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72 ORCHARD ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF / Massachusetts State Building Code, 780 CMR SALEM Revised.War 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One- wo-Family Divelling This S ction For Official s€Only Building Per n Number: D pplied: II /� Building Official(Print ame) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address• 1.2 Assessors Map& Parcel Numbers ��9 Ai2 0 1.I a Is this an accepted street?yes_W' no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: r Zoning District Proposed Use Lot Area(sq to Frontage(R) 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: Zone: Outside Flood Zane? Public Private❑ — MunicipahB On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 wner'of Record• f Pt nrc-C �� ( e2 n e 5'��e tM AL Q 0 Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) E? I Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work': _ 1 h I ,ssc Qe�. c �, , r� h 6 1'1-"57hA i f P t,7,b c- MP n.-t- 1 N, 01 _V 14-`3 I t) r "r� SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only -Labor and Materials) 1. Building $ cb/./Ly0 - I. Building Permit Fee:$ Indicate how fee is determined: �. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost(Item 6)x multiplier x 3. Plumbing $ 2. Other e 4. Mechanical (HVAC) $ List: l/` 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 'F VOO / 0 Paid in Full ❑y,Outstanding Balance /Due: r f ' SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) '2 ) 9 9� nDescription �Q n � Liceds�e Mumbcr Name ot�C��SL`H—o�l-die---r } 0 p " QN (2 List CSL Type(see below) No.and eet - 1 Type M _/� O f (Y 7(0 U Unrestricted(Buildings u to 35,000 c❑, (tJ 7� R Restricted 1&2 Family Dwelling City/rown,State,ZIP M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation "Fete hone Email address D Demolition 5.2 Registered Home� Improvement contractor(HIC) `Zl 3 ,V /U HIC Registration Number Expiration Date HIC Company Name ar F I hegis�mnt H me 79 No.and Street. IPA AA y Jt Email address City/Town, State,ZIP ,11 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.Z. ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,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. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION 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. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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 can be found at www.mass.,OV:oCa Information on the Construction Supervisor License can be found at www.mass.eov/dns 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics, decks or porch) Gross living area(sq. ft.) 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 of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost' CITY OF SALEM ' PUBLIC PROPRERTY DEPARTMENT .i,m1 YI I Y:In IN 141 \I%\IW 12C\I/MtII.%GJk \)IBeL•t' • $,%il.u, It/.11h.\l.l It W'I Iv Jl97: 1'cl: 774715•ti'ri •f Ix v7s4aC•'+aM 1Vorkers' Compensation Insurance Ullduvit: Hui lders/Contractors/Eiectricians/Ptum r slicant Information ben Plc•4s Print Le 'ht \fillnetlfllulle.sil)rR,anlrJlinNlnJnvnluall: -f- P) L A KfC 0,n 4,0 `+/ ) city,starc.7ip. Sa yyl �tM � Ilhunn it:_ Q��� ::?-7 a -A z .%re)nu an vogrloyers Cheek the,, pproyrlute bus: I I.❑ 1;un a em lu yr with 4. h)M N prof ells ructio P ) ❑ I ;un a gencnl couuactor and 1 vnlpluyevs(roll JnsYur part-rime).• have hired the soh-vunracwrs h' New euluoucuun 2.® I.ur a tole proprietor or partner- listed on the anachcd cheat I 7• ❑ Remodeling Ship allot have no vmpluyees These;tub-contractors have corking fir my in any capacity, workers'comp, insurance. S. Mmolirion I No workers'cutup, insurance 3. ❑ We are a col 9. ❑ Building addition re quired.) corporation and its otlrlaers have Clemisud their 10.0 Electrical repairs or additions 7.❑ 1 sill J homeowner Juing all work right of exemption per NIOL 11.0 Plumbing repairs or additional myself INo workura'comp, c. 152.¢I(4),and we have no 12.0 Ruut•repuia insurance rcyuired.) t cmplvyees.1No workers' comp insurance squired.) 1),❑Other •4 ny.,pphlJrY IhW chcds bus el mlyl alw till uW Iha acnun below Wwwind IAtir.wwhas'cunnpmlJYiwl pdicy mfurlwwiws 'I tumwlwnnt who nalnul this antosvil indicarind iin y art wind WI Wure and Ihwl hill MIS,An luYrntltrf mWl.YItnY a ntw alnrltrnl IrdlnJYlnd ox'h. r„nlnwlnln Ihtl eMxk This bms mIW Jllyhrd un addiliwyl+h wl ablating The nallq t/the sub.06no raoen and Ihtlr wurllera'cony,pulley nnt{Ylnalille /nrrr urr etnpioyer that It proviJfnx Irerkers'rurrrpelm/tort hrraronaa jar ray.rap/ayerr. w Is thepis/fay and/ue aib iujurinutfura Be/a Inauranee C'unlpany.Valve:-�jiEVilicy 4 ur Sv1f•ins. Lic.N: sfJ, loot J Expiration Dive: Oro City,sraretZlp:- Y�l�_UG V techs Copy orfhe workars'cumpensalloa pollcy ducta►altun pugs(showing the poticy nunlbur and usplratlua date). I-Jllury w.vecura cuvemge as required un 9 der Section_JA ul'SIGL C. I3 Gil 2 eau lead ro rh '. up h/S 1 500.00 Jnd/ur one-year imprismuncnt, Ja % 11 Js civil pcnullius in this turn of a STOP WORK URGER antis fine ni up to i2iO on a Jay�Iraiost dle violater. lie advi.icd lhut a copy of th$a otatuinu t may be 1'urwarJe4j to the Office of IlrrCa11�J1Urlb ul Chu r)Ir1 for im ariece covcngc sclilieuhun. /du lrerrhy I crtijY umler fhe puiu d peflu/t/ev ufper/rrry that the irr orusuden / n j prPageo vl'drrl above is true un f e 61 arn cf. �n•nval a ��/ I'hl•1:� :1 3 t)!/ecru!ns.uu/y, Do nor write in fhfr urea, tube rullplefrd by city ur rolling It//friol ('iry ur 11nrn: I ' i Pv'rinit/Llet'nnu to M . uing Atilhurily (circld nnc)t II. 10jur nr IIcJIIh 1. Ihuldinq Ihpar hu e Ih h, her lll I. (:il)r'runn Clerk J. L•'lectrical Ill spccfor :, plumbing Impactor i 11nll•wl I'tr+mlt I - ___ I'hune Y; i Information and Instructions eve r.an in the service of another under any Contract of hire, >lassaelwsetts liCneral Laws chapter I i2 trywrcs all tny/loycrs to provide workers' coinpensat+on lit their emplyees. 1'unuatln to this ,utute, an employee is JetineJ as rY Pe ,.press or unpliCd, oral or written." �n employer h.dctined as"an individual, Purtnenhip,associauoo,corporation or other legal eased or arty two r the mare o the Iaeguing engaged m a Iwm enterpr ise. and itleludhllg the legal reprtaengttves of" deceased vI0 ees.I Nowevcr the ecmver or uuatee ul'.m indivtJwl,pastnershtp,aaaoctati°°or other legal entity,employing p epair work on such dwelling house owner of a dwelling house having not mare than three apartments and who resides therein,or the occupant of the curg ,Iwe Itfng Ifouse of another who employs personsjolig shellto do+uotnbecause of so.chuemployment be deed to be an employer." or oht the.-rounds.-rounds or building apD e �IGL Chaper 152, �3SC(6) also states that"@very state or local licensing ageee the y shall withhold the issuance anY or ren applicant Is of ens not pr or per dueed acceptable evidence of Sittig to operate a business Or to umpOsace with the coristruct eInsurance co In ves ogelreg visions Additionally, has chuper 132, i2SC(7)states"Neither he commonwcatth not any of its Political subdivisions shall enter into any Contract for the performance of public work until acceptable wiJenCe.ut conhpliarlca with the insurance requirements of his chuper have been presented to the contracting auhorit Applicrosts applyto our situation and, if please rill out the workers' compensation alYldavit completely,by checking the bongs thattheir Y necessary,supply sub-contr.ctor(s)name(.$), •rddresa(as)and phone nufnber(s)along with thk certiScatels)of. insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the i nsuranc or Limited are not require)to carry worker' compensation insurance. If a°LLC or LLP does have employees,u policy is required. as advised that th AAlso be sure to sit"anlyidavit may be d date the ted to the ufndnvlLnt• ile Of lotrdav affidavit unit or license is being requested,not the Department of .\ccidens r'ar contynttatiun of insurance coverogs. be returned to the city or town that the upplic�a ofor thens regarding the law or if you are required to obtain u workers' Industrial Accidents. Should you have°ny y Compensation policy,please call the Department at the number listed below. Selfinsured eompaaies should enter rhea self-insuronce license numbar oa the o ro rise line. City or Town Omelets Of cite affiduvit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure that he affidavit is complete and printed legibly. The Department has provided u space ut the chum I'I vse be sue ro fill in the permit/licensa nwnber which will be used as a reference number, In addition,avit is applicant _(city or iliat pulicy�t'ormrtion (if necessary)aryl land under applications in any a Address"he applicann hould only f rite it uall'IuLvd ens in indicating ( Y current town)."A copy of he ut7ldavit hat has been ofncidily smmptd or marked by the city or town hnay be providedout each to the ts or nses. A now yepr' ant js proof that a a hums uwnerlid affidavit is on rite to a licenaa orture 1pgnnit not related o any bull nessdavit tor comjust enterca 1 venture (i.t. a dug license or permit to bum leaves ere.) said person is NOT required io complete this affidavit. d yo 1 hC 01iiCc of Invt.rigutiuns wuuld like to hank you in aJvaact fur your wuperation and should you halm:shy yuesuans, Plca,e do not hesitate to give w a call. bet: fhe D,;Paruncnt's address. telephone and fax co The Commonwealth of Massachusetts Department of Industrial Accidents 0Mce of lavesdgadons 600 Washington Street Boston, MA 02111 far. 0 617-727-4900 ext 406 or I.877-MASSAFE Fax N 617-727-7749 a_•. . d 5 ]o.u3 www,mam.gov/dia CITY OF S'U.E.`I, %L-kSSACHUSETTS BI;RDLNG DEPARTNONT 110 WASHLNGTON STRM. Y°FLOOR TEL (978) 745-959S FAX(978) 740.9846 K1J®E tLEY DRISCOLL MAYOR THomuST.Pt m DIRECTOR OF PLBLIC PROPERTY/BIL DLYG CONNISSIONER 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 1 t 1.5 Debris, and the provisions of MGL a 40, S 54; Building Permit q 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 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in XA (name of facility) Z y k /i/V le p (address of facility) signature of permit applicant G zG i� date ? Massachusetts - Department of Public Sareh ? Board of Building Rc_ulatiuns and SCtndar('1S : Construction Supervisor License �• License: CS 31999 1 DANIEL F LEBLANC 73 ORCHARD ST SALEM, MA 01970 A rt ' • Expiration: 6/16/2012 ' ('nnmiiwioner Tr#: 30641 Salem Web GIS - Map Page Page 1 of 1 g . p Property Yiewer 'B" l [iM rre t o t e fi� S h Cr of a l eu�`4<llassnrhu 'i t� ..� � "IV , :y 'j"^�` ?""'fii nM rl yAlXrincYfl if t�r� New Property Search Property Record Card 0 HELP 27, a9 , . d5dW.8 feet � / N .� eJ Jjf i'r Ik Property lD 27 _0503_0 Address 72 ORCHARD STREET Land Use 104 f \ r% Book and Page 26652-323 ' F ' Lot Size(Acres) 0.30 B'a / �� Assessed Value $353.200.00 rim { \. /. S !/ m oso f- iF I n oJss J l 9p ✓ // Choose a printable map from the dropdown list. 0407 (Select Printable Map) - T �n� Iry Q �. _= "�❑+ 'eL'Mmv�o-v",.a 0 0 0 arts kfl t?- © Scaie 1"= 55 --�� ft J$hOW Aerial Photo Salem City Hall93 Washington Street,Salem,MA 01970 Phone:978445-9595 City Hall Hours of Operation:Monday,Tuesday&Wednesday BAM-4PM Thursday 8AM-7PM Friday BAM-1ZPM Sde dea,ed by AppGeo. http://host.appgeo.com/salemma/Default.aspx 6/24/2011 j