80 ORCHARD ST - BUILDING INSPECTION Z L4 A
Phe Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revired,Nar 20//
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For.Off 'dl Use Oni
f3uildingPerrnitNumber: MO.Applied:
!fA" f
Building OtTciai{Print Name}, �; Signatue - ate
SECTION I:SITE INFORiV1ATION �•
l'V
1.1 P perty Address: � " 1.2 Assessors Map.'&Parcel Numbers � �
rn
( L la Is this an accepted street? es no Map Number Parcel Number ~?
t >\ o rTt
U J 1.3 "Zoning information: 1.4 Properly Dimensions: � :t>M
m
ti Zoning District �: Proposed Use - LoCArea(sq R) - Frontage(R) p -
I� 1.5 BuildingSetbacks(R) - -
}--� Front Yard Side Yards _ Rear Yard +7D
` RegWred - Provided -Required Provided. Required' Provided
1.6 Water Supply:(M.G.L c.de,§54) 1.7 Flood Zone Information: 1.8 Sewage Dispose!System:
Zone: Outside Flood Zone?
Public a Private❑. - _ Check if Municipal O On site disposal system 0
SECTION 2: PROPERTYO'VVNER$Iite,
2.1 vnerr of Record:
c
bine(Print) City.State,21P .
Ro (�+z
No.and Street Telephone Email Address
SECTION,3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Striding t7 Owner-Occupied O Repairs(s) C) Aiteration(s) 0 Addition Q
Demolition O Accessory Bldg.❑ Number of Units Other C] Specify:
Brief Description of Proposed Work=:
SE'01565N4. EST4NATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S L Building Permit Fee:$ Indicate how fee is determined:
2. Electrical - S 0 Standard Cityffown Application Fee
C3 Total Project Cost?(Item 6)x multiplier x
[5.
Plumbing S 2�91her Fees: S
.Xlecitanical (HVAC) S List;
Mccltnnical (Fire S, ression) Total All Fees:S
Check No. Check Amount: Cash Amount:Ta ti I'rrrject Cast: S y p Paid in 17-it 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES ;
5.1 Construction Supervisor License(CSL)
License Number Expiration Date'
Name of CSL Holder
List CSL Type(see below)
No.and Street Type. - Description .
U Unrestricted(Buildings tip to 35,000 cu.It.
R I Restricted 1&2 Family Dwelling
Cityffotvn,State,ZIP I M I Masonry
RC I Roofinit Covering
WS I Window and Siding
SF I Solid Fuel Burning Appliances
I I Insulation
Tele hone Email address DI Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.mid Street
Email address
Ci /!'own State ZIP 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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION In.OIVNER AUTHQIUZATION TO BE.COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOIWOLIES FOR BUILDING.PERMIT'
1,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(Eiectrimic Signature) _ Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,i hereby attest under the pains and penalties of perjury that all of the information
contai ithis pppllicati�s true and
accurate to the best of my knowledge and understanding.
Print Owner's or, i' ith"orized Agent's Nunm (Eiectronie Signature) h
I Datel
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
----("a registered in the Home Improvement Contractor(HIC)Program);will rr have access to the arbitration
program or gu uanty fund under M.G.L.c. 142A.Other importnnl ttnfo2tnuTton on ilia HfCPro�ram can be f—bund at"
.vww.mass.eov'oca Information on the Construction Supervisor License can be found at www.atass.go4:'d as
2. When substantial work is planned,provide the information below:
Total Door area(sq, ft.) (including ganga, finished basement/attics,decks or porch)
Gross living area(sq.R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
fype of coaling system Enclosed Open
.1. "Cola( Project Square Footage"may be substituted t'ar"Toed Project Cost"
a
QTY OF SALEM, MASSA 'S
LDCHUSET
BUIINGDEPARTMENT 120 WASHINGTON STREET,3" FLOOR
TEL. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT,
Date ' pp
Job Location
Home Owner Address-
Present Mailing Address
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
07Y OF SALEg MASSAaimm
BEnDn cDEPAE7MENr
120WA9NSMtEET,3IDFLOOR
1L(978)745-9595.
RiMttFRi FYDg��j,j,
PAX(978)740-9846
MAYOR 7MMM STIUM
DIICEcrcatcrPmucpxom Tr/BuimmamS m=
Construction Debris Disposa/Affidavit
(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 c40, S 54; Building Permit d is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
(T�4AAJ
SignatuT)O
of ap �licant
Date