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7 ORNE SQ - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF \ Board of Building Regulations and Standards SALEM Massachusetts State Building Code,780 CMR Revised Mar 2011 '1 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or YWo-Family Dwelling This Section For Official Use Only Building Permit Number:,. ate Applied: D Signam Building Officiat(Print Name) SECTION I:SITE`INFORMATION Ll Property Address: s 11 Assessors Map&Parcel Numbers OR'F' Parcel Number 1.la Is thus an accepted et? yes_ no_ Map Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) : . Side Yards Rear Yard Front 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? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes❑ r `.-SECTTON 2: '.PROPERTY.OWNERSIUPt '. 2.1 erlof eco�l:i S+�rw• tk O (9 e Name(Print) City,State,ZIP "7 Orne Sg 9745'7098 � Telephone Email Address No.and Street SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Wodct: AU, 1 SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only. Item abor and Materials 1.Building $ Z./r a 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier`'" x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (I-IVAC) $ List 5.Mechanical (Fire $ Total All Fees:$ Suppression) Check No. Check Amount Cash Amount. 6.Total Project Cost: $ $�B�6� ❑Paid in Full ❑Outstanding Balance Due: 9W- (;tw'�rc-L/ i�� SECTION Sc CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ���� � ,� ��/^, License Number FxpirationDate Name of CSL Holder List CSL Type(see below) l0 pCS jm�o ll �� Type. Description No.and Street <: U Unrestricted(Buildings up to 35,000 cu.R 1i✓�it-/1 R Restricted l&2 Family Dwelling City1rown,S , IP M Masonry RC Roofing Coverin WS Window and Siding SF Solid Fuel Burning Appliances 97�-998 0 U I Insulation Telephone Email address D Demolition 5.2r}R—egistered Home Improvement Contractor(MC) 1 �uO VRegistration A)A#0 Ash" H[C Regs ratiion Number Expiration Date HIC Co Namgor HIC R�istmnt Name /O /ICJ o/I ti No.13 Street o '97e-99K 0990 Email address City/Town,%4e,ZIP 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 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 MQ N 1TN 1 L1A w S t toIon my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) I Dad SECTION 7b OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of pedury that all of the informati ntained in this ajon is true and accurate to the best of my knowledge and understanding. 3 Z� 'nt er's or Authorized Agent's Name(Electronic Signature) am NOTES: 1. 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 Fg 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 www.mass.eov/oca information on the Construction Supervisor License can be found at www.mass.eov/das 2. When substantial work is planned,provide the information below: Total floor area(sq.fL) (including garage,finished basement/attics,decks or porch) Gross living area(sq.fl.) 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 maybe substituted for"Total Project Cose' Ant commonwealth of Mussacirusetts gmirknent ofTndintrialAccidents office of inveslVations 600.WashbgWn Street Boston,MA 02111 www.ma=govldia Workers' Compensation Insurance AffiBavit:Builders/ContraetorslL+'I pl ri t°L1 e b A lieant Information f1 G Name(Susinassiorpraization/ludividuat)' Address: \Q t Jl e \> ) City/Stoteaip: \ Phone#:_�113 FtsbUipand o Cheek the ap riate box: Type of prgied(rerloired)' p w? 4. Q I am a general contractor'and I 6• p New construction ployer with_a have hired the sub-contractors elin s(full and/or pad tnna� meted on the attached sheet= 7. KMed g le proprietor m parntet These yyrb contractors have 8. ❑pemolition have no employees workers'comp.insurance. 9• ❑Building addition �me in any capacity 5. we area corporation and its O workers•comp insurance 10.©Electrical repass or additions eir rree<it�] officers have exercised OL i 1.[]Plumbing repass or additions do all tight of exemption per MGL 3.❑ Iamahomeowner doing a 152,§1(4) and wehavemo MCIltaofrepairs myself.(No workers'COMP, mmployeGs,(No workers' 13•�Other i�ne,�.�c�1 f Ovi insurance regaired.j t COMP.insurance required.)- sppkmtdotchetebufilmumehosuwtd�eacetbabdawatrowfasmektmtl�• aeouiioamuieY'tW"dtan. new am dotes el►wodcand Oar MraoMside anfttaaarsaWrta�bnrit a�p,ag•,dgY;t;ad;eeungsaeh t H,,.wom wh,sub faathia,Mdwrt iraicebas dmy uifnmietioa aCaaueUantbsichxk thi9 bmcamstaaeehad as atditlonel ybeetshowing a¢aianoeftbe sub•caaaecton our thetr wodcars•comp.l�kr• I an an earployerthat IsprovidinS workers'CmnpeasadOn iasarancefor ray emlayees. Below is thepolky and job site tnfarmatlon. C -A - I Insurance Compaq Name: �l C7 C�S S35 Policy#orSedt'ins.LiG# n`'�r,J� L b 1 S won''"'.. Job Site Address: City/State(Zip: Attach a copy of the workers'romPeasafion policy declaration page(showing the polity number and exphsrtiou date). as under Section 25A of MGL n 152 can Fend to the imposition of criminal penalties ofa fine to secure coverage required risountem,as well as civil penalties in the form of a STOP WORK ORDER and a fine fore up to$1,500a d a agaiNornst st th vi lat ofup to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. !do hereby coo ander&cpaims aidpenaMes ofperJurythat the information provided above a and correct. Date- /Z e#: rLrwvWg use only. Do not write in this area,to be completed by city m•town o1J4cial. Town: Permit/License# puthorlty(circle one): actor 5.Pbrmbing Inspectord ofHealth 2.Building Department 3.CityPtowu Clerk 4-Electrical Inspr t Prison Phone# office of Consumer Affairs and usiness Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement;Gnnfrsctor Remtzauon -= - - - Registration: 165640 Type_ LLC - - Expiration: 3/15/2D12 Trs 2945117 AIR-TIGHT LLC_ WEATHERAZATIOO JAMES FORTIN --_-- 10 PINE KNOLL DR. BEVERLY, MA 01915 =_- - - Update Address and return card Mark reason for taaage . -_ ❑Address ❑ Renewal r; Emplor-meat Lost Card -- nasur ,� --�•..,mrs j ;� �ffe ta'oam+msvll o�..e4aaarlia4slL I _ License or registration valid for indis•idal use only r ..office ofCbommvAM;i BuriUM Regeladoa beforetheexpirationdate. Iftoundretarnta: .• HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Bosine RePlatian g Registration: --Iss54o j0park Plaza-Seite5170 Expiraliorc 31.154W2 294597 Boston,M9 03116,1 Type'_.=_ :_:-_f__._ :. AIR-TIGHT r1C yyc,(.q;}jA7ION DAMES FORTIN -`=L_%,`y- 10 PINE KNOSL BEVERLY,MA 01915 :="` Uadersecrerars 'Not valitl without sisnawre I ". Massachusetts- Department of Public Safety Board.of Building_ Re,_,ulations and Standards -. Construction Supervisor License License: CS 52S76 JAMES E .FORTIN 01, 10 PINEKNOLL OR BEVERLY,MA 01915 Expiration: 1013=3 rannni>siunvr - Tr,— MOYNIHAN LUMBER OF BEVERLY, INC. "QUALITY BACKED BYA DESIRE TO PLEASE" 82 River Street P.O. Box 509 FEIN:04-2261995 Beverly, MA 01915-0509 s a Contractor Reg No.: 978-927-0032 96 g6 Exp. Date: —//— Salesperson(s): HOMEOWNER INFORMATION l QPA/j� 4i7 . 9 - Name Daytime Phone goil Street Address(Not P.O. ) Evening Phone Cityrrown State Zip Code Mailing Address(if different from Street Address) WORK TO BE PERFORMED AND MATERIALS TO BE USED Moynihan Lumber of Beverly, Inc. agrees to perform the work set forth in Exhibit A for Homeowner and to use such materials in connection therewith as set forth also in Exhibit A,attached hereto and made a part hereof. The following schedule shall be adhered to unless circumsta arise beyond Moynihan Lumber of Beverly, Inc.'s control:Work scheduled to begin: _ /_ Expected date of completio Maybe based upon&Rval ofal order material TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Moynihan Lumber of Beverly, Inc. agrees to pQr{gtgl y1�work,and furnish the material and labor set forth in Exhibit A for the Total Contract Price of: $ W� a (which amount includes all finance charges). Payments shall mI;t de by Homeowner according to the following payment schedule: Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of one-third(1/3)of the Total Contract Price as set forth above;OR the Total Cost of Special/Custom Orders as set forth below). $ by_LLor upon completion of delivery of materials $ /_/or upon completion of install $ 1. upon completion of the Contract In order to meet the completion s9hedule set forth above,the following materials/equipment st be special ordered before the Contract wojK begins,for a Total Cost of Special/Custom Orders of$ R to be paid r building permit $ to be p 'd for $ to be paid for DO NOT SIGN THIS CONTRACT �IF THERE ARE ANY BLANK SPACES 7el T O ` Moynihan Lumber of Beverly,Inc. Ho canoes Sig ature D to Con ctor Date 1164N% : l C P 121 B : �. 1� �R uAd V � l.L�" Homeowner's Name(Printed) Nam (Printed)and Title of Signatory You may cancel this Contract if it has been signed by a party thereto at a place other than an address of Contractor,which may be its main office or branch thereof,provided you notify Contractor in writing at its main office or branch by ordinary mail posted, by telegram sent or by delivery, no later than midnight of the third business day following the signing of this Contract. See attached notice of cancellation for an explanation of this right. 1057-BEV 4/09 White-Office Yellow-Sales/Service Pink-Customer Page 1 of 5 �7i � x. _r'd�+' L` 4f ,� `�l' .,� fl ti,"k , .•3N �"r'�>Y =M ,?"i•. ' " � !M M. n�..v 4 pw M.dM.,e +Y°S'„�,.y��•�`j^'�yr�a lo, Lamm itn ��11 ,•1 �l ;.I - } a 1 y % Y a0r N N _ v f«s f 1 f Y x 4�' ,r. ' gON�IT�y�ko, 0 ���M1NB ,Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978)619-5685 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Constniction ❑ Moving ❑ Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property: 7 Orne Square Name of Record Owner: Donald Place Description of Work Proposed: Replacement of front and rear doors and trim to replicate existing. No changes in color, material, design, location or outward appearance. Non-applicable due to being in kind maintenance/replacement. Dated: March 22, 2012 SALE OMMISSION By: The homeowner has the option not to commence the work (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work. _2 J