194 MARLBOROUGH RD - BUILDING INSPECTION The COnunomrealth Ot Massachtiselti
t Board of 13uddiog RegulaliunS and Standards Pc)I2
� VII Nit,'ll'.ALII l
• Massachusetts State Building Code. 780 ('b1R. 7°' edition I 'Sli
r, ,•,i I
1uiIding PerntiI :Application To CCOnsBuct. Repair. 1?en0sate Ch DcnutlisIt a Rr o,l Jo u,,,,
0)w- or Tit u-Familr D)rrdlin,l
\ - This Section For Official Use Only
Building Per Nun er: Date :Applied: qri • ` 6 6 _.._—_----
�j — —
&adding Conmiis.,oned Inspeenn of Buildings Date
SECTION 1: SITE INFORMATION
1.1 >' - „l w 1.2 ssesrs flop & Parcel Numbers
l `I rMZ[,13oRou�e-I —--- --
\la N P:ucrl \'wuhrr
I.Ia IS this :In ❑CCep[Cd itr eel" 1'e5__ nU_ p umber
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq to Frontage(11)
1.5 Building Setbacks (f )
Fr' nl Yard Side Yards Re:u Y:ud
! Required Provided Re ruled Provided Required Piu,ided j
i
1.6 Water Supply: tM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone" Municipal ❑ On site diSpusal cystCin ❑
Public Cl Pit cute ❑ Check it yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1/
caner'of
cord: /I701 r��n ro A'rq j
Nome(Print) Address tor Service:
918-f) ig ? s-
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied Repuirsl s) ❑ Alterations) ❑ :Aldo,'' ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specity.
Brief Description„ttt Proposed Wnrk': �. ✓
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
ILabor and Materials) _—
1. I3uildi ng S OrJo t o� I. Building Permit Fee: $ Indicate how ree is d ncd:
eiernn
❑ Standard City/Town Application Fee
2. Electrical S G , �� ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing S 3DOo,tD> '. Other Fees: .S
4. :Mechanical (HV'AC) .5 List: --
I
5. Mechanical (Fire 5 �J — ---
Su� ression) Total All pots: S
Cheek No _Check .Amount _('.ish :Amount:
6 fatal Project Cost: 40 Paid in full 0 Outstanding Balance Due:--
SECTION 5: CONSTRUCTION SERVICES
4;.l Licensed Conslnuction Supervisor (CSI.) 7 L. Z1-3 y
_/—pep!'�,� 6 1 4y0 I_iti C11SCNumber lapn,alon Duce-1
N:unc of C iN Ilulder n V
'1 V,�C�Cr pT (/:.� List CSL'fcpe (srr brlu�r)
4'Y;' Tv e Dcsvrt tlon
1. (:nrc•stocted rtt to `ii000('u. Ft.i
R Rcstnrted I,\_' Fanil� D,clhne
Sq,t. lira Si \Ia'onrc Unk
ar
RC Resider flat RuofuluCu\erme
-felephone \\'S Roil.until \\lndo\1 .md Saline _
pop ,p ^ SI Ite,i dcnu.tl Sohd Feel 13wnue \pl+l i.tncr In,t.J l.iw u
Ll / 1 D Re,idenu;d Deinolnwn —
5.2 Registered Home Improvement C.unlractor (1110 11603 Z
ffIC Company N:une or 1-I1C Regisrant Name - Rcgtsnauon Number-
:Wlres, §- 14— aq
F.<ptmhnrn 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 procidc
this affidavit will result in the denial lit the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O� 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 mutters
relative to work authorized by this building permit application.
Sienature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby decline
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
k6wned
Name
Signature of Owner or Authorized Agent Date
under the arcs and penalties of erjur )
NOTES:
n Owner who obtains a building permit to do his/her own work, or anowner who hires an unre�_istered eontractoi
not registered in the Hume Improvement Comractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important irikoi oration un the HIC Program and
Construction Supervisor Licensing (CSI_) can be found in 780 CMR Regulations 110.R6 and 110.R5, rc..specni ely
_'- When substantial work is planned. provide the information below:
Total flours area (Sq. Ft.l (including garage. finished basement/attics, decks (ir porch)
Gross living area tSq. Ft.) Habitable room Count _
Number of fireplaces Number of bedroom,
Number of hathrooms Numberotholf76adt,
Tvpe of heating system Number lit decks/;)niche,
'I ype of cooling system F.nch ,cd _Open _
i. "Total Project Square Footage" may be substituted for "Total Project Cost"
CITY OF SALEM
3 PUBLIC PROPRERTY
DEPARTMENT
1_I- \f'.t.ttlN ;! INS IItII1 • S.\t! \t, \Lt��.t� In .t
.I'I l: • 1'.\x; 9,8-74--`I844,
N%'nrkers' Compensation Insurance Af idaNit: Builders/Contractors/Electricians/Plumbers
t tlicant Information Please Print Legibly
V;tltl tnusines thg.uucluon ludn ulual): G��f' l/hr�/sJ ��1 f , n L
AddreSS: J. If -+O4'r 2z
City,State/Zip:S'n lerr, it nl-50 Phone
Are you an employer:' Check the appropriate box: Type of project(required):
I. I am a employer with inn 6.4. ❑ 1 a general contractor and 1 New construction
❑ ❑
ent lu ees(full and/or art-time).' have hired the sub-contract U rg
P Y P listed on the attached sheet. 7. ❑ Remodeling
?.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. ,. (workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. R We are a corporation and its 10 ❑ Electrical repairs or additions
required.] officers have exercised their
3. 1 am a homeowner doing all work S exemption right of per NIGL I I.❑ Plumbing repairs or additions
❑ P
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] [ employees. [No workers 13 ❑ Other
comp. insurance required.]
•Any applicant that checks box nl must also till out the section below showing their workers'compensation policy information.
o I lontcuwners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
�cootractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I inn on employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.-
Policy b or Self=ins. Lic. 9: Expiration Date:
Job Site Address: CityiState/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure tit secure coverage as required under Section 25A of LvIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.5olimo and/or one-year imprisonment, as well :is civil penalties in the form of a STOP WORK ORDER and a tine
Of up to S250.00 a Clay against the violator. Be advised that a copy of[his statement may be fitrwarded to the Office of
Inv,,,ligtuions of the DIA for insurance coverage verification.
I Ja hereby vertill• nrler(Ise p ins and penalties of perjury that the injorritation provider/ t
above is true and correct.
el Date: J - O8
li"nalttre:
Phone =
ofth ial use only. Do not write in this area, to be completed by city or town official
City or Town: _--- .. Permit/License
Issuing Authority icircle one):
I. Board of Ilealth 2. Building Department 3. G"I flown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. other --_— —
Contact Person: __ -- _ -- Phone d:_
Information and Instructions '
Nlas,achuscus General Lahvs chapter 1 5' requires all c nip loyers to provide %corkers' compensation fix their employees.
Pursuant to this statute, an avnplgree is dcf ined as "._even, person in the service of another under any contract of(lire,
ecpress or implied. oral or hsrilten."
An enrltL!rer is defined a "all indite ideal, p;ulnership, association, corporation or other legal entity, or any two or more
of she foregoing engaged in a joint enterprise, and including the legal representan es of a deceased employer, or the '.
receiver or trustee of an individual, partnership, association or other le,_al entity, enhploying employees. However the
,,u ner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who emplovs persons to do maintenance, construction or repair work on Such dwelling house
or on the grounds or building :Ippurtenant thereto shall not because of Such enhploy nhcnt 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."
Additiunally, ` GL chapter 152, j25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter Into any contract for the perfornanee of public work until acceptable evidence of compliance with the Insurance
requirements of this chapter hace been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) nanle(s), address(es) and phone number(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 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 till 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) and under"Job Site Address"the applicant should write "all locations in (city or
sown)." 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 ottice of Investigations would like to shank you in advance for your cooperation and should ,you hace any questions,
please do not hesitate to give us a call.
File Departments address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Rc%i,cd ; -a; Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
NI 120 WAS I I I N6!ON S I SE ITT # SA I r at, %L%sSA( Ht S1 I I s)I')!'
'I'm, 978-74n-9595 * FAN: 978-740-9846
Construction Debris Disposal Affidavit
(I-CLILIked for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit #— --- is issued with the condition that the debris resultingfrom
7---
this work, shall be disposed
jIsposed of in a properly licensed waste disposal facility as defined by NIGL c
I 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
sign a
or permit applicant
S- fq — coo
(late