16 ORNE ST - BUILDING INSPECTION (2) a
T'he C,nninnmcealth of Massachusetts --- —T
- -
j : t 13nard of ISullding R;•gul❑lions and Standards
IYllt
M1lassachusetts State Building Code. 7Stl('S1R, 7"' edition LII V h lP III 1
Building Permit Application To Construct. Repair. Renrn ate Or I),nn,lish a K, .IN, ene+ ++
Olt, - ra' Trt+-b+unilr Dit 11illV
Is Section Fur Othclal I`se Chl!y —.—�
Building Permit Nam Date Applied: ` G aU ----
BwIJI g ('oIII1..... Clot of aw!dmgs U:uc
_--_-SECTION I: SITE INFORM.% %ION -------
1.1 Property iddress- I 1.2 Assessors slap & Parer Numbers �'w✓+��Z�
I.la 6 this an n,
.,
1.3 Zoning mrufo.c.aticn• i + i Properly tJu,+En •vas:
t ..,;.: Pro .+•,cd ' . _. ... ' - .
`los:+ Pr ,,IJ i v1 .}.! c. a :.tl t 7 F ar a Zone infe na['aa: 1.8 N, ,:,,e +tr.1 osal Sy-tem:
Outside Frn.r!Z,..nc. !r obf: in i
Y I�IN)
�,/ Moni im:i Q?11 lea �I ,i. ��I 7'tyvesu " 1l '
SECTION 2• yN—._^� R .---- ---- --------
I ..fie?. .,/r1� +',✓�C.iG{— _.._ —LJ2. ����.�/ e --..5.9��..n_�/•�e
•1d�Jlcy1, for tic:eicr:
--.----- SECTION 3: DESCFi,IS 'rip ; r)F I'RfiPOSF"A/;S*,A!K' (cbv..L. all that applyi
N••x mt ufotn C.-1 Ev,llr . Bui; .ing ❑ +)v.net Cp r c9 !e� Llt l t •.I [' I{er;+ne ni., ClT-lu I ❑_~
� ----- n ❑ Ac+esut B--i —❑�-��—N _ _ I Other ❑ n .,l}. —
_
Brief Description ,4 Prop+-,sed i4'�.I�k _-1.7s,.•�_/��11L�4.G_ �e�—� 1__—/it!-1�_�/C __ _
• _ I
- — SECTION J: ESTOJA'. ..D CONS C7:CC'TION COSTS ---- —I
'~ Estimated Gtsts: — ---_.`----
Item Official Use nl ll_ubur:md �Llaterial Of
sl� }'
I. Building 5 �t1. Building Permil Fee: S Indicate husk ice a Jcternuned:
r
l 5 1 ❑ Standard City/Tuwn Applirduon Fee
❑ Total Project Cost' (Item GI r multiplierg 'S_ ' Other Fees:cal I HS- \CI:d (Fire) S Total :\Il Fees�:f$ --------- '
0 Total f reject Cost: S (��'i�_ Check NoATXl 'ht. : rm,unt L :I.,h \m,wnt._. _..
'315 I Paid In Full ❑ OutmanJlne Balance Due:
� I
F
SECTION 5: CONSTRUCTION SERVICES
—is CS �FS�7
5.1 Licensed C'unstruction Supervisor (C'SI•)
r Ji" ' Licrnsc Numher I`.yneuwn DM:
.\unlr ul C'SI I lower I-lei C'SL'r,pe +a• helow I
J ry c
( ('ItrCSOILIed �u,to }?.1N)U Cu Ft ,
F 0 R t RestnetCJ
\1 \lu.onrN Only —�
Sty,
--...._. R(' ReslJ:nuul lhuitme('u,elin�__._—
\\'$ Rr,IJ:nu,,l w,m.l,�o anJ SiJu1'a
1'elephunr
SF R:,iJ:nu.,l SoIiJ l uel ISw nine \ li.,n_hLLil
5.2 Registered Home Improvement Contractor 011C'1
- — Regotruuon \wnhcr
IiIC Company Name ur FIIC Recutrant Nmnc /Z5 /G
Aldd ,I^ /7 72� F�pirau„n D:tt:
•lerhonc
Signature
SECT ON 6: WORKERS' NIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 4 25CY6))
Workers Compensation Insurance affidavit must be completed and submitted with this upplicanion. I=allure to pn"s tde
this affidavit will result in the denial of the Issuance otthe building permit.
i
._ ❑
Signed Affidavit Attached? Yes .......... No
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
_...... R AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
or �� �G S�- '— to act on my behalf. in all mauers
:�uthorizr ��c�IL P —� Fr
- - . 't ieatz"'
-_clalive (u v".`,s : lonzc:. bti' :his buamng pe:'rm. apP'
Date - ----i
5> ,star'• tow r
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
0�- , as Owner ur Authorized Agent hereby declart
Ihat the/statements and information on the foregoing application are true and accurate, to the best of my knowledge :Ind
behalf. e
Print Nat3-
oale
Signature of Owner or:\tit nu
(Si ned under the arcs and penalties of e(ur•) NOTES:
- n ermit to Jo his/her t own work,or an owner who hlfC] all Unl'e�_b1CrC(I crlmra..urrIC
in a
1. An Owner w'ho obtains a balldl p not
(nut registered in the Homenderr,),em nt l'_A`OttheriimpPrtantJ information ot m theve rHlCsf'rrr�ram nnJltn�n
or guarani tund u and I IU.RS. roe iectl�cl)'
cc
guaranty . . Regulations I M.RG I
program sin tCSL) can be timnd m 780<'Iv1R
Construction Supervisor Licensing
he information below:
work is tanned, provide t „r vn�h,
_ When ,ubscmUal p finished ba,c menUatncs. Jocks I
area(5 . Ft.) (including garage)h —
"total floors4 Habitable norm count --- ---
(iross living area ISy. Ft.) Number of hedrooms
Number of fireplaces Number of halt/h,uhs
I Number of hathruums ( Number tit decks/ potehcs .-- —_— ----- -
k
pe of hearing system _ li echoed _ __Upcn _ --_-- —. --
pe of cooling sysicm
-Total Project Square Footage may be eUb,,tltutcd for "final Project Cost __
✓2c -V/6MN,td/Z<[ Q2[2 6 ✓ LfldC�d
Board of Building Regulatio sand Standards
.�, Construction Supervisor License
License: CS 83459 '
Upiratton: 12/13/2008 Tr# 10724
'Restriction:
MICHAEL F GRIFFIN
PO BOX 887 �"�"
MARBLEHEAD.MA 01945 Commissioner
Board of Building Regulations sell Standards..
. HOME IMPROVEMENT CONTRACTOR
Registration:. 148054
Eiipiration: 8129/2007
Type:..Individual _
MICHAEL F.GRIFFIN - - -
MICHAEL GRIFFIN
ISO LORING AVE. -
SALEM,MA 01970 Administrator
CITY OF SALEM
s
PUBLIC PROPRERTY
3 P
DEP.�RTNIENT
r,
\\ orkers' ('omperiIion Insurance AIlidasit: Builders/ContractorsiElet:I 1Se Print nsPl niber Y
Plo:
Legi
\ ) tluant Information
r
\„tllli illr..w... hyonv.tm�n Inds:.lu.al�: ++ .
/ _ /L �
r Cr 7C- 74-co Z 3 9
S �lf�l�Pltunc
('1t} State Zip: ���f
tore %puts an cmploycr" Check the appropriate box: Type of project(required):
I ❑ I an) a employer\t ith 4. ❑ 1 an) a general contractor and I is �(New construction
t. ,rfnpluyees(full and'ur part-time).' I)ase hired thea a h-con tractors 7 ❑" Remodeling
` ( listed on the auaehCJ sheet.
_ I .tut a d d ve no empetorloyees
o partner-
and have no tin pluyees I hose Nub-Coutracton Dave 8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance. y. ❑ Building addition
[So workers' comp. insurance 5. ❑ We are a Corporation and its 1p ❑ Electrical repairs or additions
required.) officers have exercised their
ri •ht of exem tion per b
mys 16L I I.❑ Plumbing repairs or additions
i.❑ i ys a homeowner doing all work C 5 ❑152, §1(4), and we have no 12. Roof repairs
elf workers' comp. employees [No workers'
insurancee re reyuireJ.J r 13.0Other
Bump. insurance required.[
•,\try,µrplicant that checks bus N 1 moat also till out the section below shuwing their workers'compensation policy information.
r I lumeuwners who submit this affidavit Indicating they are doing all work and then hire outside Contractors must submit a new affidavit indicating such.
('.nuractirn that check this bus must attached an..ddwonil sheet.+hawing the name ot'the sub-contrition and their workers'comp, policy information.
l airs an enrplayer that is providing workers'cornpen.vation in.surunce for ury employees. Below is the policy and job site
inforwufion.
Insurance(brnpany Name:
Policy q or Selt-ins. Lie. a: Expiration Date:
Job Site Address: City,State/Zip:
.\ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure Coverage as required under Section-25A of\i(iL c. 152 can lead to the imposition of criminal penalties of a
tine op to SI.�oo oo and'or one-year imprisonment, as well as ci\tl penalties in the torm of a STOP WORK ORDER and a fine
,.1 it,, to S250 too a day against the t iolauor Be ad\iscd that a copy of this statement may be tLnvardcd to the Office of
Ian c.0 eamnms ul the 1)I:\ 1,,r insur.tnce co\Crage \cnlicanon.
is Jw herrhy.erriliv ondTthe pair urd pavodnes f p• ury Char the tit/unnufmn pruuda J arhot r m true and c orrecL
Date G-o3- o
<�rn,uure.
I'L„nr _
— —
r)l/mad are will'• Do nut terire in chit area, its he a,nnpleted by airy wr town ufficiaL
( in or Iuon:
Issuing; \uthority (circle tine):
I. Board of Ilcallh 2. Building Deparh fawn Clerk). ('ittt faw Clerk 4. Electrical Inspector 1;. I'lumhing Inspector
6. Other
('intact l'erxuo: __ Phone _—.---
Information and Instructions
\Ln,.I, ticncrll I .Iw,ch.gncr l icquu c, Al cmplo,cr, to pro%ide %orkcrs couglen,aturn for their cngllo\ces.
(',if.u.uu to din amurc, .Ili rrnplmee i, dcti,r,cd .is cn per,on in the ,osier Of ,uitaher under .ui% :olilriO oI hire.
:\11,C., Or :ttipped. oral or t\ureic. .
\:: emphPier Is dcriiici .is .,it :ndr\:dual. h.0 u:enlup, a„oci.uion, ,orporation or other lecai enact\. or .Ili hso or Inure
,•I the 101 c--oma cn_aucd in a nnm cnici pri,e. ,uiJ Inc ludnig the Ic,_al Ivpresentati\e, ofa decc.i,vd cntpl,,)er, or the
c.cr,cr or tru,tce ,It .In m,lr\iJual. p.0 tiler.hip. .1„ocialwo or other Icwl cnup. clnplo,Ind cnq\lovccs I lowe\er the
,..,ncr oI I .IKelluig house ha\nle not :none than ihree ;parnicnts ,ulJ t,ho reside, d:ercul. or the occupant of the
dK ci:Intz house of.mother who eniplo„ peron, to du ni.untrnance. con,trucnon or I-cp.ur Kork on ,itch dwelling house
-r ,vl the _totinds or bulldulg .Illpuuen.uti thctclo ,hill nol hecau,c oI filch cniplo,item be Jcenied to he .in employer."
\I(d ch.tpicr I�', ,_`SCtn) also ,fate, (hat every state or local licensing agency shall withhold the issuance or
renew if of it license or permit to operate a business or to co mtruct buildings in the commonwealth for any
applicant \vho has nol produced acceptable es idence of compliance ,s Rh the insurance cuserage required."
\dduionally, %R If- chapter 152, j'S('I -) ,tares \eitlier the unnniontsealth nor any of us polltical subdi\i,tuns shall
cuter Into any contract for [lie perlo mince of public %ork until acceptable e\idence of cullipllince K ith the tM urallce
rcquocnicnts of this chapter ha\z been presented to the contracting authority.-
Applicants
Please till out the workers' compensation atfidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) nanle(s), address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships ILLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP dues have
employees, a policy is required. Be advised that this alfidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
,elf-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to till nut in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit,license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current -
policy infbrmation of necessary) and under"Job Site Address"the applicant should write "all locations in (city or
❑ %%n).•' A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
.Ipplicant as proof that a valid affidavit is on tile for future permits or licenses. A new affidavit must be tilled out each
year. lvhere a home owner or ciliten is obtaining a license or permit not related to any business or commercial venture
I i e. I dog license or permit to burn lea\cs ctc) said person is NOT required to complete this affidavit.
I lie t illic.e of In,esngations Would like nr thank you in ;d\ance for tour cooperation and shouldyou Ila\e;my questions,
pica,c do nor he,nate it) elte its a .all.
I he 1),pairnwin', address. to lcphonc ,Ilid tax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigntlons
600 Washington Street
Boston, MA 02111
Tel. p 617-727-4900 ext 406 or 1-877-MASSAFE
Itc. ,col �-'o-n5
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
8..'4D9.841,
qvzMg5't6
Construction Debris Disposal Affidavit
(required (itr all demolition and renovation work)
In accordance N ith the sixth edition of the State Building Code, 780 Ch'IR section 1 1 1.5
Debris, and the provisions of btGL c 40, S 54;
Building Permit fk -. is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
l" //^'' —
'�/71 F�i ✓l lea v1 ) /*cJ Al
J
(name of hauler) -
The debris will be disposed of in
�'VtLL�G��� Ca4 i P=�t�
/ (name uur ttacilility)
(address ut'racility)
I¢natuicorpen appl an
-
date
loi'l i.�..,.,l,
r
i
r
X1/2 {�, T, F✓LDtM,nr '34e-
t 6
T�,e�e ,YAP«, CTP! S 6 �3ea rnI
T2 ;arc i
c All
ovi
i
6
- -..— �-...v � vaaar .aaa,vaa .a�r. .vu .,aa.�asV •VVVi�. �1J✓.�%I ViVJI —JJJJ 1'M.,JI VIVJI �JJJV
MORTGAGOR: EILEEN * MARY DUFF DEED REF: 23923'/ 349
' LOCATION: I G ORNE STREET PLAN REF: A55E55OR5
CITY,5TATE: 5ALEM MA 5CALE: I"=2a
DATE: MARCH 28,2008 JOB #: 208/00947
LOT CONFIGURATION 15 BA5ED
ON A55E550R5 INFORMATION
AND MAY NOT BE EXACT.
INSTRUMENT 5URVEY 15 RECOMMENDED
AS,
SeT �
CieG r Ln N Lu
F✓lriwi � T� encl. o W
Gi ti o �L porch
O
O
` � Z
2 story �
wood"
#16
G0.00'
ORNE STREET
CERTIFIED TO:
fYaod hazard zone has been determined by scale
and is not necessarily accurate-Until definitive plans
are issued by HUD and/ar a vertical control ""rosy ,
is perforate4 precise elevations cannot be determined