182 MARLBORO RD - BUILDING INSPECTION I fhe Commonwealth of Massachusetts CITY
((( hoard of Building Regulations and Standards of SALEM
bfassachuselts State Building Code, 7,40 C'MR, 7"edition Nevixed Anwar,t'
Building Permit Application'fo C nstruct, Repair, Renovate Or Demolish a 1, 1008
One-or T 'o-Family Dwelling
Thi 'ection For Official Use Only
Building Permit Number Date Applied: r 2 ILI
Signature:
3' I(
Building m sione/I s for ol'BuilJings Date
SECTION 1: SITE INFORMATION
LI Propert Address: / l 1.2 Assessors Map& Parcel Numbers
Parcel Number
I.la Is this an accepted street?yes v no Map Number
_
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use [.at Area(sy 11) Frontage(ft)
1.5 Building Setbacks(R)
Side Yards Rear Yard
Front 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if XesC3
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert o
Name if R ord
Vy)��i— l l VLF It
for Service:
n im) 6 Address—)�g �lo�7 I S&KS
Signature 'telephone
SECTION 3:DESCRIPTION OF PROPOSED WO Kt(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ I Number of Units_ I Other ❑ Specify:
Brief De ,ripti�of�op�ed Work r.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S I. Building Permit Fee:S Indicate haw lee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List: a G
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No._Cheek Amount: Cash Amount:_
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.11 Licensed Construction Supervisor(CSL) 6!„�_�-y- J
6 V'� ,1. V f. N License Number lis irali�n Uate
Name of CSI.-I lulder
List C'SL 1')pe(see bektw)
ft Pe I Description
I I Craesiricted(up to 35,000 Cu.Ft.)
Signature "— (�• It 1 Restricted l&2 Family Dwelling
rt-Xe ,2.�.2— S� NIMason Only
RC' Residctnial RootingCovering
fcicphone WS Re,,demial Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2�tegistered H,,RRme Improvement Contractor(HIC)
cP
I IIC Company Name or Registrant Name Regtstratiun Number
Address G
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 a 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:OWNEW OR AUTHORIZED AGENT DECLARATION
I• ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature ot'Owneror Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 flame Improvement Contractor(HIC)Program),will Ligal 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 790 CMR Regulations I IO.R6 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.) 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 S.U.&M, NLLkss.AcHUSETI'S
BUUMLNG DEPART MNT
120 WASHLNGTON STREET, 3'°FLOOR
` T» (978) 74S.9595
FAx(978) 740.9846
KimsERLEY DRISCOLL
MAYOR THOmu ST.PrEa ns
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG 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 111.5
Debris,and_the-provisions-of MGL c-40,-S-54; -- - ------
Building Permit Al 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
l 11. S 150A.
The debris will be transported by:
t
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
a
signature of permit applicant
T i daft
Icbnvlfd•x .
CITY OF SALEM
PUBLIC PROPRERTY
?.l DEPARTMENT
.1\ICl N:I'v:)xl8A I1.
\I\a11N 11�\Y/diHl.\G I UX S I XEL-l' • SAUM,MAvSACa It ilk I I N 0197^�
1-hl.:978.745-9595 • F.M 978.7+C-7846
\Vorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
tiunlicant Information Please Print Leeiblv
tp� r
Name IDudoesyQrganitafinNlnJtnduun: O���Z`��� "-"-��L�C
Address:��
City,Slam/.ip c�mr� /-� I'hune i- `�5;r 22-2
:ire)vlu employer! Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I :un u general contractor and 1 G. ❑ New construction
e I11pIJy'eex(full and/or part-time).* have hired the sub-contractors
2.Q 1 am a sole proprietor or partner-
listed on the anachcd sheet. 7• ❑ Remodeling
ship and have no employees These iub-contractors have S. ❑ Demolition
working for Inc in any capacity. workers' comp. insurance. 9. ❑ Building addition
I No workers'comp. insurance 5. ❑ We area corporation and its
rcquircJ.J
officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myself. (No workers'co nip. �
p. c. 152,g 1(4),and we have no 12. 1 repairs
insurance required.] r employees. (No workers' 13.❑ Other•
comp. insurance required.]
•nay .ytphcaut Ihut chucks box ill must also fill out the vaclian Wow slwwiny Iheir xurkua'wmpanaation fwlicy inlurrtuliun
'I lomeuwners who submit this aHldavir indicting thc-y are doing all work and then him outside cauractors must auhmil a new afndavil inJiu:Jing arch.
-C\mmwoms that thcck this box mml allwNd an additional sheaf showing the name of the subronnaclors and their wurkers'comp.ru lmy information.
l run un employer that Is providing Ivurkers'compeavmtiwr insurrnnce jar sty employees. Bengt,is the policy and job Nile
hi/arMation• 77;9 vI ";?46— �3z7�
- Insurance Company Vmne-1 --.._. - ..
Policy A or Sclf-ins. Lie.11: !_.. � / r ._ .._ Expiration Date: p C�
Job Site Addfl'SS: /: So i' (GY�� Ya �1' r"�12"�'l cit0tatei"Lip:
Attach It copy of Fite workers'compensation policy declaration pulse(showing the policy number and expiration date).
Failure LO secure coverage as required under Section 25A of.IvIGL c. 152 can lead to the imposition of criminal penalties of a
tine up m S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to)250.00 a Jay agaimt ate viokunr. Be advised that a copy of this,tutemcnt may be forwarded to the Office of
Imrangaunns of Lite DIA for ioiura:cc coverage writicatiun.
l as hereby tertijy under it teep/wins and penuldev u/perjury that the in/orintrtion provided above fs trite amd correct.
til�'11f11111'e /w/ �� Date,
O(liciui ns'e way. no net nvite in this area,to be completed by city or twva o/jicial.
i
City or'fown: _- Purmit/License V_._.._.
Issuing.kudulrily(circle one):
1. Board of Iivalth 2. Building Department 3. Cityr fawn Clerk 4. Llectrie:d Inspector 5. Plumbing Inspector
b. 011tvir _ -- _
0,111ac1 !'crson:
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for thcir enmployees.
Pursuant to this statute, an empforee is defined as"...every person in the service of another under any contract of hire,
evpross or implied,oral or written.-
.\n e,nployer is defined as"an individual,partnership,association,corporation or other legal cntiry, or any two or more
of the Ibreguing engaged in a joint enterprise•and including the legal representatives of a deceased employer,or the
receiver or trustee of a n individual,partnership,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."
MGL chapter 152, Z25C(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, MGL 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 w ith 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 nunnber(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 does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and Jule 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 Officials
Plcase be 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.
Pl.ase be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennio'license 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 uftidavil 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 file for future permits or licenses. Anew affidavit must be 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. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
I'bc t)t lice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
plea.Ne do not hesitate to give us a call.
The D,:parnnent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of lnvesdgadons
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
;t;vi.cd i-26-05 Fax N 617-727-7749
www.mass.gov/dia