11 VERDON ST - BUILDING INSPECTION (2) vj
--- fhe C•onunomreahh of IMassachusells
I a Board of Building Regulations and Standards CI'1'1'OF
\Massachusetts State Building Code. 730 CRIR SALE\I
Building Permit Application To Construct, Repair, Renovate Or Demolish a
On,,ur Avo-ka n lV Dn'ellilre
This Section For OI'rteial pie Onl
Building Permit Number: Date)pplied: _
Ihnlding 011i I(Print Marc) Signature Date
SECTION 1:SITE INFORMATION
I.I roperty Address: A 1.2 Assessurs Nap& Parcel Number
I.la is this an accepted street?yes no Map Numher Parcel Number
I.J Zonln`Information: 1.4 Properly Dimensions:
Zoning District Ilmposed U w Lot Arno I 11) Frontage(II)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Regtlirad Provided Required Provided Hcquired Provided
1.6 Water Supply:(M.G.1.c.40.154) 1.7 Flood Zone Informatlon: 1.8 Sewage Disposal System:
Ihrblic Privale 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal 3)stem 0
Check if i:30
SECTION 2: PROPERTYOWNERSHIP'
2.1 start of Record-
,
y SuY\ �c.s 20 Ae MA- G1c11-0
N;une tint► City.State.Z
1 Ve fd(1A STrneA ��• S�i� �t��, �/ --
Nu.afiJ Street relephuneEmail Addrvss
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied ❑ 1 Repairs(s) 0 Alleralion(s) Cl 1 Addition O
Demolition 0 Accessory Bldg.❑ Number of Units_ Other ❑ Spccily:
Brief Description of Proposed Work":
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelol Use Only
(Labor and .\lateriab) y
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. 1:1wrical S 0 Standard City1Town Application Fee
❑Tutil Project Cost'(Ilene 6).x muiliplier
i. 111un1hing S 2. Other Fecs: S_ --
4. .\Icch.111ie,Il III\ \(') S Lim
\icch.mical Ilue S -------.-- — — -- ..-
su p uesvon) r
('tic" No. ('heck Amount Ca. h \m1mn1:
I, I'mal Prnjcet Cost i ❑ Rdd in Full ❑Outstanding nal.mce Duc:
sec
SECI ION 3: ONS FRI c-riON SEMW P;
'"'( ,ION
""
5.1 Con it rue tiou So lien isor License(CS L)
I %luralimi DAL:
I ist('St. klic("ev hclolsl
N, 11 1 �i=i —o�r I le
1.�PC Mscriplion
No. aid,Street 11 1 nresirmcd I Iluildin it,' to 35.000 11 It
it l4cirictcd 14:21 Lund 0%%ellill
L i%'Tottli,State./III %I Nia,4111
RC Rixilin Uncrin
A S Wilidotv and Sidin
SF Solid Fuel litanillit ApliliaflAXI
I Insulation
Denutlilien
i
I c1cpholic 1(111ail adam's D
5.2 Registered flume Improvement Contractor(HIC)
Ilic Rcillibiralion Nunlhur kpiralion Oulu
I IIC Compact) Mime or I IIC l(vilistrani Nunn
No.and Street Finuil Jddrt:41
Cityrrown,State,ZIP ram hone
SECTION 63 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 ..........a No...........
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.
Print owncr's Nunic(Elcorunic Signature) Date
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
By entering anie below, I hereby attest under the pains and penalties of perjury that all of the information
L cotitain in this application is true and accurate!?I a best of my knowledge and understanding.
USQV)
'o
Print( micr'i,or
y entering
Ie
in
U h
n Q r
application p I T p
ttio rES:
I. It n Owner who obtains a building permit to do his her own work,curan owner who hires in unregistered contractor
I not registered in the Hume Improvement Contrictur(H IC) Program),will!U) have access to the arbitration
program or guanuily fund undgrM.G.L.c, 142.A. Other important information on the HIC Program can be 111und at
11 1
i Information on the Construction Supervisor License can be found at it%%,% nm,; �;o\ -fit,
2 tL\11 so 111al, a
2. Miensub anlial L�ork is planned,pro%idc the hillurni.lion below:
t Ita,
total
11" r'I(.
11 including garage. finished basetilvill.anics.decks or rordil
rotai iloorarca 14 11 ) —1'11%
I labilable rouill count Groh li%ingarea(54. It
Nknishi:r Lit hedrooins
\timber ol hall'ballm
I I)L:of herring i)SIQ111 Nmnhcroidccki, porches Open
1)lit:of�oohllq F(Mo,ed
loial Proiv,tSkItori: Fool-Ice" iia) be uh,miacd Ili"fatal Project Coll"
• 4
CITY OF S.UF.N[
PUBLIC PROPERTY
DEPARTMENT
u.o.aur ousua�
wra t b w+strw.m ftuw•Iwy VNuowwrn osro
M.10711704S"•Y.ut 976-74&164
HOMEOWNER LICLNSB EXEMPTION
Plesw hilt 1
Date
!obLacadoe Uerdoo *eei - c alem. udcycer��
Home Owner Address I llovrLGnIP vtn
Home Owoar Telephone q--�.P• s q y- '?r
ixreseot Mailing Address as
The current exemption oft"Homeowners"was extended to include owner-occupied
dwellings of two Units or Less and to allow such homeowners to engage an individual for
hire who don not possess a license provided that the owner acts as supervisor.
DERNMON OF HOMEOWNER
Person(a) who owns a parcel o[land on which hdsbe reside or intends to resider on
which there is, or is intended to be;a one or two family dweWn&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 OfDciak 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 Sure
Building Code and other applicable by4laws and regulations.
The undersigned "homeowner"certifies that hdshe understand@ the City of Salem
Building Department minimum inspection procedures and requirements and that hdshe
will comply with said procedures and equircment@
HOMEOWNER$ SIGNATI.•RE v
.APPROVAL OF BUILDING NSPECTOR Cl
Sce other side for state code