92 ORCHARD ST - BUILDING INSPECTION (2) The Commonwealth o �¢�
�n Department of Pu rc afety
Massachusetts State Building Code(78f)�t)QITa 11:
Building Permit Application for any Building otlu _ - r wo-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
92 Orchard Street Salem, MA 01970
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used 9-:1W If New Construction check here❑or check all that apply in the two rows below
Existing Building M Repair aF I Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No lk
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 6
Brief Description ofPropo�edWp : 1Seri asood shingle siding on rear side 2nd and 3rd,.'
flo
pre-primed sidewaRRlllshingles.
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-160 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ I111 ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
�� , A C'oufle-e�
(lec��lz�nnccfen�l`� a �C-�r/CJ1ac�ccle
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 104711
Type: Private Corporation
Expiration: 7/15/2016 Tr# 253662
FRONTIER CONSTRUCTION COMPANY, I
Peter Farmer
PO Box 5201
Beverly Farms, MA 01915
Update Address and return card.Mark reason for change.
scn i a tom-os n Address -_7 Renewal Employment 1� Lost Card
License or registration valid for individul use only
before the expiration date. 1f found return to: '7ill 1`(.aieu4„1,,"Al,'/'7 lla.('r/aJe(Y'
Office of Consumer Affairs and Business Regulation Office of Consumer Affairs&Business Regulation
n 10 Park Plaza-Suite 5170 ME IMPROVEMENT CONTRACTOR
Boston,MA 02116 Registration: 104711 Type:
�,, xpiration: 7/15/2016 Private Corporatic
/ 7 FRONTIER CONSTRUCTION COMPANY, INC.
Peter Fanner
Not valid without signature 198 Common Lane
Prides Crossing,MA 01965 �—
Undersecretary
i
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Nelson DeSilvestre 9 Pilgrim Heights Beverly, MA 01915
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
978-A87-3550 nalennAacil2anl COID
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Peter C. Farmer 198 Common Lane Prides Crossing MA 01965
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) /
If buildingis less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 1(O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Frontierl:Construction Company, Inc
Company Name
Peter C. Farmer 020958/Type U
Name of Person Responsible for Construction License No. and Type if Applicable
P.O. Box 5201 Beverly Farms MA 01915
Street Address City/Town State Zip
$789:22-2900 978- 423-6093 frontierconstruction@comcast.net
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes M No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$ 13,000
1. Budding $ 13,000 Building Permit Fee=Total Construction Cost x 7(Insert here
2.Electrical $ appropriate municipal factor)=$ 91
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical_ Other $ Enclose check payable to City of Salem
6.Total Cost $ 13,000 (contact municipality)and write check number here 8499
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application ' ue ar accurate to the best of my knowledge and understanding.
President 978 _ 9222900 9/22/14
Please l rut and signPeter C. Farmer name Title Telephone No. Date
P.O. Box 5201 Beverly Farms MA 01915
Street Address City/Town // State Zip
Municipal Inspector to fill out this section upon application approval: ✓ �tY�° rtti k /
Name Date
CITY OF SMY-M. TUNSSACHUSETI'S
MUMLNG DEPARTMENT
• 120 WASHL:IGTON STREET,r FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THo&w ST.PtER&E
DIRECTOR OF MBLIC PROPERTY/13UHMING CONWSSIONER
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 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 be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
Mark's Disposal. Demolition & Cleanouts LLC
(name of hauler)
The debris will be disposed of in :
ERRCO
(name of facility)
270 Exeter Road
___Epping, NH 03042
(address of facility)
signature of permit applicant
9/22/14
date
Jc6riwl'f Jcx:
CITY OF S.UEM, NLikSSACHUSETTS
BUUMLNG DEPARTJiNT
120 WASHINGTON STREET,Sao FLOOR
T L (978)745-9595
FAX(978)740-9846
K1\1BERLEY DRISCOLL
MAYOR THOmm ST.PlEm
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSMUSSIONFR
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(SwintssiOrganizationilndividwl): Frontier Construction Company Inc.
Address: P.O. Box 5201
City/State/Zip: Beverly Farms, MA 01915 Phone q: 978-922-2900
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ® I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ®Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for mein any capacity. workers'comp.insurance. 9, ❑Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
311 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13,C)
comp. insurance required.]
Other—
Any applicant that checks bon rl must also fill cut the Mctiw,below showing thou workers'compensation policy information
t I to tcournen who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a how affidavit indicating suds
=Contra ton that cheek this box must attached an additional sheet showing the name of the sub.eontrwum,and their worker'comp.policy infmmation.
1 am an employer that it providing workers'compensadon Insurance for my employees. Below is the policy and Jab site
information.
Insurance Company Name:
Policy 4 or Self-ins.Lis M Expiration Date:
Job SiteAdtln:ss: 92:10rchard Street City/State/Zip: Salem, MA 01970
Attacb a copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine
--- ---ofup to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigation:of the DIA for insurance coverage verification.
1 do hereby card n e hr ns and penaties of perjury that the information provided above is true and correct
. i r t tr Date. 9/22/14
Phone#: 9 8-922-2900
OJrcial use ally. Do not write in this area,to be completed by city"town oJJtcial
City or Town: Permit/License fi
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• _. Phone#•
I
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Camtruction Supcni,or
License: CS-020958
PETER C FARMER '
PO BOX 5201
BEVERLY FARMS t
Expiration
Con"Issioner 02/22/2016
n
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991tn')of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS Licensing Information visit: w .Mass.Gov/DPS