71 ORCHARD ST - BUILDING INSPECTION Cby -��
The Commonwealth of Massachusetts
i - Board of Building RegnIU1i0rS and Standards I OI2
y %II'Nit'll'.\I.I'Il '
MaSSaChuSCUS State Building Code. 780 C'MR. 7"' edition �S1[
Building Permit Application To Construct. Repair. Renrnate Or Demolish it R, is,'d.1uu1,1J
One- or Tit ru-Fumd v Du c1ling
This Section For Official Use Only
Building Permit No her: _ Date Applied:
Signature: /mac— - l 3lei e
13L ut I un;mi+sloner/ In eaor of Buildings Date
SECTION 1: SITE INFORML\'PION
LI Property Address: 1.2 Assessors Map & Parcel Numbers �f"1
I.It Is this :m accepted street'? ves-�'_. no Map Number Parcel \'umber
1,2t Zetr=np Information: 1.. . Yv.ncrrw Dimen!:!ro s: rn4 n/rr
--��---- -------------- 1R-gam—a - �- __
"Z.00mg District. Proposed Use Lot Areu Isy lit Frontage (it)
LS Building Setbacks(ft)
Front Yard Side Yards Rear Yard
L_P Required Provided 2cycird PoReyuil idcd
h tr Water Supply: um.G,L c. 40. §54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zone: Outside Flood Zone? Municipal ®'On site dis xtsal s +tcm ❑
Puiilie fd- Private❑ p' I )'
Check if yes❑
1 SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow inert of Record:
i
Blame(PriliLl Address for Service:
Signature Telephone 1
r SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
Ne�nstr tion ❑ Existing Building C9' Owner-Occupied Cir Repairs(s) Alterution(s) Er-11dc;ititm
Demolition ❑ Accessory Bldg. ❑ Number of Units-9 I Other ❑ Snccily:_
Dena ipnon of Proposed Work.z:
SECTION 4: ESTIMATED CONSTRUCTION COSTS �J
--
item Estimated Costs: Official Use Only
! (Labor and Materials)
I Building $ I. Building Permit Fee: $ Indicate how tee is determined:
❑Standard City/Town Application Fee
?. Electrical $ ❑Total Project Cost) (Item 6) x multipp x
3. Plumbing $ 2.
Other Fees: $ x
4. Mechanical (HVAC) $ List: C)
S. Mechanical (Fire S
Total All Fees: S
Suppression)
Check No. Check :\mount: Cash .-\m0wne__
b. 'rotal Project Cost: $l
❑ Paid inFull ❑ Outstanding Balance Due:_____..
i —
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Ispir:aion Dale_"
Nann'of CSL- I folder
List CSL"type(scc below)
;7p-e7 Descri Ilion
\dJrc s
C I Unrcsu;c ied w p to ii"tNlO Cu. Ft;
R Restricted 1&2 Family DNtelhiie
Signature M M:uonfe Only _
RC Residential R ool nw,Cm el In
Trlepl,.,mt \1'S IzC,idenIG,1 W,nJum ,md SiJin_
SF Residrnu;d Soi:d I=uel Bmj,,n_, Applmncr III s;.ill.u„a,-�
D Rnidenlial Deuudttum
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Nano or HIC Registrant Name Registration Nwahcr 1 _
F_spnadon '`etc -
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § s5C(6!S
r Workers Compensation Insurance affidavit must be completed and submitted with this application. I=m:ure nt ptuc:cr, j
this affidavit well result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... ❑ No ... .... .. ❑ "-
SECT1OiJ 7a: OWNER AUTHORI'LATION TO BE COiiIPLETED WHEN !
GW'NEWS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
l 1, as Owner of the subject property heicby
authorize. _..------_— to act on my behalf, in all matters
relative to work authorized by this building permit application. - -
I
I _ !
I Sbtua n �_ )Woer _ Date
SECTION 7b: OWNER' OR AUTHORIZED AC:EC1. Ei@.,iA to 1 IC)N
as Owner or Autl:,orized Agora hc.ahv Jeclate j
that the statements and inform:uion on the foregoing application are true and accurate, to the best of my kno:•aed;e an:1
behalf.
rrini :ravr' -
Signaturc of Cx-.Lr or Authorized Agent Date
(Si red under ale pains and penalties of perjury) _—_-_ _ —__—
NOTES: _
L An Owner who obtains a haildioe permit to do hi_: her o'.vn work,or an owner who hires an unregistered contras
(not registered in the Home Improvement Contractot ;1[ICI Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important int.;tm:aion on the HIC Program and
Construction Supervisor Licensing (CSL)can be found /SU C MN Regulations I I0.R6 and I I0.R5. respecti�..:_ j
' When substantial work is planned, provide the information bo low: 1
Total flours area(Sq. Ft.) (including _ar age, finished basement/attics. decks or porch)
Gross living area iSq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms.
Number of bathrooms _ Number of halt/baths
'fvpe of heating system Number of decks/ poaches
"type of cooling system_ Enclosed Open — —_--
3. "Toad Project Square Footage- may be substituted for "Total Project Cost-
CITY OF S-U.E-M
PUBLIC PROPERTY
DEPARTMENT
IV adF�1 Ly fywyy
Vwroa .. - 130 WAUONGTON STRM•SALEK%L%MACHLSE R 01970
71Ei 979-715-9S9S* FAX 978-740.934
HOMEOWNER LICENSE EXEIMMON
Please Print
Date G �� • fi
Job Location 7/ a,ee 4 Art D S �—
Home Owner Address t f/ 6 rZ C /y-n tr
Home Owner Telephone �t 7 8 7%y
Present Mailing Address 519- +^��
t
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engagean individual for
hire who.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 fort 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATL
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
� S\
PUBLIC PROPRERTY
DEPARTMENT
�'eK tr�i
12C \C.\i111\i, 1N SI'RH T • S.\I I'\I, \1\1i it I
Construction Debris Disposal Affidavit
(re(lUiied lur 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 It _ 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
111, S I50A.
The debris will be transported by:
/ S
name of hauler)
I"he debris will be disposed of in
5 La vr� I ( ticss�
l,✓ds4 c/ot2�N
l address of Iacllity)
signature of permit applicant
— ate