12-14 VARNEY ST - BUILDING INSPECTION R
Z' The Commonwealth of Massachusetts Pr
ITY
Board of Building Regulations and Standards L OF AL
FM
Massachusetts State Building Code, 780 CMR, T°edition
l ReviseddJanuvurrrrury
C� Building Permit Application To Construct, Repair, Renovate Or D molish a /. 2//0
V^` One-or Two-FumilylRwelling
This Section For Offifial Usg Onl
Building Permit Numbe : JDate Appl•'
Signature: � �
Building Commissioner/Ins rof Buildings 1'/r/ q to
SECTION 1: SITE INFORMATION
1.1 P e Addre 1 YAssessors Map& Parcel Numbers S�
-�� 1 �'c�rr��—► Ste- <'Ct�C�^/1 I45�
I.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 B) Frontage(11)
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? Municipal O On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP' @ c.
2.1 Otvner�f Rec or
Name Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check allgapply)xisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ A Addition ❑Demolition Accessory Bldg.❑ Number of Units Other ❑ SpecBrief espti n of roposed rkc-'•. J�L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityrrown Application Fee
2. Electrical $ ❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
J Check No. Check Amount: Cash Amount:
6. Total Project Cost: S S�YV �1�,, Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) Q
CSZ "l
� .� U,3 � —� License Number F:rpimuon Uate
Name ol'C'S •'llolJer �' List CSL Type(see below) r
Z -moo LS ( �rrgC
AJJ ss T Description °
U 11 Unrestricted(up to 35,000 Cu.Ft.
Restricted IR2 Family Dwelling
Signal �^ M Mason Only
y , �� ` �"� ( RC I Residential Roofing Covering
Telepho`ne� � r: ai T�/�' WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... O No...........0
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
I, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature 'O r or Authorized Agent Date
(Signed under,h ins and penalties ofperjury)
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 Rol 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 780 CMR Regulations I IO.R6 and I 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"
Y
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
b..4V)C 41M/S •111 1'fit•'/71•.•W111M
fft.
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the si, edition of the State building Code, 790 CMR section 111.3
Debris, and the provisions of MGL c 40,S MGL c
is issued with the condition that the debris raultinl{ m
building I'errnit Nam_- rl licensed waste Disposal facility as defined by
This work shall he disposed of in properly
111. S 130A.
The debris will be transported by:
(110111Q ut hauler)
The debris will be disposed of in :
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