32 ORNE ST - BUILDING INSPECTION (2) I� The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY
�j Massachusetts State Building Code, 780 CMR, 7h edition R v edJan ary
IrAI Building Permit Application To Construct,Repair, Renovate Or Demolish a I, 2008
One-or Two-Family Dwelling
This,Section For Official Use Only
Building Permit Number: Date Applied: r
Signature: A 6eli 1 , �-D
Building ommission n r of Buildings Date
SECTION 1:SITE INFORMATION
1.1,Pro erty Address:sTR�,E�� 1.2 Assessors Map& Parcel Numbers
� ae�
L 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear 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:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system [I
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner'of Record:
sy1f,po y C,�Q .38 oW S 7 4461
(Print) Address for Service:
J 179. '7Jky- t67y,4
t nature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ 1 Existing Building❑ 1 Owner-Occupied el Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ NumberofUnits_ I Other arllspecify/✓Eb✓ 46'OF
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost"(Item 6)x multiplier /02 x
3.Plumbing $ 2. Other Fees: $ S
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $ 8 9
®/1. Check No. Check Amount: Cash Amount:
�
6.Total Project Cost: $ / D®D-� ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
i9%Q/Gk M O rjdQt�:) License Number Expiration Date
Name of CSL-Holder
/'advx iu MARE t�/i�n� � List CSL Type(see below)
Address lyve Description
Unrestricted(up to 35,000 Cu.Ft.
Si na e R Restricted 1&2 FamilyDwelling
/Jj , /Poi M Mason Only
Telephone RC Residential Roofing Covering
WS Residential Windowand Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
5495 D pAintitllGzi A V/tf; PAra�Jr ,<aa o
HIC Company Name or HIC Registrant Name Registration Number
yy Fox Rvv A/L� T AVAoco n1A. /P�la
Address
�✓�c97�f p /PP7 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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Sy4A0A1 G,OAOIV Q as Owner of the subject property hereby
authorize M 7-A/ClK QSeaW to act on my behalf, in all matters
re ti a to work a thorized by this building permit application.
Signature of Owner Ddte
SE 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, as Owner or Authorized Agent hereby declare
that the stat ents and information on the—fore oing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 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 110.R6 and 110.R5,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"
CITY OF S.U.E.`I, NLUSACHL;SETTS
BI:Q.DNG DEPARTMENT
120 W.ksmNGTON STREET, )era FLOOR
TEL (978) 74S.9595
FAx(978) 7.10695M
p J®p�tIB D Y RfSCOLL
Y DR THOMAs ST.PMR
H Rt
E
DIRECTOR OF PL BUC PROPERTY/BLLLDNG CONOUSSIONER
Workers' Compensation Insurance Affidavit: Builders/ContractonlElectr(clanslPlumben
applicant Information C ( � Please Print Legibly_
Vatfle(Bmin ,mcLs.00rrQ0.anoorwin ivid`ual\): "" Q
Address: V pl', ", `/CP 1 1 1 1
CityAStatdzip: M��I�L�N� (� PhanN:
Are you as employer'Cheek the appropriate boa: Type of project(required):
I.® I am a Vanploya with 4. ❑ 1 am a pneral coneraemr and 1
einployeas all dfor part-time).- have hired the s&caractnr 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: y ❑Remodeling
+hip and have no employees Three sub-contnetma have B. Q Demolition
working for me in any capacity. workers'comp.insurnos: 9. Q Building addition
I No workers'comp insurance 5. ❑ We are a corporation mid its 10.Q Elxtrical repairs or additions
officers have exercised their
J.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp. e. 152r 11(41 and we have no 12.0 Roof repair
insurance required.l t cmployeaa.IN*warkar' U.❑Other-
;Any comp,insurance required.)
apPOcam our chacaaoa b et must also do ere the section below Arteries thh work..•rorneer,"poky inwnsaYm.
t Lerwowor o who water ails afildevls indicating they an doing all work and this hire auaink eatncun must aMnh a now alntlsed itatiorip rgetl
:'.mae,bw that cheek this beta mud adachoa as slditwwl shoat showing the aaee otdle wrb coati ayn ane their wartime'camp.potiey infl rtadea.
l am on aanpAoyer that 4 p wvfding'workers'conepenmdon brssreese jor aoy esrployeese edam/s the polgr and/ob do
injormadaaa �t�(( �,�
Insurance Company Name: ±e M- N A�1 o•J J✓�/ld'1
Policy 4 or Self•irts. Lie.p: L 1LIAJ�1�� 4Z Expiration Data, IO II/
!orb Site Addrere: 2 (X)iU i City/Stawzip: 0 AI (-)
•%ttack a copy of the worken'compeasatiom Polley declaration pop(skewing the policy number and espiratlois date)6
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in tin form ofa STOP WORK ORDER and a Hoe
Of up to S250.00 a day:against the violator. Ile adviuxl that a cupy,of this statement maybe furwarded to the Office or
Inve%ii1piuns of ilia MA for insurance covcrap verification.
Ada hereby cerrijy hear and penalties ojper/ury Mar the information provided above i tree and c arreea
Phnnc d: SJ 7 /IV
OJJlcial we anly Do nor write ie this area to be,utmpkied by city or rows oljfciaL
City or fawn: PcrmiN.lcense 1—
�
Muing.bulhomy (circle une):
I. lluard of Ilcalth 2. Ruilding Department ).City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Phone m•
�-- ,S CITY OF SALEM
� PUBLIC PROPRERTY
-� DEPARTMENT
.IIIIP Nit
\I U.'N ta:R'.KIII\1.;,!V)1'M L'rT TO 5.\I1%1.\1.Ni.\I I II q I.•-1'0 -
fFl:971•743.9395 •l.\!f:971•743-')846
Construction Debris Disposal Aff7davit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40,S 54;
Building Permit p ' _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
WVS )rVWU
Inane of hauler)
The debris will be disposed of in :
N6r�i 1(�Q,
("am Uf facility)
Iaddre%§of facility)
•igl' are of permit applicant
` 1 11 / O
date
Ichn•LI'.ati