69 ORCHARD ST - BUILDING INSPECTION (3) G -2-
00
The Commonwealth of Massachusetts CITY OF
3 + Board of Building Regulations and Standards SALEM
Ir / Massachusetts State Building Code, 780 CMR
ReviseJ,Wur 2011
h Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date.Applied:
Building Otticial(Print Name). Sign ore bate
SECTION 1:SITE INFORMATION
1.1/Pr5per,t,)'Address: _1 1.2 Assessors Map& Parcel Numbers
l� I U fG41Qf C
1.1 a Is this an accepted streetl yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: o
Q v
`Coning District Proposed Use Lot Arca(sq III Frontage(I1) O cmj
63 Building Setbacks(ft) c5
Front Yard Side Yards Rear Yard W A
Required Provided Required Provided Required Pro d �
1.6 Water Supply:(M.G.L c.40,§54) t.7 Flood Zone Information: 1.8 Sewage Disposal System —Z
Zone: _ Outside Flood Zone? Municipal❑ On site ills osal�
Public❑ Private❑ Check if es❑ unici p p Tcmg
SECTION2: PROPERTY OWNERSHIP!`
2.1 Ow er f Record; Adl MOO
y t�ahme(Print' City,State,ZIP I
�g Irn� � (�gl�l��t ►>�tLi(, �E�l
Nu. and Street Telephone Email Address
SECTION 3. DESCRIPTION OF PROPOSED'WORW(check all that apply)
New Construction❑ Existing Building❑ Mr-Occupiedpairs(s) ❑ Altemtion(s) ❑ Addition ❑czssory Bldg.❑ Other ❑ Specit'y:
Brief Description of Proposed\York': f AQ
X � l
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1, Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S 3?Other Fees: S
1. Mcch:mical (lIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Chick Amount: Cash Amount:_
,X\ 6.TTotta,al Project CusT S ❑Paid in Full ❑Outstanding Balance Due:
-
QV
SECTION 5: CONSTRUCTION SERVICES
5.1 Cottstructimt Supervisor License(CSL)
License Number Expiration Date
Nana of CSL Holder
List CSL'fype(see below)
No.and Street Type' _. Description
U Unrestricted(Buildings up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Tole hone Email address D Demolition
5.2 Registered Ilome Improvement Contractor(HIC)
•^ HIC Registration Number Expiration Date
'HIC Company Name or HIC Registrant Name
t
No. and.Street Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.15L$ 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,) 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 andunderstanding.
M icvek" n
Print Owners or uthorizeJ Agent's N me(Electronic Signature) �—
1 NOTES:
I. An Owner who obtains a g 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 orguaranty fund under M.G.L.c. I42A.Other important information on the H[C Program can be found at
www.mass..11ovoca Information on the Construction Supervisor License can be found at wtvw.ntas.,�ov/dL .
2. When substantial work is planned,provide the information below:
Total door area(sq. ft.) .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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 orcoang system Enclosed Open
i. 'Total Project Square Footage"may be substituted far"total Project Cost"
r.
CITY OF SALEM, MASSAMUSEM
K fI. If BUILDING DEPARTMENT
@r 120 WASHINGTON STREET,31D FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THoMAs STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COIvaffssiONER
Construction Debris Disposal Affidavit
(required for all demolition and. renovatioon..work),
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler
The debris will be disposed of in:
6V 9 CQ r�
(name of facility)'
(address of facility)
1
Signature of applicant
N
Date
J
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTN ENT
120 WASHINGTON STREET,YD FLOOR
�?nvxrxt TEL. (978) 745-9595
FAx(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRE CTOR OF PUBLIC PROPERTY/BUILDING CONCVIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 10—'R ky
Job Location `- Uc tc� S�
Home Owner Address—
Present l(}Vd II r _jl
Present Mailing Address OTcyaf lv
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 that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns 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 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 SIGNATUfj/W(a
APPROVAL OF BUILDING INSPECTOR