9 ORLEANS AVE - BUILDING INSPECTION (3) W d The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY
!�7 l Massachusetts Slate Building Code, 780 CMR, 7"edition OF SALEM
Revised Januury
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 20W
One-or Two-family Dwelling
This Sectict or Officird Use Only
Building Permit umber: Dale pplied:
Signature: l /a
Building CommisgoKerl Inspector of Buil ngs Date
SECTI N :SITE INFORMATION
1.1 Property Address: 19 •Vt L 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes no L Map Number Parcel Number
1.3 Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofRecord: r q-ONO CE-IVS ffU�
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
./�7nUC tnlw qt n
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omclal Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard CitylTown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x muukiiplieerr x
3. Plumbing S 2. Other Fees: Sor�GO
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S OO 0 Paid in Full 0 Outstanding Balance Due:
D
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) y 5'3
�2r7✓1745 Ir7 ���s��t I.iccnw Number Expiration Date
Name ofC'SL-1Il IJ�`� �// S U G List C'SL'type(see below)
f Description
Address u Unrestricted(up to 35.000 Cu.Ft.
R Restricted I&2 Family Dwelling
Signal 7�-! (/ I M Maso On]
q ` -[ !O / RC Residential Routing Covering
relcphone WS Residential Window and Siding
SF Residential Solid Fuel Rutming Appliance Installation
D Residential Demolition
5.2 Regbte dm m Home Imp fyve a Contractor(HIC) / b J 3 7 6
o BASK t
IIIC Cu�'any N• or HiC Registrant Na F Registration Number
G AJ ] - 7- 16
Address r )�_7h//�/��� Expiration Date
Signature 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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
I, � NQ 5riJrSKt 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
(Signed 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 W 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 SALEM
PUBLIC PROPRERTY
�• DEPARTMENT
I_c�_,•111\I...IV)1'alri •)•111\I, \t.\�i 1, 111 y l.•.I'1 _
I'FI�'1747 .44PA 0 P%1:N79•7*"'14A
Construction Debris Disposal Affldavit
(required lur all demolition and renovation work)
In accordance with the sirtli edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall he disposed of in aproperly licefued waste disposal facility as defined by MGL c
I11.S 150A.
The debris will be transported by:
/�6Yr1Gs �lor5k ,
Inane of hituler)
'1'he debris will be disposed of iL I nGn :
Q'T_
(name 01
, 124:1 ny)
-
/I:,d�rer>t of Ixllay/
Irnatwe oFparn,it applicant
date