61 ORD ST - BUILDING INSPECTION a The Commonwealth of Massachusetts
r +t Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 730 CMR, 7ib edition
VVVVIIII �, Revised Jrtnuun•
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. -1008
One-or Two-Family lAvelfing
This Section For O t 'al U e n
Building Permit Number: Dat /
Signature:
Building Commissioner/Inspector of Builth &s V Date
SECTION 1:SITE INFORMATION
1.1 Property ddress: i 1.2 Assessors Map& Parcel Numbers
I.la Is this an/accepted streel7yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public C3 Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of R qr&
� ST
Name(Print), Address for Service:
-/ 579- -
SigfidtVm v Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all at apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) rations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other Specify:
Brief Description of Proposed WorlId� US-C ✓ ✓ Se't
p� L12 T. NSyI ✓i * yn� 71
l,Jecii K'e 7L s+.,' n1^ l
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire S
Su - ression Total All Fees: S
MAI Check No._Check Amount: Cash Amount:
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
}
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) `6,Zy 0 31, 3 Q
License Numher lis moon ate
Name of C.'I.• I folder Ju y)- 66 . v I,
o i S S o Lisl CSL I)'pe Isee below)
MD
Description
Unrestricted(up to 35.00OCu.Ft.)
Restricted 1&2 FamilyDwellin
n turc Slason Only
Residential RootingCovering
1'elephone Residential Window and Siding
Residential Solid Fuel Burning Appliance Installation
�n orH Residential Demolition
5.2 R isterom ST11 T� pA JZC?t C Gl�/S 1 IC) /6
I I 'Co any N ne or IiiC Re li rat Nume —^ Reg istr ion umber/
Jdre rj P7QJr— /at
7p C�/� spi ion Dale
.'ig turc 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 ot'the-builc ing permit.
Signed Affidavit Attached? Yes .......... Nu...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/
1 A C r e0 St , as Owner of the subject property hereby
authorize lon'lR k cool)// t t< to act on my behalf,in all matters
relative to work autt orized by his' w 'ng permit application.
1-2 12YIZ-
Si malyr!o ner Dale
SECTION 7b:OWNEIV-OR AUA
AUTHORIZED GE T DECLARATION
I, /�✓,�71 f_ �' �,C/oj{ ) fY \ as Owner or Authorized Agent hereby declare
thattheme statatements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. 6'a 0 )
Print Name
Signaurre-o' ne horize unt --- Date
Sime under th ns andpenalties ofperjury)
NOTES:
1. 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 not 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 790 CMR Regulations 110.116 and 110.115,respectively.
2. 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.) I-labitable 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 he substituted fix"Total Project Cost"
CITY OF SALEM
rIS
PUBLIC PROPRERTY
DEPARTMENT
sing:;N:fy:Jk IA:1.11
�I.tt1e 11C WASH.M;10.7v5-IRlbl' • SAIEM,MASSAO(I it I Is6197^.
Tot.: )78.7t5-9595 • F.vx.97X-74C--.)S46
,Yorkers' Compensation Insurunce Afftlavit: Builders/Contractors/Electricians/Plumbers
\ 1 riicant Information Please Print Le ibly
All�I81Tle 11)usutessil)rganinlinre rndrouluall: S15t1 fe/ i a\7
Address:
City;Starc;/sip: / C Phone 0:— a- /7
Are v. ort employer? Chet the:yrpro iate box: 'Type of project(required):
4. ❑ l a n a general contractor and 1
I. I ;un a employer with G. El New construction
employees(full and/or part-time).* have hired the sub-contractors
❑ 1 am a sole pmprictor or partner-
listed on rhe attached sheet. �• ❑ Remodelingship and have no eanpioyevs These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'comp. iluurance 5. ❑ Weare a coiporution and its 10.❑ Electrical repairs or additions
required.] o.Mccrs have exercised their
3.❑ 1 ani a homeowner doing all work right of exemption per MGL 11.[] Plumbing repairs or additions
myself.]No workers' comp. c. 152,¢1(4),and we have no 12.❑ Roof repairs
insurance required.] r employee.. (No workers' 13.❑ Other
comp. insurance rcquired.J
•sny;yphcaol amt checks box el must alsu till out the scclion below showing iheir w•urkui cumpwriouion policy inliunutiun
't lumuuwmn who sunmil This a%Idavit indicting they are doing Al work atW then hire outside cwurnclors must.uhmit anew arrdavil indiuling such.
•fomcN„n Ihet chuck this box own attwhed an addlliunA141et showing the none of the subhomrwtors and ihelr wurken'comp.policy oiliu matiun.
/seer an ctnpluyer lhut lc pruvidirr•K lvurkers'curnpensnrinn insurance Jur cry enrpluyees. Below is the policy torr/job site
inforuruthrit. L qyrUNZ19AIO 71— ,Svl-,-)A✓C C
Insurance Company Name: R
Policy 4 or Sclf-ins. Liic.ft:��//r✓ / j G<_..✓ - - Expirruon Date:
Job Site Address: /O/ �/ CityrStuteiZlp:
Attach it copy of the workers'cumpcniation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required order Section 15A of.NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.5110.00 and/or ooe-year imprisonment,as well as civil penalties in the furor of a STOP,YORK ORDER and a fine
of up«r)'50.00 a day nguinst the violator. Ile advised that a copy of this slutement may be lumarded to the Office ul
hr\'i]ngalVms u1 the DIA for insurance covcra,c scrific.d
I du hereby certify under it ns mrd h• . of perjurytl re infurmullon provided above is true and correct.
I'h •e l® 7 s �� 7 �e
[6. ly. Od tint write in this area, to be completed by city or town ajjiciul. _
i
: Permit/License N_._.._.
rity (circle nuc):
calilt I Building Mparuncn( .1.Cilli form Clerk 4. Electrical luspector 5• Plumbing; Inspector
.__.
Cuulacl i'cnun: _ _ ,'hone d:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this siatute, in emplured is defined as"...every person in the service of another under any contract of hire,
eapress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporatiun or other legal entity,or any two or more
of the lore6oing engaged in a Joint enterprise,and nncludtng the legal representatives of a deceased employer,or the
receiver or trustee of .ut Individual,panmership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
`IGL chapter 152, +'25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, N IGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s),address(es)and phone nunmber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirnmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officlals
please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on rile for future permits or licenses. A new affidavit must he filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he t)t lice of Investigations would like tp thank you in advance fur your cooperation and should you have:my questions,
please do nut hesitate to give us a call.
The Dcparancnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel, It 617-7274900 ext 406 or 1-877-MASSAFE
It;viscd i-26-05
Fax k 617-727-7749
www.mass.gov/dia
CITY OF S.UY-.,Nl, �L-1SS.-ICHL'SETTS
• BCIIDLIIG DEPARTMENT
110 WASHLNGTON STREET, 3 °Roo&
TEL (978)745-9595
FAX(978) 740-9846
K(J(BExLEY DRISCOu
MAYOR THO.�us ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/WUMLNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
AIA
(nifine of hauler)
The debris will be disposed of in
( ame of facility)
IVIA
ddress of facility)
Si a ermi applicant
JatC
I.bnvif Jew
( ACTION, INC
47 Washington Street
Gloucester, MA 01930
Agency: NSCAP NGRID Application#:
PROGRAM: AARAWAP �- 0
JOB NUMBER:1
DOE Work Order# 0 E.S.G.performed? No
Work Order Date: 10/13/10
Primary Contractor: Bay State Weatherization&Construction
Other Contractor: NA #Bulbs installed $0.00
Cost of Bulbs $0.00
Client: Marceline Rose nspt$125.00 Max $0.00
Street: 61 Ord Street Other In Kind $0.00
City; State;Zip: Salem, Ma 01970 Electrical Work $0.1^10
Telephone: 978-745-8394 $ Amount Keyspan $0.00
$ demount National Grid $0.00
Blower Door Test: NO other utility $0.00
Inspect Knob&Tube: No
Date Job-Completed: Estimated Repair Total' 8643.75
Actual Repair Total $0.00
Weatherization I Est Act Cost Est Cost I I Act Cost
Door Kit 3 $43.00 $129.00
Door Sweep 3 $15.00 $45.00
Automatic Door Sweep 22.00
Air Sealing (per hour 4 $75.00 $300.00
Attic Air Sealin 2 art foam r hour 3 $75.00 $225.00
Weatherstr Window(per side $5.00
Sea[Ducts-Mastic $62.00
W/S&Insul Attic Hatch R30 $30.00
$0.00
$000
$0.00
$0.00
$0.00
$0.00
Weatherization Totals: $699.00
Insulation Est Act Cast Est Cost Act Cost
Front Sub-Attic R38 open 15 $1.40 $21.00
Thermodome 1 $175.00 175.00
Sill 2-Part Foam/R19 FG 143 $2.00 $28600
Attic Flat R20 restr 420 $1.35. $567.00
Crawls ace Overhead R19 FG 321 $1.78 571.38
Attic KWall R13 Cell w/Membrane $1.65
Attic Kneewali Floor R30 rest 1 $1.41
Insulate Attic Stairs&Walls $130.00
Sidewalis-Vinyl R13 DP $1.70
Interior Wall R13-Plaster R13 OP $1.81
Test Drill Sidewalls-4 sides $60.00 $60.00
Duct insulation R5&Seal Seams $2.95
H dronic Pie Insul to 1"R5 225 $3.25 $731.25
Steam Pie Insul to 1.25'R5 $5.25
DHW Pi a insuation R5 56 $2.50 $140.00
Insulate Door $4400
$0.00
Insulation Totals: $2,551.63 $0.00
.¢ Marceline Rose Page 2 DOE 0
Other Measures Est Act Cost Est Cost Act Cost
6ml Poly on Ground 321 $0.75 $240.75
Gable Vent ectan ular 1 $88.00 $88.00
Vinyl Rep lacem t Window-73 ui $3$0,00
Vinyl Relacem Window-83ui $400.00
Vinyl Replacement Window-93 ui $410.00
Vin IRe laceme t Window-101 ui $425.00
Vin i Re i.Bs Ho er Window - $325.00
SteelPre-Ha Doorw/Lite $610.00
Solid Coe Door w/Hardware $350.00
Faucet Aerator $15.00
Low Flow Showerhead $25.00
Blower Door Test $45.00
Window Grids-per sash $20.00
Building Permit Fees 1 $100.00 $100.00
Other Totals: $428.75 $0.00
Ener Conservation Est Cost Act Cost
Totals: Max$10,000.00 $3,679.38 1 1 $0.00
Repairs Est Act Cost Est Cost Act Cost
Frame Door for W/S 1 $35.00 $35.00
Adjust Door Striker Plate'- 2 $20.00 $40.00
Sheetrock/Slo a Tae 1 Coat 45 $3.75 $168.75
Reinstall Fallen FG r hr 1 $60.00 $60.00
Slide Bolt $20.00
Sash Lock $9.25
Glass Replacement-to 64 ui $42.00
$0.00
$0.00
$0.00
Health&Safety
Vent Clothes Dryer to Exterior 1 $85.00 $85.00
Vent Bath Exhaust Fan to Exterior 2 $85.00 $170.00
Replace Dryer Hose $38.00
Vent Microwave to Exterior 1 $85.00 $85.00
$0.00
$0.00
!Repair Tot: Max$2500.00 643.75 $0.00
Work Order Sub Total: $4,323.13 1 $0.00
Measures Est Act Cost Est Cost Act cost
Other $0.00
Other $0.00
"Heating System Repair $0.00 $0.00
"Action approval only -
Estimated Job Total: $4,323.13
Job cannot exceed$10,000.00
Job minimum=$200.00 Job Grand Total $0.00
AUDITOR: Brandon Dorrington