1 ORCHARD TER - BUILDING INSPECTION � � � ' � `� �I � � z �S`�`�
� j �, The Commanwealth of Massachusetfs
Board of Suilding Regulatioos and Standards C1TY OF
� Massachusetts Stalte Building Code,780 CMR SALEM
Revised Mar 1011
Building Permit Application To Construct,Repair,Renovate Or DemoGsh a
One-ar Two-Family Dwelling
7'hi,s Section For 015cia1 Use Only
Bwlding Permit Number: ate / l 3
/ �
Buildiog�cial(Priot Namej ' Si Date
SF.(.T[OhV l:SITE PliVFOR�YiATI01K
1.1 Property Add 11 Asseswrs D1ap&Parcel Numbers
`� vRr. /�o � ;
� I.7 a Is tlus�accep[ed sheet?yes ✓ uo MaP���� Parcel Numba
. 13 Zoninglnfor�atiun: - 1A PropestyDimensioos: �
Zoning District Roposed Use Lot Area(sq ft) Fmntage(ft) -
1S Bail�ng Setbacks(ft)
�Fmd Yazd . � . Side Ya�k Rear Yazd .
Reqaired Providcd Requued Yrovided Required Provided
� 1.6 Water Snpply:(M_G.L c.40,§54) 1.7 Flood Zone Iniormation_ 1B Sewage Disposal System:.
Public❑ Private❑ 7Ane: _ Outside Flood Zone? Mwucipal O On site disposal system ❑
Checki(yesO
� SEC7701V Z: PROPERTY O�VI�ERSAIP'
2.l Owoer of Reeord- _L�
KR�sz��}�1 sM�Re3�6 11x.v�n1 c,�DY �I� �
Name(Print) y.�,'pp� City,State,ZfP/ � �
� O�� �Yl�l" ����- ��J�g8�1-1����
No.and Srieet Tehphone Email Address �
SEC110N 3:DESCRIPTIOAT OF PROPOSED WORKZ(check aII tLat appl})
New Constrnction❑ Existing Bailding O�vner-0ccnpied � Repairs(s) ❑ Alterabon(s) ❑ Addirion ❑
DemoGtion ❑ Accessory Bldg.❑ N�ber of Units Other 0 Specify:
Brief Description of Pra�osed Wo�:
�7-1 r C �_� �— J _�U
SF;C'f10N 4:FS7'fiNATED CONSTROCT[ON COSTS
Ttem F_st�a�ed Costs: Otfieial Use Only
. (Iabor�d AAat�ials
I.Building $ g ?q �. ����g P�F�:� Indicate how fee is determined:
2.Electrical � ❑Standard City/I'own Applica[ion Fee ,
❑Total Project CostB((tem 6)z mulliplier x
3.Plumbing $ � 2. OlherFees: $
4.Mectiar�ical (HVAC) $ ��
5.Mechanical (FiTe - � 1'orial Atl Fces:S
S cession)
�f7 eck Pto. Check Amount Cash Amount:
. . 6.Total Project Cost: $ '� I ❑Paid in Full ❑Oubtanding Balance Due: .
� S � �
SECTION 5: CONSTRUC170N SERV[CES
5.1 Construction Supervisor License(CSL) �� � .�� �
� �� �`�'�j� License I3mnber Fx irauon at . .
Name of CSL Holder � J
� List CSL Type(sce bebw)
� 5 ���f�r'7 �
No.and Street TYPe lhscciprioo . �
Q����� I U Umeslricted uildin ro 3S,W0 cu.ft.
�d�(/V �'11-Y f' R Restrictedl&2Farni Urellin
- City/fown,State,ZIP � M Masoory � �
' RC Roofin Cov ' �
� WS Windo�v and Sid- -
. \fJ��-��7�d��(J' . �������S��J�In� S� SolidFuelButnrogAppliances �
� t Insulalion
Tel hone Email addnss D Demolifion
51 Registe(re��d Home Impm(vement Coohador(FIIC) / 6 i�r� �0�%l3!/Y
�'4�17 ) �fl� > HIC Regishation➢V�unber Ezp-iration Date
HIC Com _Nmoe or . C Regstrant Namc �
1 � 1(�l�G(,J7Y R�
No.and ,�� 1^ Email addfess .
� �"1
Ci /I'own,State,ZiP Tel hane �
SECfION 6:WORKF.RS'COMPENSATION I�ISURAIVCE AFFIDAVIT(M.G.L.c 152.g 7SC(6))
Workets Compensation Insurance affidavit must be completed and submitted with this appGcation. Failure to provide
this affidavit will result in the denial of the Issaance of the building pem�ik
Signed Aflidavit Attached? Yes ...----•-- AHo.........__O
SECfION 7a:OWNER Ai7THORIZATTON TO BE COINPLETED WEIEN
� OWNER'S AGE➢VT OR CON7'RACfOR APPLIES FOR RUiLDIIYG PERMIT
T,az Owner of the subject ,hereby authorize
to ac[on my behalf,in ma celative to wo�c autharized by Wis buildiug pamii application.
� �
Print Ownds Name(EI �c ) �e
SE(.'1lON :OWNER'OR AU7'fiORIZED AGENI'DECLARATTON
. � � By entering my narne below,I hereby at[est�mder the pains and penalties of perjury that aIl of the infortnation
contained in t6is appfication is hue and acculate to ihe best of my knowledge and unders�anding.
Print Owner's or Aut6orized AgwPs RVame(Elechonic Sigoatare) � �
i�0"1'FS'
l. M Owner who obtains a building peimit 1to do his/ha own work,or an owner who hices an nnregistered contractor
(not registered m the Home Impcov��t Conlractor(HIC)Pmg�ram),will eot 6ave access to the arbitration
pmgram or guarnnty fund under M.G.L.a 142A.Other important infortnation on the I{1C Program can be found at
Infomiation on the Cons�uction Supervisor Liceose can be found at
2. Whw subslantial work is planned,provide 11ie information below:
Total floor area(sq.fl.) (including garage,finished basemenUattics,decks or porch)
Gross liviag area(sq.fl.) Aabitable mom coun[
Numb�of fireplaces Number of bedrooms
Number of bathrooms N�unber of halflbaths
Type of hea[ing system Number of decks(porches
Type of cooling sys[em ����� ��°
. 3. "Total Pcoject Square Foouge"may be substituted for"I'otal Project CosP' � .
� n S
t i
✓�te T061)Lnto'Itu/eRi ,,,� u[6BQ6 - LIMr
Office of Consumer Affairs&Bf iness Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
- Registration: ^161517 Type: Office of Consumer Affairs and Business Regulation
Expiration 10/23/2014 DBA 10 Park Plaza-Suite 5190
iiijua Boston,MA 02116
FRH
FRED HOPPS
15 WALCOTT RD
BEVERLY,MA 01915,11 Undersecretary Not vandOMit u nature
^,� ✓ "-; FI'�` sun.oinG PERFORMANCE INSTITUTE, INC.
I 107,H ea Road;Suite I20
Malta.: 020:.,.'
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Department of Public Safety f^" ` t1,
Board of Building Regulations and Standards It S i' IiuFit'..
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License: CS-07208
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Commisslt:+'�'`
Expiration
U4/27Z4
BUILDING PERFORMANCE INSTITUTE, INC.
I
1 1 .
o yYmvreJY S'er
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iAX�}
mass i°v PARrrciyA7lNG
h_ KniStiar Smedberg _ ,owner of the oroPertv'ncaie?zj-
i0w,Wi Name,pileted?
41-Grchard Ter 5a!em
hereby Authorize The M1RassSave.Home Energy Se.vices Program assq;nea Participating Contractor
tistedbeiow toactan M'-,behalf a��dc^.,A;,.ina a:Pdsng pe=r :ttc;,etiarrs it uts i::a?anaj:x -
awea.hrP_aticnwork on r:y pmpp .ty.
FOR CSG OFFICE USE ONLY
Conservation Services Group`iins assigned the following Msss Save Hone CnnrgySe mccs Ta-Cidp .nng
Con'rRctor w&YYt e above'raferenced,project" j Jj
j .)LF_-3_—
Participating Corvraet'or i-Date
y0.9
iev.12132011