52 ORNE ST - BUILDING INSPECTION t
�!D The Commonwealth of Massachusetts
j Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 71s edition OF SALEM
g/ sss Revised Junnury
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number Date Applied: ' 3/
Signature: /(21, A
Buildin o u o s t r Buildings Dates
SECTION 1:SITE INFORMATION
IA Property Address: 1.2 Assessors Map& 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 I)) Frontage(tl)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owtt�t oJ`RerKu/'L
Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': �-* .Z
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost(Item 6)x multi fer x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
�/ — lsC Check No. Check Amount: Cash Amount:_
6.Total Project Cost: S ' 7 f0D/ 0 Paid in Full ❑Outstanding Balance Due:
F .
SECTION 5: CONSTRUCTION SERVICES
5.1/Licensed Construction S�sor(CSL) /1�00��'� /z ,
(License Number Expiration Date
ranee ul'CSI.•Ilulde List CSL Type(see below)
�C� t--- rype Description
Add u Unrestricted u to 35,000 Cu.Ft.
` � R Restricted 1&2 Family Dwelling
Si it urc M Mason Only
2/2 YCJ2— RC Residential Randfing Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 i�t�re,yHon ImpyovementContracI r(H)C)
/ 'i(se LSrz1/��
HIC o my N.. cor 11 Sistmnt N�e/ Registration Number
iAd ` lr lv-,— 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. , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION J%/�77b:OWNEW OR AUTHORIZED AGENT DECLARATION
i L✓ ✓i� ,as Owner or Authorized Agent hereby declare
that the statements and info on on the foregoing application are true and accurate,to the best of my knowledge and
behalf. /yam
Q-
Print N
Signature ot'Owne Authorized Agent Date
(Signed under th ains and penalties of perjury
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 MoJ 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 I IO.R6 and I IO.RS,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 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 SM.E.`Ia NLUSACHi:SETI'S
BLMOLNG DEP.%RT.%ILNT
110 W.Asmt:NGTON STtEiM )'s FLOOR'
T L (978) 745'9595
FAX(978) 744984
KIMBEAMY DRISCOLL
MAYORT1tOh1AS ST.PrE2tRs
DIRECTOR OP PL BLIC PtOPERTY/BL•aDL%IG CO\L%OSSIO%ER
Workers' Compensation Insurance AMdavit: guilders/ContractorslElectrlclans/Plumbers
%millcant Information �/_ Please Print Legibly
Vaine IBusirw+r0rpntrariorvin,tvtdual): O[`/i-CK//,
Address: - 111 1VO C /
V
City/StatdZip: rtii�-/� /1 phoneM.-
Are oa as empleyer'!Cheek thyapproprfato boa: Type of project(requira�:
am■employer with �o e. ❑ 1 am a general contractor and 1
employees(full and/or part-rime).• have hired duo auh�conracan 6. ❑Now construction
2.❑ 1 atn a sole proprietor ar partner- listed on the anachod sheet: 7. ❑Remodeling
,hip and have no employee These sub-contractors have B. Q Demolition
working for me in any capacity. workers'comp.insuraam 9. Q Building addition
I No workers' comp insurance S. ❑ We are a corporation and its IO.Q Electrical repairs or additions
otYeea have exercised their
).❑ 1 am a homeowner Joins all work right of exemption per MOL II I gpumbing repairs or additions
myself.]No workers'comp. c. 172,91(41 and we have no repair$
insurance required] 1 cmpleyee.thin wdxkarsI 1) _OOrer
comp insurance required)
•Arty appikate mar eiw rl cts bss It ma alw fin um the Mum tot"stoning their workers'to vauail'a policy irdumotloa
'I haseuwratra who submit this amldvil indicating Ihsy an Joins an week ate dsas him amide canncsas axe"limit a rtw amdavit indicaiq rt.L
<',auavwa rho cheek ibis boa mug amine d an slditwaal d as"wiq Ilia neat of 16a albatalrerlara cud that wwbera'tamp:.policy infnnaauaa,
r eat an employer that hi providing workers'caapeniadon Usatrasarfer my earp/ayoest Qrlow is the poHey end foI star
informunlora
Insurance Company Name:
Policy M or Sell-ins. Lie. M: Expiration Date:
Job Sire Address: City/StatuZip..
.%ttacb a copy of the workers'compeaaadon polity deeleratlem pap(skowing the policy member end expirsdom deft).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lad to the imposition orcriminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,ae well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. Ik advi.wd that a copy of this statement maybe rurwardad to the Office of
Inccsttgmiuns ol'tha DIA for insurance coveralls vcritication.
/da hereby rerrij 0-4 th sun r as ajpe►/ary that tM injoraast/oa provided above is true and,:depc
Y /
Dater
Phone 07 � �V -�C�L- .
O/Jlria/use only. Donor write in this area,to ba casnp/rtd by airy or town a/lrial i
City or fawn: Pcrmit/Llcrnre p �
Iwuing Authurily (circle tine):
I. Ituard of llvallt 2. Ruilding Department J. Cily/fown Clerk a. Eltctrical tnspecto► S. Plumbing Inipeetor
6. other
l ,,macl Pcrson: _ _.. Phone C
,S CITY OF SALEM
i PUBLIC PROPRERTY
�•', ' DEPARTMENT
Nit) '•Nlv '•I1
�rNkrr •5.111 M.MA"'it nl a 1
1'fl:'17t-71i•li'IS 1'.\!f:778.749 16
Construction Debris Disposal Affidavit
(required fur all demolition luld renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR scetion 111.5
Debris,and the provisions of MGL c 40.S 54;
Building Permit N _ 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:
aas r U f
t name of hauler)
The debris will be disposed of in
(name ul aci rty
plJdrc+e ul'licility) I
Signature of ly applicant
date