3 ORCHARD TER - BUILDING INSPECTION (2) r
1 The Commonwealth of iVlassachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR CITY OF
' SALEbI
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised dlar 2011
One-or Two-Family Divellrng
Building Permit
This Section For Official Use Only
Number:
Date Applied:
Budding Official(Print Name). Z
Signature - Date
1.1 Property Address: SECTION 1:SITE INFORiV1AT1ON
1.2 Assessors Map g Parcel Numbers
� rr
L In Is this an accepted street?Yes_ no__ Map Number -.--,.-
I arcel Number
1.3 'Zoning iii furTia Hall:
Ld Property Dimensions:
Zoning D— is— tr— ion proposed Ua— .e--
Lot Area(sq Frontage(It)
IS BuiklingSetbacks(ft) 11) I
Front Yard Side Yards I
Required Provided Rear Yard
Required Provided Required y Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Fload Zone Information: L8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal[3 On site disposal system ❑
2.1 Owner]of Rccort SECTION 2: PROPERTY OWNERSHIP!
Gh,State,ZIP J�
No. an Street rt �- �7
Telephone LnnmI Address
SECTION 3: DESCRIPTION OF PROPOSED 1VORKi(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units
Brief Description of Proposed 1Vork�: Other ❑ Specify:
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and iblateria]s) Official Use Only
I. Building $ 1. Building Permit Fee:$
2. Electrical $ ❑Standard City/Town Application Fee
how fee is determined:
3. Plumbing ❑Total Project Costa(Item 6)x multiplier x
2. Other Fees: $
4. Vechaiical (HVAC) $ List:
5. �\Ie, anical (Fire
Su ression) S "Iota]All Fees:S
6. Tutai Project Cost: $ Check No._Clieu Cash Amount:_
❑Paid in Full Cl Outstanding Balance Due:
68
��DrZI (_2(2) G�1
SECTION 5: CONSTRUCTION SErRRVICES f
5.1 Cmtst ctit n Supervisor License(CSL) 167 Evp aatio te�
License Number
List CSL Type(see betowl f
Name of SL t older -
Y gJ Type;, Description
R.
No.and - O Unrestricted Ouildin s u l0 35,000 cu.
R svicted 1&2 FamilyDwellin
bl M Mason
ityirown,Slate,ZI RC Rootin Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 7 / I Insulation
!o � C)� p Demolition
Tcic honeaddress
5.2 Registered Home Improvement Contractor(HIC) �S — /
HIC Registration Number Espi alion Date
ill Co n any Name ur I tegislrantNa e
Emml'ffddress
No.an Street 10
'Cele hone -
Ci /Town,State,ZI
SECTION 6:WORKERS'CObIPENSAT[ON INSURANCE AFFIDAVIT(M.G.L.C. 152.§ Z?C(�),.
leted and submitted with this application. Failure to provide
Workers Compensation Insurance affidavit must be comp
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........❑
No...........❑
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN
OWNER'S AGENTOR CONTRACTOR APPLIES FOR BUILDING PERd1IT
1,as Owner of the subject property,hereby authorize
tq act on my behalf,in all matters relative to work authorized by this building permit application. a
f D.
Print Owner's Name(Electronic Signature)
SECTION 7b:OWNEW OR At
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 2
- /J o
!'riot wner's or Authon d Agent's Name(L'Iecvonic Signature
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or au°illni er shavetac ess toires an nthe arbitr�tiontractor
(not registered in the Home Improvement Contractor(HIC)['rowram),
program
r�sv naus. oy.v'!uca InfamUlfion on the Constru tioon Supervisor Lirtant cense can bet and aton the Cvorma ton Prognm can biLfound at
i. When substantial work is planned,provide the info(i a ion below:ige, finished basement/attics,decks or porch)
uding gar:
Total floor area(sq. R.) Habitable room count
Gross living area(sq. ftJ_--- Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
Type of heating system�--- Enclosed___,_____.Open
Ty pc of cooling system
"may be substituted for"rotul Project Cost"
3, "Total Project Square Footage
7�! Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor -7.. `
License: CS-104381
ARTHUR R CARUO
3 PINEWOOD ROAD'S
PEABODY MA ff1960;,� •s
Expiration
Commissioner 12/11/2015
f in 3S
r Otfictot Consumer Affairs&B smess Regulatioq%'
i — HOME IMPROVEMENT CONTRACTOR
y� Lr Type:'___" s
Registration: 159367
Expiration 412412014 DBA
q�
,i AC ON SIDEINGT-1 j t ¢ TM
ff
ARTHUR CARBONS
R r3PINEWOOD.RD
PEABODY MA 01960< ',9 { Undersecretary j
i
�I
i)
i
GUIMARAES CONSTRUCTION
t i 21 BALCOMB STREET
SALEM MA 01970
1' FONE: 978-836-7279
✓.x
To: Mark and Danielle Csogi
QUOTE: 01
3 Orchard Terrace
Salem MA 01970 DATE: January 28, 2014
978-594-5697
f
s
Quantity Description Rate Amount
Demolition
Frame
Install insulation
Frame floor
t"` & Install blue board and plaster
"s Install cement floor on shower wall and floors
Install tile in the floor and walls
t Reframe closet
Install 2 doors
Install vanity
Install medicine cabinet
l
Install trim in the window and doors
O
OTotal Price includes, permit, disposal labor, and material. $9,000.00
Quotation prepared by: RodriEto Guimaraes
Signature of Rodrigo
GUIMARAES 50%down 4,500.00
CONSTRUCTION 50% due when job is completed : 4.500.00
21 BALCOMB STREET To accept this quotation, sign here and return:
SALEM MA 01970
FONE: 978-836-7279 Complete Name of person signing this quote: Yes
Date:0
CITY OF Si>t .r M NL-1SSACHUSETTS
3 BUILDING DEPARTMENT
120 WASHLNGTON STREET, 3-FLOOR
TEL (978) 745-9595
Rita(978) 740-9W
M\IBERLEY DRISCOLL
\VYAYOA THOMAS STTIERR& '...
DIRECTOR OF PUBLIC PROPERTY/BCBDING CONLMISSIONEF j
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A i slicant Information Please Print Legibly
Name (nosiness.Organizatian.'Individunl):
Address: et
City/State/Zip: Phone it: 417 9 3
Are you un employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1
6. ❑New construction
employees(full and/or pan-time).' have hired the sub-contractors
2.® 1 ana it solo proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have h. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
(No workeri comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No workers' cunap. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. (No workers' 13.0 Other
comp. insurance required:]
'Any applicant rut checks box HI must also rill out the section below showing their workers'cornNnsatiun policy inlltrtnation.
'I it tine who submit this affidavit indicating they arc doing all work and then hire outside contractors must ai him it a new aMdaviI indicating suck
$entnctoo that check this box must anachc i an addidowl shmi showing Ile name of the sub•conlncton and their workers'comp.put icy infarmatian.
1 ant an eatplayer that is praviding workers cunlpensadon insurance for my eanplayees. Befmv is die policy and jub site
information. _
Insurance Company
Policy it or Self-ins. Lie.d: 6aSf� 9P�G' Expiration Date:A*
Job Sile Address: � (SQ .,..e.jbt_ 7�Y-G_
,! City/State/Zip:
,it ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage its required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/ur one-year imprisonment,as well as civil penalties in the form of u STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage vcrificatian.
/do hereby cerrijy wider the psi cord penult! ojperjury that the inforvnutlon provided ubupve j.. irue as ccorrreca -
Phone 7: /
Official use only. Do not write in this area,to be completed by city ur tarva official
City nr'I'uwn: Permit/Llcense p
Issuing Aulhurily(circle one):
I. Board of I lealth 2. Building, Deparlutent J.Cityfffmn Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Other
Cuoluct Person—_