19 VARNEY ST - BUILDING INSPECTION - ---- I'he Commonwealth of lassachusclls
Board of Building Regulations and Standards CIT'l,OF
Massachusetts State Building Code, 75B(AIR SALEM
rerc+e Jurr
Building Permit Application To Construct. Repair. vote Or Demolish
One-or rn u-Futnifl Urre[ V
This Section For r ul Use Onl
Building permit Number: Da Applied• ! �7
Building Official(Print Mane) ISi t rc Ay --Dage` r /
SECTION 1:SITt IAFOVdAtiqN
I.I Propperty Address• I. sensor .Hap d's Parcel Numbers
cr �/em �Jlf/Ol�
I.la Is this an acce ted street?yes no AaP un 'r
I Parcel Nunttser
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Uw Lot Area(sq 11) Fronlage(11)
1.5 BuI1dIng Setbacks(rl)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. Jo,§54) 1.7 Flood Zone Inrormallon: 1.8 Sewage Disposal System:
Ihmblic❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipd❑ On site disposal s)stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor
fang ,n �aoi>i//lr rd f" /,a m l ���
N;/-:(r(Print) � � City.State,ZIP '
Nu.;utJ Street ' ielephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alterat(on(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ .Specify:
Brief Description of Proposed Work=:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
Il.abur and .\laterialsl y
I. Building S I. Building permit Fee: f Indicate how tee is determined:
2. Electrical S ❑Standard Ciry,Town Application Fee
❑Total Project Cost t(Item 6).x multiplier _..__,x
t, 111umhing S '. Other Fees: S
J. \lechunic•tl 111\ Lisl:-- ----- --.---- Cf/�
S. \Iedt.utie.d IFirc
Su++rcs,iont S Total .\11 Fees: S_ — — —
� Check No. ('heck Aluount: l'.uh \mount:
it lrroject Cost: i z cl[5.D� .
�J� ❑ paid in Full Cl Outstanding Ilal:utce Due:
SF.('I*[()N5: CONSTRUCTION SERVICES
5.1 ('onstructiuliSul)enisort.icellse((SL)
I wense Number D111c
I PC mscriplion
0
I InNstrioeJ t lluddiogS it to 35.000 0 It
R 1,tv,triocd I&I?I il"111 1AW1111A
L ilNf kmo.SLIM/11' Slam it
KC CoNcrin
%S window and sidillit
F
D
A solid Fuel litiming Appliances
SF
ail aJJresi
I Insulation
D Demolition
I'Vicylloilc
. Improvement
tHIC)
.4.2 Registered Illorne Improvement Contractor(HIC)
mc ii4writwn Number Eviration Dulc
I IIC Compan) Name or 111C I(egistrunt Nana Enalil addruss
Nu. m1J Streit
City/Town, State, ZIP Eli )hone
SECTION 6:WORKERS'RKERS'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 atYidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........a No...........0
— , - OWNER i�.;�i 0 E AUTHORIZATION SECTION 11
� . [ON TO BLOFIIPLETED 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.
/ -7 Z/3—
4 Ile Date
Wt Owner's Notre(Liectrullic Signature)
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 or my knowledge and understanding.
5 . S"
Print mmur lot Imillowl: A.Mit �i to I H�Ctrolllc ittWINN) pate
.NOTES:
1. An )%sotr%%huoblailis a�building permit to do his her own work,ur an Owner who hires an unregistered contractor
(not registered in the Hume Improvement Contrietur 11-110 Program).will no have access to the arbitration
program ur guar-1111Y Fund under M.G.L. c, 142.A.Othcr important information on the HIC Program can be round at
I Information an the Construction Supervisor License can be found at �o" 111,
711en substantial�k%ork it planned. provide the information below:
rotal (lour area(iq. n ) ____..—I Including girage, finished basement attics,decks or porch)
Gross lit itigarea I iq. It.I Habitable room I
\oillbvirottlirvillaces Ntillitter ofbcdroomi
\umhcrot'hathrooms \umber o(halt,hallis
I
Nkillherofic�ks, porclics
lic.itilig SN Stem
. 11col 01'cll
I'M,e"I'cooling i.%ilcltl
llroiQ0 squarc footage" I'm t1c substituted ?Air IlrojeO Cost"
CITY OF S.U.Ellf
PUBLIC PROPERTY
DEPARTMENT
u.outar 0•••••�
Vwwe i7avae.ra,�oulrus� WA%MmWaasmsoff'e
ML 9-.8-74r95e5 a V%L r.t7+s•saw
HOMEOWNER LICLNS6 EXEMMON
Plow Frllst
no q b c3-
Job Location l' I a rO 60f r D
Home Ownar Address
Home Owner Telephotse a
Present Mango!Address
no current exemption of"Homeowners"was extended to inchWe ownar-occupied
dwellings of two Units or less and to allow such homeowners to=gags an individual for
hire who does sot possess a 6crose,provided that the owner acts as supervisor.
DE INMON OF HOMEOWNMt
Persons) who owns a parcel of land on which he/she resides or intends to reside,on
which then 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 holshe be responsible for all such work performed under the Building
Permit
The undersigned "horneownee assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that hatshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
.will comply with said procedures and requirements. �>
HOMEOWNERS SIGNATURE ,,,
.APPROVAL OF BUILDIYG INSPECTOR
See other side for state code
CITY OF SAL&NI, A%ss.1CH(,'SETT3
f3LtLDL�IG DEP.1RTtF,�;Y
120 WASULNGTON STUarI jw FLOOR
itt (973) 745.9591
KLI M A'BV DRLscou FkX(978) 140.9SM
MAY01 MO.W f ST.PS711Jtg
DIRSGT04OPPLaLlcPROPlRT1r/gt:M,0 gGC011311SStONeg
Construction Debris Disposai At7tdavit
(required for ali demolition and renovation work)
In accordance with the sixth Debris, and edition of the State Building Code, 130 CMR section 111.J
the provisions of MOL a 40, S 54,
Building permit AI n lti
is issued with the condition
S IJOA. that the debris resug from
this work shall be disposed of in a properly licensed waste disposal that
as caused lti L e
111,
The debris will betransported by;(nume urheuler)
'rho debris
�wiiill be disposed of in :
(na rrha.b f�cdityl ' �—�
r,ddrv„
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