65 ORD ST - BUILDING INSPECTION =' -7 � ( � _� (I Z LA
ED
'rile Commonwealth of iVlassachusetts IASPEC 10"A` ry OF
Board of Building Regulations and Standards AL��bI
�f Massachusetts State Building Code, 730 CMR 1QIy ekil,[/dr 14
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appl'
I
O �
Building O(ticiai(Print Name).
Signature- Dae
SECTION L alTE 1NFORSIATIOi F
2 erty address: 1.2 Assessors Map&Parcel Numbers
Number
I.la Is this an accepted street?yes 'to— Mao Number Parcel
1.3 Zoning Information: I� ror!.vV Dimensions: — '3Cg-(2Y
Zoning District Proposed Use Lot Area(sq It) Frontage(It) j
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Rcquired�= Provided i
1.6 Water Supply:(NI.G.L c.40, 54) 1.7 Flood Zone Information: I.S Sewage Disposal System:
Zone: __ Outside Flood Zo e7 Municipal H•On site disposal system ❑
PublicZ Private❑ Check if es)
SECTION2: PROPERTYOWNERSNIPI`
2.l i0?vncl t Re¢6r f— G,_ LP.l A K 662 I
�Yme Pnnt City,Stale,ZIP J r
(/(' Ord
No.mtd 8rmel Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) <a Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specit'y:
Bricf Description of proposed Work'::: 0
SECTION q: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
is determined:
I. Building S 1. Building Permit Fee:3 Indicate how fee
❑Standard City/Town Application Fee
3. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
L Mechanical (HVAC) S List:
5.Mechanical (Fire S Total All Fees:S
Su tression)
Check Na._Check Amount: Gtsh:\nunmt:
6.Total Project Cost: S 25b ❑Paid in Full ❑Outstanding Balance Due:_
S�jJD To H• O .
SECTION 5: CONSTItUCTION SERVICES
5a�]Cunst ruction Supervisor License(CSL)
1 . ^q4 tj" License Number Expiration Date
N;une orm IluWer List C SL'rype(see below)
"type Description
No. and Sucet
U Unrestricted(Buildings tip to 35,000 cu. It.)
It Restricted 1&2 Family Dwelling
Cityll'orvn,Sane,ZIP bt Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Doming Appliances f
I Insulation
rcie hone Email address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dote
IIIC Comp;uty Name or HIC Registrant Name
No.and Street Email address
Cit frown,State ZIP Tole hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 151.§ 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 PEIIN11T
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's N:mte(Electronic Signature) Dale
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
containe 1 this; lication is tru nd accurate to the best of my knowledge and understanding.
4JI/ l
Print Owner's or,kl6diorized Agent's Nome(Electronic Signature) Date
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 net have access to the arbitration
program or guarmtty fund under M.G.L.c. 1 T2A.Other important information on the HIC Program can be found at
trwrv.netsS. goy rr'uea Information on the Construction Supervisor License can be found at wraw.ma;;. ov'JL
1. When substantial work is planned, provide the information below:
rotal tloor area(sq. R.) (including garage,finished basement/attics,decks or porch)
Gross living area(sal. It.) Habitable room count
Number f fireplaces Number of bedrooms
Number of bmhroonts Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system_ Enclosed_ Open_.
1. 5aal Project Square Footage"may be substituted Ibr"fatal Project Cost"
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASMNGTON STREET,3F0 FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KINMERLEY DRISCOLL
MAYOR TrIOMAS ST.PIERRE '
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
f'
Date
00 area �l ew 9Z aj2n
Job Location l a�
Home Owner Address
Present Mailing Address _-�
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there 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 "homeowner" 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
CITY
`,�! 4 � � �+� / � ( t� ` [�T r Cyr--r��+loll i 0 Jig E'N[2 LY li��7Ji1C11 VrJL1 1J
111.•=LYG DEPARME,NT
` 130 WASHLNGTON SIAEET, 310 FLOOR
-I.EL (978) 745--9595
F.kx(978) 7-W-9M
Ifl1IBE.lZIsY DRISCOLL
NLAYOR THObLA3 sT.P1ERRB
Dt.ZECCOR OF PUBLIC PROPER7Y/8CILDLN<;CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 C&IR section I 11.5
Debris, and the provisions of tblGL c 40, S 54;
Building Permit k 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 NIGL c
111, S 150A.
The debris will be transported by:
y
,l
(name of hauler)
The debris will be disposed of in
w..+w.ra•.K:
(name of facitity)
(address of tzeility)
siynaturc ofpermit applicant
-46;Lj ZON