50 ORCHARD ST - BUILDING INSPECTION ti
The Commonsveallh of Massachusetts Town of
Board of Building Regulations and Standards 4mmom
.� Massachusetts State Building Code, 780 CMR, 7"'edition Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One- or Tsco-Fumilc Dsrrlling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: �����bel
Build g Co t:sioner/Ins f tuldings Date
ECTION I:SITE INFORMATION
I roparty Address: 1.2 Assessors Map& Parcel Numbers
U fSfZ�Ia.
Ma Number Parcel Number
1.1 a Is this an accepted street'!ya, no p
I.J Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq A) Frontage III)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.U.L c.40.154) 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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'ofRecord: �� br(4���/ ,�.� _-, �
N (Print) l fl e L rx Address for Services �L
hr j79-6� "t-Ib23 culR -`f00-
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Constructio Existing Building Owner-Occupie Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units 1 Other ❑ Specify:
Brief Description of Proposed Work': Rc"rtds
h,`--L-.. L-'t-�-CR-4 Trr Y—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: 0 aclal Use Only
Item Labor and Materials
I. Building f I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical f ❑Total Project Cost'(Item 6)x multiplier
3 Plumbing S L Other Fees: f
4. Mechanical (HVAC) f ise
5 .Mechanical (Fire f Total All Fees. f
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost f jrjC Uv ❑ Paid in Full ❑Outstanding Balance Due:
D-VI-Q--
r
SECTIONS: CONSTRUCTION SERVICES
5.r1�Licensed Construction Superxisor(CSL) C-3 -71 3.72 (b (E Cs
License Number Expiration Date
N;Ime of CSL HplJer Lit CSL T
'�7a �Rr(Ga2Y r7'( P141dr3D MY� YDe Im below) 121
ress T Description
_ U I Unrestricted u to 3l.000 Cu. Ft.)
Signature 't
R Restricted Ik2 Family Dwellm
?3f—C3et�3S Zq M Masonry Only
RC Residential Roofin Coverin
Telephone WS Revden Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5,2,Registered Home Improvement Contractor(HIC)
D -T —r <z� t ;-76r3
HIC Comp y Name or HIC Registrant Name Registration Number
S 'Y �iQ.17 t 5 i th kkrm r kY3
ss Itai
Expirati�Date
Signature Telephone _
SECTION 6: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 .......... O No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNEER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
f 1, Ka�� NleclI//e ,r-Ch✓rtt' p/zey lVv rfryl as Owner of the subject property hereby
authorize -DYavt� S_ f�IP.¢ctc. h�Yt.r]�eSxS �rSrcrJ to act on my behalf,in all matters
relative to work authorized by this building permit application. nn� � __ Q
azze,'Sil /
nature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I. ,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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 10 have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total Ooors area(Sq. Ft.) (including garage, finished basemenvattics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces .Number of bedrooms
Number of bathrooms Number of halfbaths
Tv
pe of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. "Total Pro)ect Square Footage" may he .uhstitutcd for 'Total Project Cost"
e.V NZ\ti"-'D
CITY OF S.u.Em, UxSSACHL'SETTS
_ BL'RDNG DEPARTSEEINT
.._.,._. 120-WASHLNIGTON STREET, 3"FLOOR.,, •.,.°,
"I FL (978) 74S-9595
FAX(978) 740-9846
KIN(BFRi FY DRISCOLL
MAYORI?iOh6tS ST.PffJtltt -
DIRECrOR OF PLBLIC PROPERTY/OCQDNG CO%L%RSSIO%ER
Yorkers' Compensation Insurance Alfldavit: Builders/Contractors/ElectrlciansiPlumbers
>nnlicant InformAdOil _j ,,, Please Print Legibly
Vaine (ousirwuOr�atttraltomindsvtdual): Vt0 (YQ(2cia.. CMP�Piue�-��W�
Address: T "- 134Y cf 21
City/State/Zip: Fa --'e0''uA�`M ~p 61 � Phone N' WI'
.%re you a■employer!Cheek the appropriate box: Type or project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor aml I New construction
employees(roll and/or pan-time).• have hired the su&contmctors
I am a sole proprietor or partner- listed on the attached sheet. : . ❑Remodeling
:hip and have no cmploycea Thew sub-contneton have B. Demolition
workingfor me in an capacity. workers'comp.inwranoe.
y p ry• 9. ❑building addition
[No workers' comp. insurance S. ❑ We am a corporation and its
required.(
officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I-❑Plumbing repairs or additions
myself.(No workers'comp. C. 132.#1(4),and we have no 12.0 Roof repairs
insurance required.] t employees.(No workers'
comp. insurance required.] I3.0 Other
-Any upplicanl that•tench boa el Mae alwr rill aid the aeunin be'"ineriaa their workers'companies l puliry infumueoa
'I lumanrmss who submit this aaldays indicting tire,are doing all world and then like outside contractors dmal submit a nave affidavit irdiaidy neL
=(',xuraYon dal A ak ibis box mum attacked an additional slrl+howing the name of tM arbsemmclare and thus worhm.natty.policy imaatmo .
i one an employer that b providing workers'rompensodon lnaaronee for dry ennp/oyeas Sdaw ii the pallet'and kh sib
information.
Insurance Company Name:
Policy if or Self-its. Lic.p: Expiration Date:
Job Site Address: City/State/Zip:
%ttach a copy of the workers'compensation policy declaradow pep(skowing the policy number and expiration date).
Failure to wcum coverage as required under Section 25A of MGL 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 well as civil penalties in the form of a STOP WORK ORDER and a rind
of up to S250.00 a day against the violator. Ile advi."that a copy of this statement may be furwarded to the Office of
I nvesugatiuns of the DIA for insurance coverage verification.
/Jo hereby certify under thepains and penalties ofprrJary t
that tka information provided above is true and correc
�� •n uure.�� /- Date: id 2-7I Gcf
Pore a' `-%, Get - 3S72±
01riciai u3e only. Do not write in this area, to be complete/by dty or town oJJ&i'a
City or ruwn: errmiN.lcense N__.
i
hsuing.\whurily (circleune): -- - -- - --- i
I. Ituard of Health 2. Ruildfing Department J. Ciiylrown Clerk 4. Electrical Inipccto► 5. Plumbing lntpeetor
6. Other
Phone a: ___._._......_. .
r CITY OF SALEM
�; PUBLIC: PROPRERTY
DEPARTMENT
Ili "N '4; 1;1; 0
Construction Debris Disposal Allida% it
(rctluircd li,r all demolition and rcnot a on work)
In accurdance wlh the sixth edition of the State Building Code, 780 CAIR section I If S
Debris, and the provisions uf'.bIGL c 41), S 54;
Building Permit d is issued with lift condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
1 1 I. S 150A.
The debris will be transported by:
NYJR�it—c�ctsc� CP.nF'Ct�
Inane(if hauler)
he debris will be disposed of in
t c3�aarrc� TiwPf,-0r'T_ SiAsc�.
(nutnr ullaei uy) \ -
�—te'S� 5410�E 'Ptt��+r �i•-',WR�"Yv1�M4) 1
LiJdre,. ..I'gcihtvl
apn.rWa of pi unit .ygdit ant
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