Loading...
192 MARLBOROUGH RD - BUILDING INSPECTION 'rhe Commonwealth of Massachusetts CITY OF n ) Board of Building.Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR Revised blur 2011 © Building Permit Application To Construct, Repair, Renovate Or Demolish a N One-or Tivo-Family Dwelling This Section For Official Use Only Building Permit Number: I Data A plied: V Building Olticial(Print Name) Signature• - vote M SECTION 1 SITE INFORb1ATIOW •J 1.1 Pro9perty Addr s: D J 1.2 Assessors Map&Parcel Numbers Ili. f � Murl�cro� 1\A 1.1 a Is this an accepted street9 yes no Map Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 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: Zone: _ Outside Flood Zone? Municipal O(On site disposal system ❑ Public Private❑ Check if es❑ p P y SECTION2: PROPERTY OWNERSHIP!' 2.1 Owner of ecord: _i 1 h0{� j0Y Qq �ep o i1 1 O! Owner'of b� ley o d s cross Rr t n v) i)cl-!.S I ti 9 N7 me(Print) City,State,ZIP fo (fix lyr1 ti�-ft UzYO) hr;440C�qlz (ha)l- ro ` No.and Suet Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Altemtion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description ot'Proposed%Vork=: 1A(t Is Iftl-)rn Carr T Qmodel I Ile-,+k SECTION 4:ESTIMATED CONSTRUCTION COSTS Itc n Estimated Costs: Ofticial Use Only Labor and Materials) I. Building S 13 ,00 a I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost?(Item 6)x multiplier x 3. Plumbing S3 2. Other Fees: S 4.`lechanical (I-IVAC) S List: 5. Mechanical (Fire S Total All Fees:S Su ressiun) p Check No._Check Amount: Cash Amount:_ G, 'rotul Project Cost S I D V�� [3 Paid in Full ❑Outstanding Balance Due: P . U . SECTION 5: CONSTRUCTION SERVICES 5.1 Cottstructiml Sup/elrvisor License(CSL) Xtio ��License Number EsDate Name of CSL Holder List CSL Type(see below) -1 '1`�- H -Type - Description . Nu.;md Street /1 Q C') U Unrestricted Duildin s u to 15,000 cu. IL A-C ( 1 7f i R Restricted I mnil Dwelling Citylrown,State,ZIP I h' masomy RC Rooting Covering WS Window and Siding S I Solid Fuel Doming Appliances 1 L (I hb+x'1� LQYVIGII�fd II Insulation Tole hone - Email address d D I Demolition, 5.2 Registered Home Improvement Contractor(HIC) 10 10 C s -7 ZZ ) '�s 7(tiy+ �Cl"v4 HIC Registration Number Bkpirikion Date HIC Company Name or HIC Registrant Name f S n h0< � ��f hG 7! " S uYL\ Np n q1 o.and Street i� � n Ol�'S f. 2l1 �'� Email add ss Ci !town Stat ZIP*1 1 Tele /hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.¢ 25C(6)J, Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Isiu ce of the building permit. Signed Affidavit Attached? Yes .......... E3 No...........O SECTION 7a:OWNER AUTHORIZATIONTO BE COMPLETED WHEN' OWNER'S AGENT OR CONTRACIrOR APPLIES FOR BUILDING.PERMIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all mat ers relative to work authorized by this building permit application. 0 PrintPrint owner's is Signature) D L 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 cons 'led cation is Aue and accurate to the best of my knowledge and understanding )p )c ) 6 Print( Tuner's or Authorized Agent's Name(Electronic Sigttnture) Date 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 Litt have access to the arbitration program or guaranty fund under M.G.L.c. 1 a2A.Other important information on the HIC Program can be found at Tv+v+v mast cov'oca Information on the Construction Supervisor License can be found at w+vw.mass.sov'dns 2. When substantial work is planned,provide the information below: Total fluor area(sq. ft.) (including garage,finished basementlattics,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 Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substitUlCd for"rutal Project Cost" r v The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information JJ )) Please /_Print Le ibl Business/Organization Name: (Zoein &ecl e5 C7 co- /IP)e (0?6s Address: I q *7Z Jq -Rd M/� G City/State/Zip: Ue d ! "ITl Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1.C&I am a employer with Z employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp, insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑ Manufacturing no employees. [No workers'comp.insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 1 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy information. Insurance Company Name: Tf cgIr r S Insurer's Address: (J City/State/Zip: � 1 Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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 day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t do hereby certi under the pains and p'�j{jla/lit of perjury that the information provided a ovpe 's true and correct. Si nature: G0'���i"`` yko Date• I��1 D�i6 Phone#: , /� ,5-z I9b1 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia c Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an 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,§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,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 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 your insurance company's name,address and phone number along with a certificate 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 date 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 Please 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. Please 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 permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary). 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 file for future permits or licenses. A new 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. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Revised 02-23-15 ti Cny cF SALEK MAsmimn XVMWDVAXDEnrr DL 715-'3995. $IA�BRIBYDXL RM 740-9 b MA" DXUAsSUUM DntBamcrrUUx r/sw=ca Construction Debris Disposo/AffidWit (required for•all demolition and,-renovation work] in accordance with the sbA edition of the state Building Code, Teo OUR, Secdon 111.5 Debris and the provisions of MGL coo,S S4; Buihfhg Permit B . I Is Issued with the condldon drat the debris resultft from this work doll be disposed of In a prope*licensed waste deposit fadllty as defined by MGL c 111,S 156A. The debris will JJb_�e-transported by. erl (name of hauler) The debris wwill be disposed of in: (name of facility) (address of facility) Signature f qpplicant Dat Unofficial Property Record Card http://salem.patriotproperties.com/RecordCard.asp 1 Unofficial Property Record Card - Salem, MA General Property Data Parcel ID 46.0066.0 Account Number Prior Parcel ID 11-- Property Owner SMITH SUSAN E - Property Location BAKERS ISLAND SMITH PHILIP C Property Use One Family Mailing Address 15 BRADY AVE Most Recent Sale Date 1/1I1900 Legal Reference 10846.517 City DERRY Grantor Mailing State NH ZIP 03038-4202 Sale Price 0 ParcelZoning RC Land Area 0.310 acres Current Property Assessment Xtra Features Card 1 Value Building Value 67,600 Value 400 Land Value 134,500 Total Value 202,500 Building Description Building Style Camp-Seas. Foundation Type Piers Flooring Type Hardwood #of Living Units 1 Frame Type Wood Basement Floor NIA Year Built 1848 Roof Structure Hip Heating Type None Building Grade Fair(+) Roof Cover Asphalt Shgl Heating Fuel None Building Condition Good Siding Clapboard Air Conditioning 0% Finished Area(SF)1476 Interior Walls Minimum #of Beret Garages 0 Number Rooms 4 #of Bedrooms 1 #of Full Baths 0 #of 314 Baths 0 #of V2 Baths 1 #of Other Fixtures 0 Legal Description 1 of 2 10/18/2016 10:03 AM Unofficial Property Record Card http://salem.patriotproperties.com/RecordCard.asp Narrative Description of Property This property contains 0.310 acres of land mainly classified as One Familywith a(n)Camp-Seas.style building,built about 1848,having Clapboard exterior and Asphalt Shgl roof cover,with 1 unit(s),4 room(s),1 bedroom(s),0 bath(s),1 half bath(s). Property Images Disclaimer:This information is believed to be correct but is subject to change and is not warranteed. 2 of 2 10/18/2016 10:03 AM