38-36 ORNE ST - BUILDING INSPECTION $2- 10 CAStL
�v� T 5 2�1.7Jo S
Che Commonwealth of Massachusetfss !° k -fR `i1C CITY OF
n Board of Building Regulations and Standards SALEM
Massachusetts State BuildingCode, 780 C�1 NOV15
Idev/seJ,Nur10/l
Building Permit Application To Construct, Repair, Renovate Or Demolish�a J t
i One-or Two-Family Dwellhig
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print N:une) Signatrue Date
SECTION 1:SITE INFORMATION'
I. Property Address: S� 1.2 Assessors Map&Parcel Numbers
-- - k o(-,,,
1.to Is this an accepted street9 yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy R) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
ReyuireJ Provided Rayutred Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
r Private❑ Zone: _ Outside Flood Zone? Municipal gYOrr site disposal system ❑
Public Check if es❑
SECTION 2.- PROPERTY OWNERSHW
-----------------------
2.1 Owner'of
175me Print) "` CityCity,Smt
30 non
Nu.and Strect Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Buigi
ner-Occupied Repairs(s) ❑ Altemtion(s) Addition ❑
Demolition AccessoryBmber ofUnits� Other ❑ Spec
Brief Description of Proposed\York i
< O� t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building ; L Building Permit Fee: Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (EIVAC) S List:
5.;\fcc11
anic1
I (Fire S 'rotal All Fees:
Suppression)
Cheek No._Check Amount; Cash Amount:_
6.Total Project Cost: S (� Cl Paid in Full ❑Outstanding Balance Due:
IIJIS (TM1tt.&iY.) Qu Irl•O ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
Type Description
No. ;md Steer
U Unrestricted Buildin s u to 35,000 U. Il.
R Restricted I&2 F:unil Dwellin
Cilyfrosvn,Stale,ZIP M Masonry
RC Rooling Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Telephone
Email zddrcss D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP TA hone
SECTION 6:WORKERS'COMPENSATION INS URANCEAFFIDAVIT(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........... O
SECTION 79:OWNER AUTHORIZATION,TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 9it on my behalf,in all matters relative to work authorized by this building permit application.
H I I5 l(v
4,ntwner's Name(Flee nic Si arum) DeIC
SECTION 7ti:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and curate to the best of my knowledge and understanding.
t I \5 / (o
r of wocr s or Authorized gen ' Name(Electronic Signature) Date
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 nor have access to the arbitration
program or guaranty fund under NI.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.ma�
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. If.) Habitable room cows
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
rypeofcoolingsystem Enclosed Open
i `Total Project Square Footage"may be substituted far'Total Project Cost"
3 QTYOFS� ALEM, MASSAQiUSE TTS
;r~ BUILDING DEPARTMENT
}3 120 WASHINGTONSTREET,3ft0Flom
TILL. (978)745-9595
KIMBERLEYDRISODLL FAX(978)740-9846
MAYOR TwAw ST.PIERRE
DIRE GTOROF PUB LICPROPERTY/BUILDING ODWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE P I1NT:I
Date [ 15/
Job Locatio X . �Q nPIQ � o_m
Home Owner Address
Present Mailing Address �Jg
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 he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
Ci i V/ SALE L}�����CSS GMUn
BUXUMMR' iW I4Yi/w71Y���)[��
74-5,
H1�BRt8YD P 0 7�i4l4 6
MAYOR �o�tsS7:P
DBEcruncrREUMMOkarAmmmamossam
Construction Debris DisposalA davit
(required forall demolition andrenovation work]
in=or&=with the sbcdi edition of the state&AWk gcDft mow sec w ills Debris,
and the provisions of MGL olo,s 54; hdift P~# c is issued whb the
condition that the debris reaMW from this work sha0 be disposed of in a properly!based
waste deposit fad ftyas defined by A4GL c 111,s 154t
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
SiInature o pliant15 l (�
Date