60 ORNE ST - BUILDING INSPECTION l� o
/1 The Commonwealth of Massachusetts
(f } Board of Building Regulations and Standards CITY
Massachusetts State BuildingCode, 780 CMR, T°edition OF SALEM
Revised✓unuarV
Bui ding Permit Application To Construct, Repair, Renovate Or molish a /, 2008
One-or Ttvo-Family DrvellinK
This SectiogTor Offici I Use Only
Building Permi Numb Da plied:
Signature: �//4-4v LA -- 5-z/-o
Building Commissioner/Inspectorof Buildin Date
SECTION 1: E t FORMATION
1.1 Property Address:>� l� 1.2 Assessors Map& Parcel Numbers
L I a 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 B) Frontage(il)
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 ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner' f Re d:
,
Name(Print) �/h9C ddress for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ S ify:
�rie[De cription of Propo d Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllcial Use Only
Labor and Materials
I. Building S / 6 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S C:Fzz, er-o 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S 0-p p, 4`D 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
G � Liecn mti se um e E pi n 1)aIe
Name ol'CS�.-II IJerj List CSL Type(see belo
Type Description
ss U (InreslricteJ u l0 35,000 Cu.Ft.
R Restricted 1&2 Famil Dwelling
t aturc M Masonry Only
&-7 -7iW7 vlRC Residential Routing Covel
.Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burnina Appliance Installation
D Residential Demolition
5.2�egi�tered pme Im ove at Contractor( IC) l/����
HIC CQm� Name or HI ' rant Regtsimtion Number
G
rcss ;�Gp���J Expira' nDate
i uture hone^�T
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 7b: OWNNEW OR AUTHORIZED AGENT DECLARATION
1 C_ ,as Owner or Authorized Agent hereby declare
that the stater ents and informatio on the forego ng applicati are true and accurate,to the best of my knowledge and
behalf. --
e e5
S' ureorOw;a,ns
tw
Agent Date
i ned under t ies of r'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 1 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 I IO.R6 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total Moors 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 &U-E.`I, INLA.SSACHUSETTS
13L'ILDLNG DEPARTILNT
120 W.itsHLNGTON STREET. )aa FLooR
TIEL (978)745.9595
FAX(978) 740.96M
KI�IBERj-EY DRISCOLL
MAYORTHohW ST.PtEalts
DiRFCTOa oP PL guc PROPERTY/11V I DNG CONMOSSION ER
Workers' Compensation Insurance A111davit: Duiiden/COniraCtOra/Electr(clantt/Plumben
-%nislicant Infarmallon Please Print Lesibly
Nainc iIluaaevrorganetstioev individual):
Address: /� <
Cily/Statdzip: ` PhoneM:
F
a empNyw►'Check the appropriate boa: Type o/project(require:macmployawith g. ❑ I am a general contractor and 1 6. ❑Now construction
ploycee(full and/or pan-tiara).• have hind the subtexna"
a salt proprietor d>r partners listed an the anatdled shed: y ❑Remodeling
and have no employee Theo sub-commeters haw e. O Demolition
king for ens in any capociry. workers'comp insursnca: 9. 0 Building addition
workers'comp insurance S. ❑ We an a corpendm and is
nquirtx4l
ol'lleels have exercised their IOU Electrical repairs or additions
1.❑ 1 am a homeowner doing all wort riWu of exemption per MGL I I.Q Plumbing repairs or addltiom
myself.(No waters'comp n 132,0101 and we haw no 12.0 Roof repair$
insurance required.)► employees.Lido wrakaw' I).❑Other
comp insurance required.)
-Any apyhcM i chocks boa et wan e a m no err the wanks below Amving their go 'Q w gwud,M Pdbr doe.'I herrdrwetaa wtiho abeet ebb intendsindtodog day are doing all work aid than h co
mets rit near caauason wrhmh anew amdavk indioe ien see►
:c""anew Are climb ibis ban newe aashoa as addaeiaw ddol showing the ate of an ark4aYraMe sae th*ao 1 'rang pdky iamenraew
/war ere tarp/oytr that k ptev/rh g rewriters'roayasaaden/naaroace jar ag ewp/ayett whir ie hair pelh7 eeel/o1 XW
inferarur
In.vunnce Company Name.
enlicy M car Self-iss.Liec i /1?aeyx—�4 7/ — .5�' O Expiration Due:
Job 3 ire Addresv //-0 ee City/Staubizip
Attach a copy of the wor ken'competndoa Ptrgey decb nllan pep(showing the pocky number ad expiration date)6
Failure to wxum coverage as required under Section 23A of MGL e. 152 can Ind to the impwition of criminal ponaltie are
fine up to S 1.500.00 and/or one-year imprisonment.ere well as civil penaltie in the form of a STOP WORK ORDER and a dos
• l'up to S150.00 i day auainsl the violator. [in adviu'd that a copy of this sstemcm maybe rurwurded to the OITlce of
I nvc,o gattUl{a ul'the MA for insurance covcralp vuilication.
/Jo here rri/y an Mapes. and a/r/n a/pt/wry that tM in/arrraNM provided/above is Irmo and correca
OJJlcit/oat me/y. Da Her wrirt ie this area,to be.urnp(etd by oily or/awe a//kidl
I
City orruwn: _ PermiNl.leenree__, _.
INsuing Authority (circle one):
1. Ituard u(Iltallb 1. Ruilding Mparrment J. Ciq/town Clerk J. Electrical brspeclor S. Plumbing Impactor
6.Other
Phone M•
CITY OF SALEM
� j PUBLIC PROPRERTY
DEPARTMENT
,111Ii MI hl I BIw '•I I
I'.�"M I_'C Vt'.\il IIXO;JN 51'NL•l'T�).111'\I,�LNi.\h I II N 1 1 :I't .
CH:471.743- 395 •t'\Y:978•740.9446
Construction Debris Disposal Affidavit
(required fur all demolition mid renovation work)
In accord:mce 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 It . _ is issued with the condition that the debris resulting from
this work shall he disiwscd of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
ptame of hauler) /
The debris will be disposed of in
(name ut aci ty)
(address of facility)
\ignatur of permit applicant
date