22 ORNE ST - BUILDING INSPECTION (2) LA
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~ — 1 'File Commonwealth OfNlassachusetts
Board of Building Regulations and Standards CITY OF
d1t Massachusetts State Building Code, 730 CNIR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revfeed,tfru•?oll
One-or Two-Family Dwelling
Building Permit Number: This Section For Official Use Only
P
t _
X ui ding Official(Pr nt N;une)
D
1.1 Proper
SECTION SITE INFORMATION e
t Addr S. L•
el? v V 2 �` S r'�-(-2 I,' VA 1.2 Assessors iVlnp& Parcel Numbers
I.In Is this an accepted street?yes_ ❑o Map Number ,
1.3 Zoning Information: I arcel Number
1.4 Property Dimensions:
Zoning D�—. pruposeJ Ua�.e --
Lot Area(sy tt) Fronluge(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards
Provided Required Require) Provide) Rear Yard
Required aired
y Provided
1.61Vater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: ._ Outside Flood Zone?
Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTVOWNERSHIP-
2•1 On�fReco,rrdd Is 12
1 2
N t✓ rc n t� O I ct c�
,hme(Fon g I {� //"\
�> U i L"K S� City.Son ,ZIP `�vVe" `
Nu.mtJ Slut
Tnlep one Exhail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ gltemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units
f Brief Description SVork: Other ❑ Speci
Of Proposedfy:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1, Building $ I. Building Permit Fee:$
Indicate how fee is determined:
2. Electrical 3 ❑Standard City/Town Application Fee
3. Plumbing $ ❑Total Project Cost(Item 6)x multiplier x
2. Other Fees: S
4. klechanical (FIVr1C) S List:
5. i\lechanical (fire
Su) ression) S 'Fatal All Fees:S
6. Total Project Cust: 'Sea 000 Check No. Check Cash Amount:
❑Paid in Full ❑Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -----
License Number Expiration Dale
List CSL'rype(see below)
Name of CSL Holder -
Type Description
No.and Street U Unrestricted Buildin s u l0 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
M Mason
City(rown,State,ZIP RC Roofin Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
— Email address D Demolition
Tele hone$.2 Registered hme o Improvement Contractor(IHC) HIC Registration Expiration Date
I IIC Company Name or HIC Registrant Name
Email address
No.and Street —�
Telephone
Cit /Town,State,ZIP
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.C.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 ..........Cl
SECTION 7a:OWNER AUitHORIZATION.To BE COMPLETED W IIEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
1,as Owner of the subject property,hereby authorize
tq act on my behalf,in all matters relative to work authorized by this building permit application.
Date
Print Owner's N:une(Electronic Signature)
AUTHORIZED ACENT DECLARATION
SECTION 7b:OWNERI OR
By entering y name below,)her nets and penalties of perjury that all of the information
cot m thi �plicatio and accurate to the best of my knowledge and understanding.
X alC
Print O1 or r Iorized A • cctronic Signature)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an otlln'rf`havetac�ss toires an tthe arbitration contractor
(not registered in the Home Improvement Contractor(b1IC)Program),
Program or guaranty fund under NLG.L.C. I42A.Other important information on the HIC Program can be found at
wlwv.mass.^av'oca Information on the Construction Supervisor License can be found at wwly mass.-ov4lp_s',
2, When substantial work is planned,provide the info(i icludinglgarage, finished basement/attics,decks or porch)
Total tloor area(sq. ft.) Habitable room count
Gross living area(sq. ft.) Ntunber of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches_ _—
'1•ype of heating system Enclosed__.---_—__Open
Type of cooling system
3. "!'otal Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHIINGTON STREET,Yo FLOOR
TEL. (978) 745-9595
F
KIMBERLEY DRISCOLL FAx(978) 740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date I I Z
Job location
Home Owner Address S{ e
Present Mailing Address
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 that 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 form 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that h ill comply with such procedures
and requirements.
HOMEOWNER'S SIGNATU
APPROVAL OF BUILDING INSPECTOR
r _
CITY OF SM-F- ,l, NWSACHUSETTS
BCLm NG DEPARTJLF.NT
` 130 7"FiLNGTON STREET, 3'FLOOR
T EL (978) 745-9595
F.�.x(978) 740-9M
KI1iBERLEY DRISCOLL
�4VL1Y0It THO%Lu ST.PI£Rn
DIRECTOR OF Punic PROPERTY/BLADLNG COS12,II55IONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5
Debris, cuid the provisions of NIGL c 40, S 54;
Building Permit A is issued with the condition that the debris resulting from
this work shall be
l 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by tMGL c
The
�de�briiswill be transported by:
(name of haulor)
The debriss will be disposed of in
(name o —"
(address of tacillty)
,
s re of perm' plicant
Aare