12 ORD ST - BUILDING INSPECTION (2) � The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR. 7"editio MON
n
t� Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a *kvo"Wmft
One- r Tiro-Famili,Duelling
is Section For Official Use Only
Building Permit Numbe Dale Applied: t
Signature:
Bui in Commtssi ner/I for of Buildings - Date
SECTION 1:SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map Qt Parcel Number
Ij2 0/� st
1.la Is this an accepted street?yesJC no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) Frontage(It)
1.5 Building Setbacks(It)
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: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outride Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�11 ) A-2 GJ-J 5� -
ame(Print) ` Address for Service:
972 - 77./ - 2SS�
i a ore Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Descripti n of Proposed Work': l fU, S
� Cn
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ORiclsil Use Only
Labor and Materials
%I. Building S I. Building Permit Fee: S Indicate how fee is determined:❑Standard City/Town Application Fee
l S ❑Total Project Cost(Item 6)x multiplier x
g S 2. Other Fees: Scal (HVAC) S List:cal (Fire Sn) Total All Fees: S
O Check No. Check Amount: Cash Amount:6. ota roject Cost: S ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 94IL15 a 2 /I
PG�r�- Lzwn i( Lacroe Number Expuauon Date
Nyoe tit CSL- HplJer Lut CSL Type Uee beluwl
s ilti�/1 Cl (� �7G�J (' n T. Description
A�Li/J C��✓rr^^� o l 3 3
U Unrestricted(up to 35,000 Cu. Ft.)
Restncied I&2 Family Dwelhn
Signamre M Masonry Only
97 RC Residential Roofin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Im rovemeot Contractor(HIC) /S. 7� S
G� C sip)A Tf)C
HIC Company Name or HIC Registranl Name Registration Number
q?� r_ 1Y fr
01
— Z6G'Jr / 3�) Expirat on Date
Signature fl, Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(Q)
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........... 0
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I 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
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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
Signature of Owner or Authorized Agent Date
Owned under the pains and penalties of 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 a(have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total Moors 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 halfbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
1. 'Total Project Square Footage'may he .uhmituted for"Total Project Cost'
,61� CITY OF S.U.ENI, AxSSACHL-SETTS
Bl:I DLNG DEPART.%j&NT
120 WASHIINGTON STREET, r FLOOR
TEX_ (978) 745-9595
FAx(978) 740-98U
KI�fBEP- EY DRISCOLl
MAYORTHohtAs ST.PIERItE
DIRECTOR OF PL BLIC PROPERTY/BL MDMG CO.%L%f[SSION ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciam/Plumbers
Alanlicant Information (� [y Please Print LLeeibly
NatTle (Busimw Orrysintion,ln,hvtdLW): NJ( er7- J c�la�nlnG �11�� Sl�n (CxQ2 lC�
Address: O:�X 1n24CA (21-1-Of
City/State/Zip: v Phone q: 7 360 _Sly 3a
Are you as employer?Cheek the appropriate box: Type of project(required):
1.0-1 am a employer with nc)o f 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(rull and/or pan-time).• have hired the subcontractor
2.❑ 1 am a sole proprietor it partner- listed on the attached sheet, : 7. ❑Remodeling
,hip and have no employees These subcontractor have B. ❑ Demolition
working for me in any capacity, worker'comp.insuutulm 9. ❑Building addition
[No workers' comp. insurance S. ❑ We are a corporation and its
required.)
oly1ce s have exercised their 10.❑Electrical repairs or additions
J.❑ 1 am a homeowner doing all work right of cxemption per MGL I I.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152.41(4),and we have no 12.0 Roof repairs
insurance required.) t employees. LNo workers' I7.❑Otha
comp. insurance required.]
-Any applicant thus chacb bts Of must altos fill out the Yetits hot"ahawiag their rvorkee'raxttpettaai,m policy inrotmtad
'1 Lmwtnvrtee who subaul this aflldi vil indicting they ate china all work Ltd than hire muide cnntntcien must submit a now amdovit indicating suck
{„ninonon that chwk Ohio box mud anuhad an addiliwnl dons-hawing the none of the oulo ocam usm and their workers,temp.policy infgmau".
l ate an employer that 6 providing workers'compenmfion lnsuraccer for my employees, Bdow/i tke polyry and jab slfe
information. 1 {� T
Insurance Company Name: G L-0,6 / f �_ t--
Falicy N or Self-ins. Lie. N: a 7 IF;2 O O Expiration Date: U D
job site Address: /a D City/State/Zip: SG /Cojo M 9-
,\ttacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
nine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the room of a STOP WORK ORDER and a nine
of up to S250.00 a day against the violator. lie advised that a cupy of this statement may be rorwarded to the office of
Inve,ngatum of Ilia DIA ror insurance Coverage vcriticdhen
l do hereby certify attdta rho pains)and penohles of perjury that ilia informmloo provided above is owe and carreea
1 �1! /
��r attune: Uatc 71
PFane,i /—g �� �G� � s / 3
Ofrial use anly. Do not write in this area, to be aaatpleted by rigor town ajjicial
City or futon: m g y —._; Fermi0.IceeN
i
Asuin \ulhorit (circle une :
I. Iluard of Ileallh 2. Building Department 5.C'ilyfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
4-milact Parson: _ _ -_. __ Phone 4:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
III 'I'X 'N-'�"�` • I �C 'i',Y 'J: 'i�L.
Construction Debris Disposal .affidavit
(icyuired lilr all demolition and renucaUun work)
In accurdance %%fell the sixth edition ol'the State Building Code, 780 CMR section I 1 1.5
Dcbris, and the provisions of%IGL c 40, S 54:
Building Permit H is issued with the condition that the debris resulting front
this work shall he disposed of in it pruperly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be han;portcd by:
)i425A
(nume tit hauler)
I he debris will be disposed of in
(twine ul lauhty)
GAT 13 3 Geo r�etu�n /�1 /-�
I IddrCSN ul Gc slily) �J)
a�nwtwe nt pi unrt .q+phcunl �-
7/ai�� 9