6 ORCHARD TER - BUILDING INSPECTION r
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7" edition OF SALEM
Revised Januury
Building Permit Application"fo Construct, Repair, Renovate Or Demolish a 1. 2008
One-o o-Fumily Dwelling
is Sec ion For f cial Use Only
Building Permit N ber: D•to Applied: -
Signature: 3
Building Commission&1fisrectoro i ings Date
SECT ON is SITE INFORMATION
Ill Property ddress� ` 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes ` no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. wrier ofRecorAN t d:� \\
Name(Print) 1k ��- M
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Briel"De,scription of Proposed Wgrk':
GI X
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost (Item 6)x multiplier x 1
3. Plumbing S 2. Other Fees: $�/� /vAv\1
4. Mechanical (BVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Nance of CSL-I loider I.ist CSL Type(see below)
'fype Description
Address U Unrestricted(Lip to 35.000 Cu. Pt.)
R Restricted 1&2 Family Dweilin,
Signature M Masonry Only
RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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 .......... O No...........❑
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.
Signature of Owner Date
SE V TtIO O N 7b: WNEW OR AUTHORIZED AGENT DECLARATION
I, N ,as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties o(perjury)
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 trot have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can-be found in 780 CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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 SMY-M
PUBLIC PROPERTY
DEPARTMENT
OfOWS7 n�.r•,w
wro. i3ov�omw�on!Weer 44,-- stwsuoRsarnON'e
M r.F'1•s9sss•FAX r.a•»o9sw
HOMEOWNER LICENSE EXEMPTION
pies" "t
Date (�
Job Location v�
Home Owner Address
Home Owner Telephone
present Mailing Address k%x,
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a licenses provided that the owner acts as supervisor.
DE INMON OF HOMEOWNER
petson(s) who owns a parcel of lend on which he/she resides or fntenda to reside, on
which chars 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
"lomeowne"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 and r quirementa. ' (�
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING INSPECTOR
See other side for state code
�J
CITY OF SM.E.tiI, U),SSACHUSETrS
• BUILDLNG DEPARTMENT
130 WASHL*IGTON STREET, 3''FLOOR
TeL (978) 745-9595
FAX(978) 740-9846
Kj.%tBFRr FY DRISCOLL
MAYORTHonL+s ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUIIDIING CONMISSIONER
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:
(name of hauler)
f l
The debris will be disposed of in :
(name of facility)
(address of facility)
signature ofpermt apple ant
date