67 ORD ST - BUILDING INSPECTION 'rhe Commonwealth of Massachusetts INSPECTI NALCR$WCES
Board of Building Regulations and Standards SALEM
blassachusetts State Building Code, 780 CNIR � 1 I
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Ttvo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date
Ilt,lIding Official(Print Narne) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prope Add ss: / t 1.2 Assessors Map&Parcel Numbers
1.I a Is this an accepted strf eet?yes no Map Number Parcel Nurnber
IJ Zoning Information: 1.4 Property Dimensions:
i
Zoning District Proposed Use Lot Area(sq 11) Frontage Ill)
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.do,§5J) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes13
SECTION2: PROPERTY OWNERSHIP!
2.1 O- - rr of�ccard� t `27 /2/ " d tF/?
� lie(Print) e City,State,ZIP
6 '717 210- 62146) leer-uz Ag(2 %/rfa a )%-I
No. and Street Telephone Email Addr• s
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alterntion(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of P/r9n posed Work`: e - 1-1f e Ill. di
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
[3.
. Building S (9�'� 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityrrown Application Fee
. Electrical S � o ❑Total Project Costa(Item 6)x multiplier x
Plumbing S �� 2. Other Fees: .S. Mechanical (HVAC) S List:
. \lechanicul (Pirc S 'rutal All Fees:S
u res ion)
Check No._Check Amount: Cash Auwunt:_
G. Total Project Cost: $ 26 v ❑Paid in Full C]Outstanding Balance Due:
l
f a7
AlsECTION5: CONsrRucrIONSERVICES
5.1 Construction Supervisor Lrieeuse(CSL)
(4 a :2A 2 S f� 3 ��(«} License Number Expirutiun Date
Name ol'01,Holder List CSL'rype(see below)
Type' ' - Description
No. and Street
U Unrestricted(Buildings tip to 35,000 cu. It.)
R Restricted U2 Family Dwelling
Cityi Town,State,ZIP M Masonry
RC Rooling Covering
WS Window and Siding
SF Solid Fuel Bunting Appliances
1 Insulation
'fele hang Email address D Demolition
5.2 Registered Ilome Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Nome
No. and Street Email address
r City/Town, State ZIP Tole hone
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 Is$uance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7at OWNER AUTHOIUTr1TI0N:T0BECOMPLETED.WHEN.= '
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERAIIT
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:une(Electronic Signature) Date
SECTION 7b: OWNEW ORAUTHORIZED AGENT DECLARATION
i
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in'his application is trueand accurate to the best of my knowledge and understanding.
, l
Print Owner's or Authorized Agent's Name(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[tome Improvement Contractor(HIC) Program),will Lint have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the H[C Program can be found at
www.nmsS.aov'oca Information on the Construction Supervisor License can be found at www.mass.eov!Jps
2. When substantial work is planned,provide the information below:
'total floor area(sq. It.). (including garage, finished basementlattics,decks or porch)
Gross living area(sq. 0.) Habitable room count
Number of tireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Fype of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may be substimtcd for"total Project Cost"
QTY OF SALEM, MASSACHUSETTS
" j BUILDING DEPARTMENT
120 WASHINGTON STREET,3'FLOOR
'ILL. (978) 745-9595
FAx(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR TrIONIAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date o? / /
Job Location Ln/� V 7 �� S Su r e yz"
Home Owner Address 7 Q�� S
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 OF S:ULEI,t, NLUSACHUSE-FrS
l' r 13UILDLNG DEPARTMENT
, t`• �` 130 WASHLNGTON STREET, 3%0 FLOOR
T EL (973) 745--9595
FAA(978) 740.9844
KEN 1HERI.EY DRISCOLL
NLAY01 T No.%Lu ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILONG CO"WISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, ind the provisions of tb1GL c 40, S 54;
Building Permit ik 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 tMGL c
l 11, S 150A.
The debris will be transported by:
(nameofhauler) �—
'fhe debris will be disposed of in
—__---(address of facility)
signature of permit applicant
latc