73 ORCHARD ST - BUILDING INSPECTION (2) !, The Commonwealth of Massachusetts Town of
�I ,+ Board of Building Regulations and Standards �w
Massachusetts State Budding Code. 780 CNIR. 7*edition Building Dept
Building Permit Application To Construct Repair. Renovate Or Demolish a
one-or Ttro•fumrls'Ots'el6ng
This Section For Official Use Onl
l Bwldind Permit Number: Date Applied:
aV(,J1 Signature: 2� �,
Building st r/InspeetorolBwldmds Date
SECTION 1:SITE INFORMATION
1.1 Property ddrgs: A LI Assessors Map i Parcel Numbers
Sa ls� M
i 1.is Is this an accepted street''yes no Map Number Parcel Number
ii Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq R) Frontage 1 RI
I.! Building Setbocka(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zones: _ Outside Flood Zone? Municipal 0 On site disposal system O
Public 0 Private 0 Chock i(yesCI
SECTION I: PROPERTY OWNERSHIP' Y_
2.1 Qwoe 'of or :
No Prin Address Its,Service:
- C � -7u4-�s�
sips Telephone
SECTION): DESCRIPTION OF PROPOSED WORK'(chock all that apply)
New Construction O Existing Building O 1 Owner-Occupied Xr Repairs(s) O 1 Alteration(s) 0 Addition O
Demolition O Accessory Bldg.O I Number of Units I Other O Spairy
Brief Description of Propos Work': OWE
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: 011lclal Use Only
Item Labor and Materials
I. Bwldind S 41000 1. Budding Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S OD 0 Total Project Cost'(Item 6)x multiplier x
Plumbing S &00 2. Other Fees: S �
i. Mechanical IHVAC) S List: / �LJ�i-
t Mechanical (fire S Total All Fees: S
Su ression
Check No. _Check Amoune Cash Amount._
to Total Project Cost S C� 00 0 Paid to Full O Outstanding Balance Due
R l..
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
w
• Li.enx.Number Espuauon Due
N,yee or'CSL Irpldn Ltst CSL Type Isec he luwl
a _
A,hkess go
Dean non
Unrestneud u to J7,000 Cu. Ft.
Restncted IA2 Fsmd Dwelhn
srgMlYr! .Mason ResidentTelephone Residential Window and SidrnResidential Sohd Fuel Bumm A fiance Installation
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.e. ISL/ 2SC(61
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.......... 0 No...........0
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
authoriz
e to act on my behalf,in all matters
rel 've t work authorized by th'a building permit application.
Si of Owner Data
JSECTION 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
behalf.
Print Name
Signs ure of Owner or Authorized Agent Date
(Signed under the gains and penalties of r
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 sg have access to the arbitration
program orguaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSLJ can be found in 780 CMR Regulations 110 R6 and 110 RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenVattics,decks or porch)
Gross living area(Sq. R.) 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 coolingaystem Enclo.ed Open
1 "Total Project Square Footage"may he.uh.tituted for-Total Project CONC
I
. Y
CITY OF S.UXENf
PUBLIC PROPERTY
DEPARTMENT
.MY� ��I����(�.�1�, � • f4 .M1L�10.�3o�7Y
7�1.9'1.7li9S4i�p.�1L 9'L7g7W
HOMEOWNER LICENSE EXE..NMION
P1ew IMat
Dan I O 1
T Job Loeatioa v v'
Home Owner Address:j I- O rc CV
Home Owner Telephone a 3 9 a
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lean and to allow such homeowners to engage an individual for
hire who don not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a pneel 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures requireeIments.
HOMEOWNERS SIGNATURE l
APPROVAL OF BUILDING INSPECTOR
See other side for state cods
CITY OF SALEM
t � PUBLIC PROPRERTY
DEPARTMENT
I'AIt RI h} •NM '•II
\I'J�9t I�Q\�.\A IINIII U,N$1 NErT �S.\I r\t, fit.\ii.\I I II it 11+.I I -
I 978.744'1846
Construction Debris Disposal Affidavit
(required fur 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 # - _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
1 11. S 150A.
The debris will be transported \by:yam(II
(name of hauler)
'file debris will be disposed of in
(n ne ul aci ny)
(address of facility)
nature of permit applicant
date