7 ORANGE ST - BUILDING INSPECTION r
_ The Commonwealth of Massachusetts
Department of Public Safety li 6 DEC -b P 3: 2 g
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
I
1 7 Orange St. Salem 01970
( No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition IX (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Removal of Drywall,Flooring,Cabinets,and fixtures.
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) ee ee
Attachmen 4 Attachment
Total Area(sq.ft.)and Total Height(ft.) 4860 37 4860 37
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ Hh❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ I-4❑ M. Mercantile❑ R: Residential R-10 R-2❑ R-3 X R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IAO IB ❑ ILA fIB ❑ IIIAO Ilia ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal:
Public X Check if outside Flood Zone;( Indicate municipal X A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:CA35et I q
permit is enclosed fM 61,1V TKAV"ex FfAria,
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable T Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ orNoV Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
M�1 ��� 1 2-( 1 4
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Scott Perry 4 Cleveland Rd. Salem 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Mr. 5p_g_ 932 1275 per[y.sc79flgmail.com
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Carol Perry 4 Cleveland Rd. Salem MA 01970
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
01 building is less than 35,000 cu.ft of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Scott Perry 186501 Home Improvment Contractor
Name of Person Responsible for Construction License No. and Type if Applicable
4 Cleveland Rd. Salem MA 01970
Street Address City/Town State Zip
508- 9321275 perry.sc79@g mail.corn
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152.§25C 6
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes;, No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$---- (contact
ta` municipality)
5.Mechanical (Other) $ Enclose check payable to �) V
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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 of my knowledge and understanding.
Scott Perry ftw:o� Mr. 508-932- 1275 IA , 10 t
Plearint and si name Title Telephone No. Date
dlevelan'd Rd. Salem MA 01970
Street Address City/Town ate Zip
Municipal Inspector to fill out this section upon application approval: lv�o
Name Date
CITY OF SM . , 1iIASSACHUSETTS
'. BuIL.DII DEPAR[1IE.iT
130 WASHINGTON STREET,3w FLOOR
T L (978)745-9595
FAx(978)740-9846
KI,,IBERI.EY DRISCOLL
MAYOR THObtAS ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%ASSIONER
Demolition Permit Sign-Off
(Supplement to permit application)
1 Scott Perry hereby supply the following releases as part of the
application for a permit to demolish the structure located at 7 Orange St.
Salem, MA and shown on the Assessors Maps
of Salem, MA as being on Map # 35 Block # Lot# 366
The sixth edition of the Massachusetts State Building Code, 780 CMR,states in part: "A
permit to demolish or remove a building or structure shall not be issued until a release is
obtained from the utilities, stating that their respective service connections and appurtenant
equipment, such as meters and regulators, have been removed or sealed and plugged in a safe
manner."
-Utility to be Notified Notice Received by Date Received
Gas
Telephone.
Electric
Public Utilities (Municipal)
Health Department
Fire De artment
Other-
Other-
Demolition debris hauler: Cassella
Location of licensed
demolition debris landfill: Peabody Transfer Station -300 Forest St. Peabody, MA
Signature of Applicant _ Date: l a
Signature of Owner _ Date: 1a .(o aal 1.
�� p
This sheet must be returned tot a Inspections Department along with a completed
application for a permit, a site plan, and any other applicable information and fees.
Demoperm.do+:
i CITY OF S.UX.M, i'L-kSSACHUSETTS
' BunmrNG DEPARTNMNT
120 WASHNGTON STREET,P FLOOR
TEL (978) 745-9595
FAX(978) 740-9M
1CI\IBERL.EY DRISCOLL
MAYOR THomm ST.PtERRe
DIRECTOR OF Pt;BLIC PROPERTY/DuummG COJLNUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
1 11, S 150A.
The debris will be transported by:
Cassella
(name of hauler)
The debris will be disposed of in :
Peabody Transfer Station
(name of facility)
300 Forest St. Peabody, MA
(address of facility)
signature of permif applicant
aal t.
date
debrisatCdet:
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
j
120 WASHINGTONSTREET 3' FLooR
TEL. (978)745-9595
KIMBERLEY DRISOOL FAX(978)740-9846
I,
MAYOR THomAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: /a (7 ' Z01 L
JOB LOCATION_ I O kA O &L S 1 ILt G I YA L e t-)! ��fGl
HOMEOWNER ADDRESS: cle y I' " ,( 1-I ii l� Ye- 0l9,9-v
PRESENT MAILING ADDRESS: C I U f V
e
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two(2)units or less and 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:
Person(s)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 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 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/she will comply with such procedures and requirements.
HOMEOWNER'S SIGNATURE fn
APPROVAL OF BUILDING INSPECTOR
UNITED STATES
CUSTOM HOUSE
53
g AREA a 4600 S.F.
r
N/F a 1D' To CUSTOM HOUSE
UNITED STATES
DODGE
k.A. 9
S
0
c
tr
3 STORY' c
DwtLuNG 4I
5+'
ORANGE STREET
REFERENCE: THIS PLDT PLAN WAS NOT MADE FROM
FOR
DEEM REC. OK. 37778 PG 126 THE PURPOSES Cf TH INSTRUMENT SUREE BANK ANDIONLYY,
UNDER NO CIROUMSTANCES ARE OFFSETS
TO:: EASTERN BANK TO DE USED FOR ESTABLISHMENT OF
FENCES, WALLS. HEDOES. ETC,
1 CERTIFY THAT THE OJ:L NCS SHOM HEREON
ARE LOCATED ON THE GROUND AS SHOW AND THEY
CONFORM TO THE HOR120NTAL DIMENSIONAL REGULATIONS
OF THE Z0fmG BYLAWS OF THE CITY OF SALEM MORTGAGE INSPECTION PLAN
AT THE TIME OF CONSTRUCTION OR ARE PROTECTED UNDER LOCATED
GENERAL LAWS CIIAPTER 40A SECTION 7. u. 7 GRANCE~SIREET
I ALSO CERTIFY THAT THE PREMISES 910'Mi ARC NOT J�ytNOF SALEM
LOCATED WTTHIN A FLOOD HAZARD ZONE AS PREPARED FOR
DELINEATED 011 THE MAP OF COMMUNITY #250102 GAIT L.
SAlEU . MA., EFFECTIVE 7 16/2 4 SMmi O CAROL A. PERRY
DY THE FEDGM EMERGENCY MANAGEMENT AO£NGY. u n SCALE t' - 20' APRL 6. 2016
`f�b ll9 �,JCu.� F"o'asaap 14 OR( SHORE STREET
CORP.
14 BRO'A4i STREET
DATE �� PROFESSIONAL LAND SURVEYOR 4is0 9 SALEM. 0 778744--48DD 1 4281 T
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block# and Lot#for locations for which a street address is not
available)
7 Orange St. Salem 01970
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No PK Provider notified and Release obtained? Yes ❑ Noo
Gas Shut Off? Yes ❑ No 2fProvider notified and Release obtained? Yes ❑ Nox�
Electricity Shut Off? Yes ❑ No 16 Provider notified and Release obtained? Yes ❑ No;K
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item submitted incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing(include local connections)
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investi ation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(S
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address
Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address
Registration Number
Street Address Ci /Town State Zi Discipline Expiration Date
CITY OF S�I.EtiI, N1ASS. 'SEM
• BuI DLNG DEPARMENT
• 120 WASHiNGTON STREET,3=FLOOR
T EL (978)745-9595
FAX(978)740-9846
ItiJ(BERLEY DRISCOLL
MAYOR THoNw ST.P(ERu
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG COMMSSIONER
Workers' Compensation Insurance Affidavit Bui(ders/Contractors7Electricians/Plumbers
Applicant Information Please Print Lepi6ly
Name(Busimy OrganizatioN(ndividual): Scott Perry
Address: 4 Cleveland Rd.
City/State/Zip: Salem, MA 01970 Phone k: 508-932-1275
Are you an employer?Cheek the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no Cmploycm These sub-Contractors have S. ''Demolition
working for me in any capacity, workers'comp.insurance. ❑ Building addition
[No workers'comp. insurance 5. El We
Buildi We are a corporation and its 10❑ repairs or additions
required.) officers have exercised their
3.® 1 am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13:00ther
comp. insurance required.]
•Any applicant ilud chocks box o I most also till out the section below stowing Their workers'compensation policy information.
t I lomeownem who submit this affidavit indicating they are doing all work and lboa hire outside cantmctuts most submit a new amdavil indicting such.
-Coma corn,that check this box mast anadxd an aldiiioa al sheel showing the name of the sub-comratbtx and their workers'camp,policy infomwion.
l am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name:
Policy H or Self-ins. Lic.N: Expiration Date:
Job Site Address: City/State/Zip:
Attacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section25A ofMGL c. 152 can lead-to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify under the pains and pen allies of perjury that the h1 f ormation pro u ov
p b e/s true and correct
Sienalure• Date, I (r' egoI V
Phone
Ofrcial use mtly. Do not write in this arcs,to be completed by city or town off chlL
City or Town: Permit/1.1cense q
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4,Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: __._ Phone q:
r
FLOORPLANSKETCH
Borrower: Carol Anne Perry File No.: 16-120997
Property Address:7 Orange Street Case No.: 1603000079
City: Salem State: MA Zip: 01970
Lender: Eastern Bank
8' 8'
4 m q m O
Bath Bath T Bath �3'
in Kitchen
Kitchen Bedroom Bath Unit#3 Kitchen BMroo b
Unit#1 Kitchen
Unit#2 Unit#4
3' 3'
Bedroom Bedroom
Den Den Den Den
N N
Living Room ® Living Room Living Room ® n9
Uvl Room
40' 40'
8'
10
4P T 19,
in
Attic Room Attic Room
c
�O N
N N
Attic Room Basemen[
Attic Room
c
N
40'
40'
Sketch Is
Approximate
SYaf[ii Q/A�5�ekM1 v591antlaN^'
Comments: Z
14�1c-
7- &l >�i�� s�� s ys ft 2
^— AREA CALCULATIONS SUMMARY LIVING AREA BREAKDOWN
"Code Description Net Size Net Totals > ' Breakdown Subtotals
M.Al First Floor 1430.00 1430.00 First Floor
W.A2 Second Floor 1430.00 1430.00 40.0 x 5.0 200.00
BSt4T Basement 1554.00 1554.00 43.0 x 10.0 430.00
20.0 x 40.0 800.00
Second Floor
40.0 x 5.0 200.00
43.0 x 1010 430.00
= 20.0 x 40.0 800.00
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The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code (780 CMR)
o � a
Building Permit Application to Construct,Repair, Renovate or Demolish any
Building other than a One-or Two-Fancily Dwelling
Code and Other Requirements for Building Permits
The Department of Public Safety has issued these building permit application forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in order to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the building permit application,that no outstanding property taxes,water fees,
etc. exist.
Filing Instructions
1.Please contact the city or town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done.
2.All applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3.Please include a check for the Building Permit fee. The fee may be calculated using the information to
be supplied in section 12 of the Building Permit Application. The check is to be made payable to the
local city or town where the work will be done.