8 VERONA ST - BUILDING INSPECTION The Commonwealth of Massachusetts
CITY
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
1 Revised Junaurt'
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• '0118
One-or Two-Family Dwelling
This Section For Official Use OnlyIII
Building Permit Number: Date Applied: r0 jf�
v\ Signature: aV I /I`
Building Commiioner/Inspect ssor of Buildings Date
SECTION 1:SITE INFORMATION
1.1 R Propel�Address: 1.2 Assessors Map& Parcel Number
}� �RoN�t '�i2EET
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lol Area(sq B) Frontage(tt)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private O Check if es❑ p po y
SECTION 2: PROPERTY OWNERSHIP'
2.ln Owner of Ree rd:
f�Alnt) I�ENGAPEC
Nnp a(Print) /�� Address for Service:
RO:.QLI_�_21 Y1� t D &
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': D,C2 4- D
x U f0r gj24- ETA
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityll'own Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S e — \
4. Mechanical (IIVAC) S List: �� 1
5. Mechanical (Fire S Total All Fees: S
_Suppression)
Check No. Check Amount: Cash Amount:
X 6. Total Project Cost: S 4_OLX3 GL� 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I.iccnw Number Expiration Date
Name of CSI-- I[,,]Jet
Litt CSL rype(tee below)
Address r Description
U Unrcstricted u to35,000Cu.Ft.
R Restricted IB2 Family Dwelling
Signature M Mason Only
RC Residential Routing Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 1152.§ 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...........❑
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.
SignaturcofOwncr Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1, bleh MePF-IV 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. n
x KA�-PSI �F�1EA4�ES
Print N ��� �ti _ ru>LILW -.E I m 1 ao(o
Signature of Own r or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 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 1 I0.116 and 110.115,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"
1
CITY OF S.ULE.�I
PUBLIC PROPERTY
DEPARTMENT
Vwvar 130 WASWl GWW hoar 9 SAurt VA.aAORscns 01970
ru.97s•71}9s"• RAn 978.740-964 -
HOMEOWNER LICENSE EXE.r MON
raw Print
Date 5 �`� 20l 0 C
Job Locatim O A- J'—
Home Owner Addren o
Home Owner Telephone &- 8
Present Mailing Addtesr oNA —x Ce—%
The current exemption of"Homeowners"was extended to include owner-occupied
�ceup
dwellings of two Units or leas and to allow such homeowners to engage an individual for .
him who does not possess a license,provided that the owner acts as supervisor.
DEFIN NON OF HOMEOWNER
Pason(s) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to bs, 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 Olficial,on a fora acceptable to the Building
Official, that he/she be responsible for ail 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 andd requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING DiSPECTOR
See other side for state code
CITY
OF SALEM
PUBLIC PROPRERTY
�" DEPARTMENT
I'.11: F111 "MIY�'I I
I K' .i76.1 4MN 0 1`
Construction Debris Disposal Affidavit
(required 1'ur all demolition altd nnurrtiun work)
In accunl:oa:c with the sixth edition of the State Building Code. 790 CMR section I I I.S
Debris, and the provisions of MGL c AU, S MGL c
is issued with the condition that the debris resulting from
Building Permit q rl licenstd waste disposal facility as defined by
this work shall be disposed of in a grope Y
l 11. 5 130A.
The debris will be trunsportcd by:
I Utarra ut hauler)
fhe debris will be disposed Of in
tnamt ut xI Ity
plJdres l of KwIllI l
.I nature of permit apphnnt
Jats