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0066 ORNE STREET BPA-17-211232 The Commonwealth of Massachusetts s "i Board of Building Regulations and Standards Massachusetts State Building Code,780 CMR SALEM Building Permit Application To Construct,Repair,Renovate Or DemolisZQ l l ,"I MA2Nha One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Dat lied: Building Official(Print Name) Signature Date 1 SECTION 1:SITE INFORMATION 1.1 Property Address:_ 1.2 Assessors Map&Parcel Numbers 6 Q,-rig -so—, 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 RequireLLI 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 Owner'of icord: Name(Print) City,State,ZIP 7 S tJ7 I,S Z e-1 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction 1 Existing Buildin Owner-Occupied Repairs(s) Alteration(s) Addition Demolition Accessory Bldg. Number of Units Other Specify: Brief Description of roposed Wppr_k2: A _Za, ice' i Gi YL.t Z,,r, re SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use OnlyLaborandMaterials 1.Building/ p 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical it) Standard City/Town Application Fee Total Project Cose(Item 6)x multiplier x 3.Plumbing Gv 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Total All Fees:$Suppression Check No.Check Amount: Cash Amount: 6.Total Project Cost: $ 7 Paid in Full O Outstanding Balance Due: JQ ' 1 $ _ 5 ' 5 6 i SECTION 5: CONSTRUCTION SERVICES 5.l C nstruction 4upervisor License(CSL) I'/l -16 Cyy :y//,/A9 J ) , License Number Expiration Date Name of CSL Holder/ List CSL'rype(see below) Al” ` ke, Type Description No.and Stree U Unrestricted(Buildings up to 35,000 cu. 11. 7e) R Restricted 1&2 Family Dwellin Citylfwvn,State,ZIP MMaso 49 7Q c7 C G d 1 ` r- RC Roorinr Covering WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation Te hone Email address D I Demolition 5.2 1 gistered Home Improvement Contractor(HIC) S-12- HIC Registration Number Expiration Date IIIC Company Name or HIC Registrant Name No.and Street Email address Ci /Town State ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 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 Is§uance 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 I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 71b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I h by attest under the pains and penalties of perjury that all of the information contained in t4i5 appylti atr47 I u and accurate to the best of my knowledge and understanding. , DateX,_p,riat.Gmer's'or Authorized Agent's Name(Electronic Signature) 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 ng_gl have access to the arbitration program or guaranty fund under ivl.G.L.c. 142A.Other important information on the HIC Program can be found at xv%vw.mass.gov'oca Information on the Construction Supervisor License can be found at 4v w.mass.gov'dns . 2. When substantial work is planned,provide the information below: notal tloor 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 lumber of bathrooms Number of half/baths type of heating system dumber of decks/porches type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted ror,Totil Project Cost" t 3" ly . 70 All Now Ca stntteta, Counte rs, Aseaff*71ws, Doors, Ukrolowb, t Fitxt4ress, Mets; Firaehes 4 Colors $f*a4 be Selected l i 4k:' the Owner i k f 1 i i R.aumpr n k.K, l Ov Sow Down to tirtg1"lE?C tBt f OSClroOtl+ auuZu ro wwrrrrwrrw.w. rrA i3^P.+`t5 Now Wak4m CAkc wt 4fQ7*af i q41 F att ton rNOWSKW rrrr" the faun Now L~ Closet x x S"show=:2=00 DurtslMn aft=W! 1 ifs' ekN71 CG t,Ir'iMt1R' iY3 FM/drf Nt 10.i1nClvi id+n gx*" Bedroom t 1 Cam Z- x -v Now Laundry Closet 2 Not C"loC#adlyd t tea wrsc+ 1 J i T$ed X41` rrwr Ov s ivurrc undl A1.2g+ a 4'-(r3• t?orn tmm 1 aecara Fla©r Plan, 1/4" = r-Ol ttstrl. G,r r ., e i j ` J z'E J i_ i i ` a 1 j 1 s+aa r; 1U f 3 g ti w