B-19-1197 - 0017 VARNEY STREET - Building Permit CC.,
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMN�, �.,iON A! cs,
ALITY
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling Z00 OCT 25 4' 51
This Section For Official Use Only
�. Building Permit Number: Date Applied:
v
1 S�&Jg '&e
�-' Building Officia Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map&Parcel Numbers
l.la Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage.(ft)
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❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ogf�ed:
AJo � 4P�
sa-le "q DIq
Name(Print) City,State,ZIP
/ 97�55 y�.3i� �2�r��6�aTU P
No.and Street • Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 7 f 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing Is 2. Other Fees: $
4.Mechanical (HVAC) $ 9- List:
5.Mechanical (Fire $ /
Suppression) Total All Fees:$
6.Total Project Cost: $
�/ c Check No. Check Amount: Cash Amount:
13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
.• ��fl/V 11 License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street
" Type Description
U ' Unrestricted Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 .......... ❑ No...........❑
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 y behalf,' all matters relative to work auth 'z by this buil ng permit application.
(Z/
/-
P ' t Owners Name(Electronic Signature) Date
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
contaiVA4n this application is true and accurate to th best of my knowledge and understanding.
(4)pj.4T) Z
2
Print wner's or Authorized Agent's Name(Electronic Signature) Da e
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.g_ov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 halfibaths
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 SALEK MASSACHUSE M
4
r BUILDING DEPARTA ENT
120 WASM4GMN STREET,370 FLOOR t
IkL.(978)745-9595
KUMERLEY DRISOOLL FAX(978)740-9846 1
MAYOR THCMAS STT1E1W
DIRECTOR OF PIIBLICPROPERn/BunDING OOIumSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: l
JOB LOCATION
HOMEOWNER ADDRESS: (/ {� 0 j � 7
PRESENT MAILING ADDRESS: U '44 4
The current exemption of"Homeowners"-was extended to include owner-occupied dwellings of two(2)'units or less acid to
allow such homeowners to engage an individual for hire that does not possess a license,provided that the owner acts as
supervisor.
Definition of Homeowner.
Person1s)who own a parcel of land on which he/she resides or intends to reside,on which there is,.or is intended to be,a
one-or two-family dwelling,attached or detached structures access6ry 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 he/she be responsible for all such work performed
under the Building Permit.
The undersigned"homeowner"assumes the responsibility for compliance with the State Building Code and other applicable
by-laws and regulations.
The undersigned"homeowner"certifies that he/she understand the City of Salem Building Department minimum inspection
procedures and requirements and that he/ will c mpty with such procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR