52 ORCHARD ST - BUILDING INSPECTION The Commonwealth of Massachusetts
y� Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition NmftbgBuilding Dept
Qs� Building Permit Application To Construct, Repair, Renovate Or Demolish a
or Tiro-Fumily Dwelling ANN&
his Section For Official Use Only
S� Building Permit Number. Date Applied: _
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION l: SITE INFORMATION
rroperty Address , S'r 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes i/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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 ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
.1 Owner'of Record:
Ckarle�ne ToloP_�.1 �Sa or - &P-6 ST-
Name(Print) Address for Service:
�' lsa/,ao 4/ G7g --7q0 - 107a
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
••-, License Number Expiration Date
Npme of CSL- Holder List CSL Type(see below)
Type Descri Lion
Address U Unrestricted u to 35.000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidinit
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature 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 on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 , 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
be
�ar1eine Tob-e
Print N e .+
1
Signature of Owner or Authorized Agent Date
(Signed under the ains and penalties of jury)
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementiattics,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"
CITY OF SMYN
PUBLIC PROPERTY
DEPARTMENT
VAYOt 130WAMM ONMKIFr•sMA MAUAnw.'S M01970
TW-9'6-74i95"• FAX.97r.74696"
HOMEOWNER LICENSE EXEMPTION
Please Prime
Date
Job Location 5 a o ac C i i a e D ST
Home Owner Address <a n nGi-1 n rr b Cr
Home Owner Telephone G-7 q-`7 4 n - i m a
Present Mailing Address
The current exemption of"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.does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s) who owns s 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 responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner'certifies at he/she understands the City of Salem
Building Department minimum inspec ' n procedures and requiremrnts and that he/she
will comply with said procedures and uirements. �p
HOMEOWNERS SIGNATURE J
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
a. . A PUBLIC PROPRERTY
DEPART'NIENT
\I .n ill 12"A.\,,IH\I.,,INS IlQ1 T ♦ l.\i I'\I,
Construction Debris Disposal Affidavit
(re(luired for all demolition and renovation work)
In accordance \vith the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit if is issued with the condition that the debris resulting front
this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transportedby:
f-.7
(name of harder)
I he debris will be disposed of in
(name offacility)
(address of Ihcility)
Signatnre of permit applicant
�2 , D PD
late