9 ORLEANS AVE - BUILDING INSPECTION t ,
K"13 The Commonwealth of Massachusetts
h Board of Building Regulations and Standards TOE
Massachusetts State Building Code, 780 CMR, 7ib edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two- Jou_ Dwelling AMMOL
This coon For icial Use Only
Building Permit Nu ear: Da a Applied:
/
Signature: `LT11O 3)���5
Building Commissio r/Inspector f Build' Date
SE ION • TE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
GI OrlCianri ��4
L I a Is this an accepted street?yeses no_ Map Number Parcel Number
IJ Zoning Information: �� 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 75 Frontage(fit)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
E
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
or
Nam (Print) Address for Service:
Lc.
Signal a Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition 64CAccessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
�moc�� i� C4 S +coal
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building g I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S O Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
e
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S 60,00 Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S `L ❑ Paid in Full ❑Outstanding Balance Due:
�� 000
SECTION 5: CONSTRUCTION SERVICES •
5.1 Licensed Construction Supervisor(CSL)
t,.
"Re
Expiration Date
N.4mc of CSL- Hplder low)
Address Descri Lion
d u to 35,000 Cu. FL)
Signature I&2 Family Dwelling
M Masonry Only
RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 72: 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 au rued by this
bbuilding e t apgg cation.
Si nature of woer 2w - �sAZ�
�'��--CC Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, ,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 I'I
(Signed under the pains and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(no(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 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"
b
CITY OF SALEM
r PUBLIC PROPRERTY
DEPARTMENT
q:
I \S: 978 '4:'Ii L,
Construction Debris Disposal Affidavit
(required Iilr all demolition and renovation work)
In accordance \�ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit tf is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
I 11, S I50A.
The debris will be transported by:
/n S E l F-
(name of Italller)
I he debris will be disposed of in
(name of facility)
lj t c� a >y) .n S c, o -ff 1 )vi
lade cis of facility)
uature of p.rmit.Ipplicant
date
CITY OF S U.EM
PUBLIC PROPERTY
DEPARTMENT
iufnE•�w n....-.v L
Vwvoa 130 WARM .ROM Shear•LUdl MAUAC3%-=rti 01970
TEL 97 a-7iS-MS 9 FAY:97S.74&964
HOMEOWNER LICENSE E3MMPTION
Please Print
Date a -a (v -O
Job Location q- ii�l t l✓ Qu Q
Home Owner Address = fi o u
Home Owner Telephone �Z 7 S- 7</41-I C6
Present Mailing Address :54,4 Ff9 5 abo ucL
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 who.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 fort 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requir rents.
HOMEOWNERS SIGNATURE p
APPROVAL OF BUILDING INSPECTOR
See other side for state code
0009 ORLEANS AVENUE 484-08
Gis #: 1724 COMMONWEALTH OF MASSACHUSETTS
Map:' _ 08
Block: CITY OF SALEM
Lot: : 0035
Category: REPAIR/REPLACE
Permit# .:' 484-08 i BUILDING PERMIT
Project# ?; JS 2008 000763
Est. Cost: $1,000.00
Fee Charged: $25.00
Balance Due: $00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: ' Contractor: License: Expires
Use Group: applicant
Lot Size(sq. ft): 12050.874
Owner: Thomas R. Potorski
Zoning: B
.i
Units Gained: ,; Applicant: Thomas R. Potorski
Units Lost: s.. „SAT: 0009 ORLEANS AVENUE
Dig Safe#: $
ISSUED ON: 22-Oct-2007 AMENDED ON: EXPIRES ON: 22-Mar-2008
TO PERFORM THE FOLLOWING WORK:
CATHEDRAL CEILING IN SUNROOM ADDITION OF STREET TO SUNROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House tt Smoke:
Treasury:
Water. Alarm: A$$¢SSUr
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-200MOO921 22-Oct-07 cash $25.00
GeoTMSIO 2009 Des Lauriers Municipal Solutions,Inc.