17 VARNEY ST - BUILDING INSPECTION (2) The Commonwealth of Massachuscus
Board of Building Regulations and Standards CITY
\, OF SALkM
Massachusetts State Building Cude, 780 C'MR, 7'edition xrvirrJJwuu.vr
a� Building Permit Application To Construct, Repair, Renovate Or Demolish a
\ C One-or Two-Family Dwelling
�1V^) This Section For O.(ticial Use Onl
Building Permit Number Date Applied:
Signature: 'L Z ` 0
Huilding Come isaioned Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: A 1.2 Assnsors Map A Parcel Numbers
r-71ferne—W 57�11� IT fro � (09 —d
I.1a Is this an accepted street?yes no Map Number Parcel Number
1-3 Zoolag Information: // 1.4 Property Dimensions:
�elro�Gti A r,� g FrD o 3 (o F%
Zoning District Proposed Use Lot Am(sq 11) Frontage(11)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public G/ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system- ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP' e
2I o o�M L-`d9ea.� � 7 t/GVr11ec� ��� �d� ftM rM�
Nome I Address for Service: C—el
Sign ure Telephone �—
SECTION 2: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition 01
Demolition ❑ Accessory Bldg. O 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Wor •: W1 02 4FAF a n ` X 2fJ ` belcx
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building s loo3Y 1 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier x
). Plumbing S 0 —J 2. Other Fen: s
4. Mechanical IHVAC) s List: r
5. Mechanical (Fire S D
Suppression) Total All Fees:s
A Check No. Check Amount: Cash Amount:
6. Total Project Cost: S �VQ 0 Paid in Full 13 Outstanding Balance Due:
,
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
A((A- License Number Expiraliun I}atC
Name ot'CSI_• I lulder List CSL fype lsoe below)
f Oescripeion
Address U I Unrestricted(up to 31,000 Cu.Ft.
R I Restricted IR2 Family Dwelling
Signature I M I masom Only
RC Residemial Rooling Covering
felaphnute WS Residential Window and Siding
SF Residrntial Solid Fuel Bumin A fiance Installation
D I Residential Demolition
[5.2Reghterc:d Home Improremeat Coatnctor(HIC)pany me or HIC Registrant Name /^ Registration Number
rt/ Espiralian Date
'felephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a ISL/ 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
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. -
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, Z , -e as Owner or Authorized Agent hereby declare
that the statements and information on the forcgoin ap Nil are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signalu t' rater w Aut on nt Date
iSiunedunda the pains and Penalties of 'u
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home improvement Contractor(HIC)Program),will dW 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 110.R6 and I I0.R5,respectively.
When substantial work is planned,provide the information below:
Tidal floors area ISq. 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 healing system - Number of decks/porches
Type of cooling system Enclosed Open
). "Tula, Project Square Footage"may be substituted 1'or"Twa, Pmjed Cost"
CITY OF &XI-EM
PUBLIC PROPERTY
DEPARTvmENT
waWi�M='�3
M 9-3•715`9sss• FAX f.t}7+o.7sw
HOMEOWNER LICENSE EXEMPTION
Plea"Enter
Data 2/ ?a v
Job cation (lQr»e & �� a/tti( M d i97d
Home owner Address
Home ownar Telephtma 97 - 30fe, 321(49
Present Mailing Address its/ AIrJ
no current exemption of"Homeowners"was extended to include owneroccupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a Hcens%provided that the owner acts as supervisor.
DE 1NMON OF HOMEOWNER
Persons) who owns a pared of land on which he/she resides or intends to resider on
which them 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 shag not be considered a homeowner. Such
''homeowner'shall submit to the Building O®cial,on a form acceptable to the Building
Ofllci4 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requ' eta. �✓
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR
See other side for state code
kJj I Y Vt' OALLIvt
- �r sp. PUBLIC PROPRERTY
'''. .' DEPART vIENT
1
Ili v'9-'I;.r; 5 � 1 ��. ':'�.•�_' ;bi
Construction Debris Disposal Afticlavit
(required lirr all demolition :old renuvation work)
In accurdancc %\itb the sixth edition of the State Building Code, 780 CNIR section I 1 1.5
Debris, and the provisiuns of MGL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licuued waste disposal I•acility as Mined by MGL c
1I1. S 150A.
The debris will be transported by:
r7runer �S �u G//,
I name of hmdrr)
l he debris will be disposed of in
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