18 ORNE ST - BUILDING INSPECTION /,/� • Gd moo'/�
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 71"edition OF SALEM
Revised Jarruarr•
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. '008
One-or Two-Family Dwelling
1I`1\ This SectipAlFor Official Use Only
V Building Permit Number: Date Applied:
Signature: `tt9'v 2� 1 I}�i o
Building Commissioner/Instur Bdt di Date
TIO 1 S E INFORMATION
1.1 Pro 1C 2,perty Address
1 8 O : -S'S.\ 1.2 AssessorsMap& Parcel Numbers
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: -�_ ...
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Require) 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 Zmrc1
Public❑ Private O Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record`: t(
%--*N\\t�.n G4.al.TroyN� l8 'Orn2 ST'
Name(Print) Address for Service:
(179 59y 6773
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building K Owner-Occupied ❑ Repairs(s) O 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.0 Number of Units 2 Other ❑ Specify:
Brief Description of Proposed Work': ,
A {
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S j 5-6 D I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S #> 3,5pp ❑Standard Cityrrown Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S O 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
a �t7 Check No. Check Amount: Cash Amount:
6. Total Project Cost:. S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 066 60 3 S(/'f
=<xr 3 es A'-W OC4 License Number Expimtion Date
Name of C'SI.- IIu1Jer 4/� /� List C'SL Type(see below) �/
(�� L.(�O SS hk/Q.. I " "r .f,pe Description
.4Jdrcss U Unrestricted u to 35,000 Cu. Ft.
��� � R Restricted 1&2 FamilyDwelling
Signal(f M Mason Onl
� 5t7i� . 73S• O°JS7 RC Residential Roofing Covering
1'dephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address Expiration Dale
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.3 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 �%%W C-S oo 'r 2��'a 1.�c�af� to act on my behalf,in all matters
relative to work authorized by this building permit application.
S- aF- ta
Signature of caner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
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.
�d.Wt-CG ��c7o
ia�6
`J -a
uthorized Agent Date
and penalties of 'u
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 Z(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.
? .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 half7baths
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"
.n ,Y
CITY OF S.U.E.N(9 tiLx5mcki SETTS
3L MDLNG DanarmENT
=, 120 W.\3HCVGTON STuzT. 340 FLOOR
TM. (978) NS-9S99
F.ut(9'11► 1249$"
KID BEA"Y DRISCOLL 1140MUST•PQA"
MAYOR DIRacroa or IR eLIC?ROKRTY/K MDLVG Co-%WMlO.%art
Workers' Chmpemsa(lon Insurance AMda.it. OuildwslContrsctorWEleetrlclanslPLrn(hen
� 1 II t Infnrmatlaw �-(� f7 Please PrIrltLed6Lt
Vattte levnw++aaidtrateiew latsivtdtrall' J \` � �U ��S �^L • -
Address' LA C-(-05.5
Cily/Shtdziµ Salewr Ma 81970 phone
.\rat yes w employer?Cltaek the appropriate pro Typs orprolea(regrtrMk
a. 0 1 ma s eahasraeast Well 1. 1 am•ompbym wits Z• prrard R ❑Ness cosamuctioa
,mplsycee((WI and/or par�dar}e have hked ter as► comeaeers
lWWMthre"ddabated1 7. Renalsiinp
i.0 1 am a sole pteprios ttr prow► Then so►cdrerasasrs have ❑Dsmolitlos
.hip ante have rrs ample
worth{ for me is my capacity. workrs'comes.Inv rasoa 9. 0 DuiWGy ad"c s
1 No wSes ms'comp.insurance S. ❑ We are n edtrpaadas and im I O.Q geeeniese repairs or atditiorta
ruquitetLl OWAMa haw etorsisd their
).0 1 am a horrwwnar doing ad week ^Ylse ofoamnprlos per MOL I t.0 PhunbMg repairs or additional
myself.INe workers'comp. c. 13%f 1(4),as/we have to 12.0 Rsef repairs
U inattrtmee rcgtoredl► crnplO2 lNo wo'�w I).❑Otkrr
asap.irttmmnesregaimil
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!'.sups Aar rhra All bW ewes asarltad AN alAtf.el knee rb+iM Ate,rate tr INS eAaenreetae ad their werre'tr W palsy{ttarrtar
/rYw es nq(ger rAae b y/erNArR wweers'rewperasdrs/aersrsrap frI aq raydsrws AeAtne b rAePs/Iry awd�s(ar
in�Narslllea
Insurance Company Nome: bit tN V}00.
Policy te or Self-ina.Lie.r: (J`) C' 2 - 3+ 5 - 377 2 5 5 -O 11 O Expiration Date: `i -,2 0 - if
Job Site Address: , V O er.a ')k Cary/Stamezip Se 1 e.m M A y 1i7d
.\naea ace"of elm Workers'compossaWs policy dealwalMa pap(aMwlif lbe pNkT number sad explrsrNa date}
Failure to soca m coverep as rrgaired under make 3SA of NGL a 132 can lead to the imposition of criminal ponsides arm
sins up to 11.500.00 and/w ant-yew imprisocurmik as well to civil prnaties is the them of a STOP WORK ORDEK and a flea
Of up to S250.00 a day rlpinm the violator. IN adviwJ Cho a arpy of this atatemrM may be rwwarrdod rs that 011fice of
I nr..0 ealauns,all he MA for ittstranee eowrap vsirkatiea .
f de hereby C" uw/w the peiM awl yrwe/rha ej/w/ery rAw Aw infermodew provided Mace is true eaed t:writs
P•„rat a: 47 g 73 5 - 03 S'7
O/JI{'ie/Yde ew/yt /)e met wrim he this dreg lose tYtwy/e/er dJ ri/y eII/M n/�idlt
Ciry or ruttn: PrrmiNl.ltenw r-- _ —. ---
lautnt.\W bent)Icircle nnep
I ❑uard u(Ilealth 1. Auddlea Mparemenl I. Cily/fame Clef IS I. tleclriral Unpcator 1. I'lumbtnt Inspector
i.th phi er
l 114%t Person: _ _ Phone r:
.' CITY OF SALEM
PUBLIC PROPRERTY
; i DEPARTMENT
L.!
PIr\ • rw r•I1 Ile W.\J 11.1..•iV51xtrT •).\t1\r.�t.\K\1 I11 J 1.•:1'r•:
%I .�•'M 1•rl:Y7/-714•lyH 1=\!r:•)7/•i IS'171M
Construction Debris Disposal Affidavit
(n-yuired Cur all demolition lord renovation work)
In•rccurdance with the sixth edition of the State Building Code. 780 CMR section 111.5 .
Debris, and the provisions of MGL c 40.S 54;
is issued with the condition that the debris resulting Roo
Building Permit M_ --- .
perly hcenscd waste disposal Facility as defined by
This work shall he disposed of In a pro
I11.S 150A.
The debris will be trrrlspo rtcd by:
Alor �, � � ��
Inarrte m hatter)
The debris will be disposed
,(of_i(n :
(n!!a ul x11ty -
I;„t,@e�s ur rataity)
lrnatWc of permit Jpplicam
date