
I do hereby certif under the put.ns and penalties of perjury that the information provided above is true and correct
Data: 1
F6Other
al use only. Do not write in this area,to be completed by city or town official
r Town: Permit/Mcense#
g.\uthority(circle one)-
Is1. Board rd of Health 2, Building Department 3.City/town Clerk 4.Electrical Inspector 3. Plumbing Inspector
.._...ct Person: __ _ __. Phone#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
JEWiz,,2;v del Ay=a r7Q License Number Expiration Date
Name of CSL Hold r
List CSL Type(see below)
No. and Strreeteet/f .u�J �.r✓ l�iS 'L�wCSTUw/ y✓!7 Type Description
a
Unrestricted(Buildings up to 35,000 cu.ft.
ST�1ty/1 ��"� �3QL I R Restricted 1&2 FamilyDwelling
City/Town, State,ZIP M Masan
ry
I/, RC Roofing Covering
—��j-V-- WS Window and Siding
y.,, v SF Solid Fuel Burning Appliances
f d 1`�yr{ EEO 70 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
`` FAR, `� A!a'rZ-e �
-J � 'e� �� HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
�� �NCQ✓2.y✓5 L V
NR..b4and Street 2l
Email address
-tS 'Ty,nJ :v 1�
City/Town, Stat , 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.
ff t 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 J 1✓FFp—PV M60'7W,
to act on my behalf, in all matters relative to work authorized by this b ilding pe&it application.
Print Owner's Name(Electromc)gnature) 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
contained in this application is true and accurate to the best of my knowledge and understanding.
_)EGk-o-,l M V6F L G
Print Owner's or Auth rized 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
LA .mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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"may be substituted for"Total Project Cost"
Massachusetts- Department of Public SafetN '
Board of Building Regulations and Standards
CohS4r'ucYioq.Supervisor License
License;.CS 103474Yffl,e- s4..
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