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26 ORD ST - BUILDING INSPECTION Ci-4 /y-7 The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards % t SALL-'M Massachusetts State Building Code, 780 CMR L... Reri.rrd Ilur?!1/l uBuilding Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Famih_' Dwelling / This Section For Official Use Only Building Permit Number to Applied: >/ _ r p ,y U Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property AddrEss: 1.2 Assessors Nlap& Parcel Numbers C7r rJ utCeet 1(#-005'3-0 1.1 a Is this an accepted street?yes no Map Number Parcel Number i 1.3 Zoning Information: i 1.4 Property Dimensions: oning District Proposed Use Lot Areeaa(sy tt- — Frontage/. Frontage(II) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Reyuired Provided 1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal On site disposal s stem ❑ I ublicK Private Check if yes❑ P K P I wA SECTION2: PROPERTY OWNERSHIP' 21- Record: f U�'1L%lY M Nine(Print) City,State,ZIP Ut+, reno. �/i ila Avenue- No. 611,950-00 iJ�� �M&, Ill Y°�Lro and Street Telephone Entail Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)X I Addition ❑ Demolition p( Accessory Bldg. ❑ Number of Units._ Other ❑ Specify: Brief Description of Proposed Work-: eio © ty�-- a hB✓'1 n If e 62 „ -te roki A,% r SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building S 11,0000 1. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee '_. Electrical ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 0e)o 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5, \lahmn) (Fire o S Total All Fees: S `j Su tressin Check No. _Check Amount: Cash 6. Total Project Cost: S i ❑ Paid in Full C3 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES VNI struction Supervisor License(CSL) tionDateLicense Numhcr I{�pimtinu DmcSL. IIuWcr Ayrlo,ovcList CtiL'fypc l+ee helms)eet '1)-pe Description V� M /`V 1�+� U llnrestricicJ(13uildi...s u' to 35,u00 cu. It.l City/roan.Slate.ZII' C/ _"i R Restricted M?Fantil Dwellin> M Nlasou RC Roofin,Coverin WS Window and Sidin pp &(7•�"}$ ,6 NOrwos> ) SF Solid Fuel Burning Appliances ( �� I 1`Vlci;i �': R� I Insulation Talc (tone limail address U Demolition 5.2 Registered Home Improvement Contractor( IC) 5 a�� I'"jo �3 ` n d'�ool� 1G �� 6' 1 ,2013 I IIC C ora l's}Name or I IIC'Registrant Nance I IIC Registration Ntu»hcr Expiration Date r'ti PesJoo�No.and Street Email address Cl /Town, State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 .......... ❑ 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. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' PR R AUTHORIZED AGENT DECLARATION By eat ring my a below, I hereby attes rider the pains and penalties of perjury that all of the information c tta' ed d th' plication is true and curate to the best of my knowledge and understanding. I' in O ner s or Authorized Aget s Name(Electronic Signature) Dale 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at \1P 9 1I1A,- -SoY oc i Information on the Construction Supervisor License can be found at tk%ytq_n ras:.�ot Up; 2. \Then substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage, finished basement'attics,decks or porch) Gross living area(sq. it.) __ Habitable room count Number of fireplaces _-_-_ Number of bedrooms -- Number ofbathroonts -----____--- Number ofhalf'b;tths -------- T)pe of heating system -__--- ---- Nuntberofdccks, porches__ T)pe of cooling sy stem -— -- ----..__--------.—_.-._-- E'nclosed Open -- 1. "fol:d Project Square Footage-may be Substituted for rtnal project Cost" . CITY OF SALEM ;, , PUBLIC PROPRERTY 1 DEPARTMENT LENT .1 Y.•n IN rl l - \1 Nrgf I!.^ WANINt;IU.\j7:tC11' 4 $,1lPN, III 4II\ I117,^. Ihl nf,•IL/41J • pt.r v)earG•I,rM Workers, Cumpenaation lnsurunce :ltfiddvit: Uullden/Cuntroctun/ElectricJynWPlumben 1 )Ilcant In onnallo N'llne I Ilum ,si17 •ylvninlvinJir�Juul,1: I I (' ^ n \\ �rope`\'Y \Ad DYVO otr� �i me r� eel �y 8Ver-,AVI�re-. 01/c 1�t�s/ C .5rarc.%ip `7c �e n M AOt "I7d / a I hone its (". (7• �� �•O t 1 6 I .kru)ua an vnq,loyert Check the approprluto box: L Giant a cmpluyur wish 0, � I aln a gunural ceulnclOr and I type orproJuct(required): ?.�mnpluyeux(lull mlpur part-time).• huvu hired the.xub•uunlrrcwra (t. ❑t\'uw construction i and a sole prnpricntr or partner• lived on the anached.vhcet 7• ORmnodelins .rltip;Ilttl have no ulnpluyccw These sub.conlncron have ourkind Air me in any capacity, %vorkero'comp, insurance. a' Demoliri00 I NO work-rs'cutup. insurance J. ❑ We are a crhporatinn and its 9• ❑Ouildind addition nyuind J )IrC4rB have crenixud their !0.[]Electrical repairs Or additions J. 1 am a holm u,wtcr Juind all work righr Ofu.rcmption par hl(iL 11.❑Plumbing npuin us,udditiory mysvIt IN•o gorkcn'comp• c. 1 JJ,f}I(1),and we hnvu no iltxuranc0 rcyuired.J r unploycee.(No workers' I g•Q Rwl'repuin coinit invarancu nyuircd.J 13.0 Other •.1 ny.�iplcue ilia:hs,cka Ow el muel.IIW NII uw Ih 'I I.,mr,•wns,re who tiynul this anlJavil inalulin IA"•,bill of In:lur awrina Ihs,ir•n+rkwe'cwtlls"Wis ,jewicy ulPlrlrw,iwa l,•nlnwhr,IAst thrck Ihla a +re allow +11 work sna Ihu,hlw uwsiM rtaer ,u Ibe mlaY Jllachwl.In aJaltiurW.hues,Purina this,mete arthe rue•caer ntlon m r-elms a I, alnaarif inJlay;na vkP. /a/a on e/upleyn thuf k pro vlJlnr tvorAnJ'ru/npenrntlOq Grrunmce/w/xy p��arts 1Pee Ntllts,n'coup.hldtey matrntaYlla in`Y/IIIYfGIK p/J rrq Br/ulv IS the pY//ay ofis�djvblmv Ilnurauw C'untpany .Vmntr Policy Y ur Sclr-ins. tic./s: - -- EApiratlorf Date Jub Siru -1dJnvx: �—� .UtacA a tin Oly,Slate/Zip; yy or the Yorkers'cumpvntatluq polie) duclarallun page(showing fhe policy numb--and esplraNuq dote). PJe III) lu wcure cwerujojlu u required ulr im incrit. 'JA ul'.NGL u. I J;eau lead to III*imposition oreri,ninal penalties Ora eti tit nt.l'LJnOJNI JntYurlbi do of ilnprivumncni, J./ Null as civil Ilcnullics in the 1'unn ura STOP WORK ORDER and a fine •trap nt i230,114.1 Jay I�t;6r 1 Ilse vL,iuuv. tic sdvi.tcd that i uop urthla.wivinunt may bu Iurw Jrdud l0 the Ullire us, Im CTII�JIP 1111 ul :hu IIL\ i9f III,IIr.U'Ca GI�rCN /du/rc•rrAi/I• r�r //Its,)/•ri ,nil /rno//%ru /U^U / �prr/nry Yf/Ile ll/�'VrnrY//On//ryrir/ed YOVYe it true rrlh/re/rerP o IG 0//4-iu/me un/y, py not Vrife in this� u •u, oAe runtpletrd 41y city us,/own a/Ilriud t (ityur 1'o It'n: _ I Pcnnit/Llcrmr!„uiny .\ulhunly (cirvle until: L IL,,/rJ •I'll"Itif 2. Iludlhny Ilgl.v hncill I. lil). f ultu Clerk J. [:'Icefriral Int ,vs,Ns, ., Its. 171hvr I Plumping Impactor I t'."u.tcl I•tr,uu: information and Instructions r eVe son in the service of another under.lily :unmet Of hire. Ala>so:hu:atu licnenQ n r��lulli 132 dctirted� all an�lo�n m provide workers' compcnsauun tat theta Culp Jyces. Ihlrnustt to Jill$ >'atu vPress Jr unpl":d, Jfal 'It wnuen.•' of lilytwo or more tj lu s.( ur the to anpluyer I+delinad as"an mdtviJual. partnership.assoeianJo,coryorahun ur other legal docntiry, a iha G,regomg engaged in a 1alnt enterprise, and includ)ng the legal rgp %:nG'l dro to ao eel plo)ees However the teCClvef Jf Iraalae Ul .lit IUd,vlJwl. pa+tnenhtp, assoetaaoo or other regal anoty, D Y e ' to be to employer." eons to three m:lintenanca.d willfuction of repair work oa such dwelling house owner of a dublear l{house having not more than three apartrnenu aaJ who resides therein,or the occupant of n house of another who employs t L shall not because of sueh employment be JeemeJ wv Ih oral. .I g t th or on 'hit.rounds or building apP unanan I or local Ileenslar agency shall withheld the Issuoacr or �IGL chapter 152. 425C(6) also states[hut"every or 20 None+vat of a Ilccnw ur pornslt to upualt•huslneu of to construct with thecoverage lrequr say VP produced acceptable >bl eaYlNeuher the ommonwcalth nor aaY of ill political withsubdivisionsiiashall licant who has not p 1JJitionally,bIGL chupter 15.. i-S l an[er into any contract tor the perfomtun'!enteJbo; work the connect O ccepli ofcumpliwtce with the insurance Y. requirements of this chapler haw been p' Applicants checking boaea that apply to your situation and,if ad vitti )' phone rtumber(s)alone with thou cemploy e s of Pla:isa fill out the workers' compensation affidavit eoel;plaentde Y.by with no employees other than the nacc$$try,supply sub-coelfuctor(s)o can°(a),• Partnerships(LLP) have workers' compensatio submitted to the Depurotmant ofr LILP ��atrial Insm-anea, Limited Liability Companies(LLC)or Limited Liabilityjosuriance ineinbers ar purtaers, ate not required to carry employees,a policy is required. 1!e advised that this alfidavit uuYwasted,not the L3"Partment of \ccidenu for contlrma►ion of inauraaeo coverage Also be sun to sl�a and Jute the afsted-N The affidavit show ld tic rageAdon for the permit or license is being requested-required to obtain a workers' he renamed to rho city or town ea haveat the questioas regarding the law car if you ad he reltriul Accident$. Should y ay 4ud..li$t the number listed below. Self-insured compaaiee should enter their Indusucol"Penaancin policy.D1C0n call the Oep self-insursnes license number on the a crapriato line. ('try or•rown Officials the applicant Masts he sure that the affidavit is complete :mJ printed legibly.Inve The Departons his to has provcontact youfe u space at the bottom cant of ills alfidavit fur you to lilt out l the avant the OITke of i l be ul{ae t"s'iced only submit one�111davdit indicating curtent I'I:ase be sure to till in the pannit/licen$e nwnbrt�which oM in any given year, a reference bmit u. In addition,an aDP t.it or that mwt submit multiple i sary)'And%se app ed or marked by Ile city or town trtay be provided[u this Policy.. lion lif necessary) and under flab Site Add...."the applicant should writs"all Iocatiun$in Y Policy..�\copy of the utTldavit that has been officially stamp' Permits or licenses. A new atT)Javit must ro filledldeci out each ennit not related to any business ar eommereisl venture applicant as proof that a valid affidavit is can file for 1Lture p erson i$ VOT required to complete this alfidavit. aear. Where a home uwnor of citizen is obmining a license Jr dal{licence or permit to burn leaves ate•)+a'd D coo oration and>huujJ you have.IAY que>umis, I he >'Ii:e at luva+tigatiun% would lice to thank you in advance fut your P I,ica,e do nut hesitate to give us a call. nc,: u:p.uunent's addre+s, telephone and fax number. The Commonwealth of Massachusetts ()epart went of Industrial Accidents Office of levtadgadons 600 Washington Street Boston, MA 02111 f al. p 617-727-00 617-72 O71J9"-MASSAFE www,man.gov/die CITY OF S,U-&�i, ��LISS.�CHL'SETTS 8L'ILMNIG DEPARTMLNT 120 W.ISMC4GTON STREET, 3'O FLOOR TtL (978) 745-9595 PAX(978) 740.9&M KIMBERIEY DIUSCOLL MAYOR THOsW ST.Pmean DIRECTOR OF PLeLIC PItOPERTY/RI'RDLN(;CO\pIISSIONER Construction Debris Disposal AftIdavit (required for all demolition and renovation work) !n accordance with the sixth edition of the State Building Code, 780 CMR section t l I.5 Debris, and the provisions of MGL c 40, S 54; Building Permit H 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 I 11, S I50A. The debris will be transported by: U 0 ; �,f (name of haular) The debris will be disposed of in -- (name or ravany) (jddress or facility) Asisn-4r-uizeozrpc2m,j applicant Shn,.d.b¢