107 MASON ST - BUILDING INSPECTION 4,
l'ortunuuwcalth of 11as,achu euS
I t )It
c` Board of Iiuildin� Re�ulanons and Standard, \tl
( � \ Sla sa:hu.setts State Hwlding (ltJr. 781)(AIR. 7"' edition \I
luilding I'errnn Aliplicatitm To ( 'HAIL el. Repair. Renmate OI I)enudi.h -1 -I K -,1 /....,.... .
One ,I Tnt,-1'lnnilcOnr11111('
I his .Section Fnr Official t 1,e Only 00-4--
Build m eu)e Pennu Nur _-- --- Date .\pphrJ: -
Huddling Cunmu..i,mn nTector ur I1w IJmg, Date
SEC"I ]ON I: SITE INFOR.MA FIO.N
1.1 Props ly \ddr ss: 5.., �•+� /Ir 1.2 .Assessors Nlap & Parcel Numbers
—L��_--T71�so t', -� 54 , - ---- - ---- - --- - -
/
la 6 tlu:, tin cceped trceLtin--- %1t \umhvr 1 .u.r1 ..\wnhcf
� --
l.3 Zoning Information: l.1 PrgFer!- Dimensions:
Zoning District Pnrpracdl L'se Lot :\rca oy 11) Fnrma.e lit t
1.5 Building Setbacks (f0
j From Y'arJ Side Yards Rear Y uld
ReyuueJ Pro%idled ReyuueJ Pnnided ReyuueJ PI...ljcd
--y
i
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 iZ/On ,tie Ji,l>,i,al +v,icm ❑
Public Pneare❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2 1. win rr of Rec d I
(J Q SO
Nate tin Addrdress 'ter Service:
Signature Telephone
SECTIO 3: DESCRIPTION OF PROPOSED WO11"W(cheek all that apply)
New Construction ❑ E.xixfine- Building Owner-Occupied ❑ Rcpa-rs(s) ❑ -Vterarnmtr.) ❑ :\JJnuvt ❑III
Demolition ❑ 1 Accessory Bldg. ❑ Number of Unns-3- I Other ❑ Specify
Brief Description of Pro tsed Work;: ----
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Cosa: Official Use Only
Item (1. l�p/ d��alSl ------ . .- - --
r"— I. Building Permit Fee: $__ Indicate how fee i, Jetei mined:
I BuJdutg 'S-
❑ Standard City/Town Application Fee
_'. Electrical ❑Total Project C)at' (Item 6) x multiplier x
!. 1'lumhmg ' _'. Other Fees: 3
1. ,tee,""r 'M'' \CI 5 Luc
5 Mechanical (Foe i """--- - -----
r„1.d :\H Fees: s
� 1u t ves,uml ---
--~ ('heck N,) —__—( hCLk Alnuunt: ( .�•tt \n1"Llin
O folul Project Cosl. ❑ Rod B
Ro in Full ❑ futsfandri ,tLm.e ()re
/ -
MG . J O �—
SFC'I JON 5: CONSTRICTION SER1 WES
041 3 Q>,
. .I l.ii-t nst-d ('uiislructioiiStipc Iry tsar (CS 1.)
9- ,cii,cNumh�r I 'im I 1),d�
4
74 If
wo l t 1:1
C r -
hl
- - R( R
4-
12
ii
H J, .,1 S, I 'I I t I I L: 1 1,1 1 h,'I.d
5.1 Registered I Ionic I niproi,ernent Curten-ctor II
HK Lolllp.m� S.unc tit IllC R"I,tljl]L Name
\ddics,
I Dme
Iciellholle
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT t M.G.L. c. 152. § 25(-:(6))
Wurken Compensation Insurance affidavit mwt be completed :utJ ,uhmiueJ with tht, .tppLuu��tn. F.olurr to pntudc ,
this affidavit will result in the dental of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..-..... 0 No ._.. 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. -,1 pi,,peit� hereby,as0vknerotlh� -lhj,,
all[bi""e to ac( tw lllv
to ,.%ork authorized by this building permit application.
�S ,,Itiuiew Owner Date
SECTION 7b: O"NEWOR AUTHORIZED AGENT DECLARATION
1. Nal<1 0 -LI" ---, as Owner or .,\uibon/ed \,,en( heichy deCl.11e
— -�I
that the starcme V , h infor mation on the foregoinc application .tie true and accurate, to the best of -ro, know ledge and
behalf.
Print N.jIne
Signature of 0wnerur.AT
u,wdAger
Dae
u IIer t he jais id naltcsof cjuri U NOTES:
I. An Owner who obtains a building permit to do his/her own %%oik. oratiowner �%ho hues an urnCIII,eJed 101111.1LI"i
(not registered in the flonic Improvement Contractor (1110 Program). will toot have acce,s ill thcaihmatilm
program or guaranty fund under M.G.I. c. 14'A. Other important information on the MC Pn�ci,iri ind
�SoCMR Regulanon� 1 11) RO :,nd
7
ConSIM01I)n Supervisor Li,,ensing (CS1.) can be found in . I [(I R5, fc,pe,onclv
When uhmannal %%,)rk is planned. pio%ide the mroin-taiwn helow
I,,tdI tll,ors area (Sq. F( i ini,cludr)g garage. tou,hed ha1CrW1lliAltl1S. dc,ck, ,-r pt,i,h,
Gw,, living at-ea tSy. 17r) Hahnable olom count
NUITIber 11 tllCII1ACCN Number of bvdro--in,
N'11111,cl of Nurihcrof hat: h,oh,
I he'litniz, c,em
I _-
sloe it,1, 'cd
I (a I P r"j C c I S If u.I r c 1:l,,,i,ig e I n,tv he It In s i I I u i c d for F, II ['I,,)c,t
CITY OF SALEM
r ,
s 1
14 . ,.. PL BLIC. PRc�PRERTY
--, ; DEPAR'I'�IENT
'.I 'r. I \� r.l ". .. 1l?I i r 1.\I V, \L\ \\ I . • .I'
Construction Debris Disposal .affidavit
(rewluired for all demolition and renovation work)
fit accordance with the sixth edition of the State Building Code, 780 CAIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ri is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal lacility as defined by MGL c
I 11, S 150A.
The/debris will be transported by:
cor
(name of hauler)
The debris will be disposed of in :
(name of facility)
l addre.r of facili(y) - ..._ . .Le
_ e f pc rout ,q\phc fit
ale
CITY OF SALEM
, PUBLIC PROPRERTY
DEPARTMENT
.I\Ill:R:I',':)MIiCI'I l
xl.,\tA I2^-WASHING IONSIALL 1' * Snu�:.\�.M.\�s.,aa ir.nvG197�
Thl.: 1)78-'45-9595 • F x. 978-741'�)S46
Workers' Compensation insurance AtYdavit: Builders/Contractors/Electricians/Plumbers
A ) )lic:int Information r
Please Print Le ibly
au ` l e
Nam ilia<iuevs[�rSanir:uiuNlndry uluuU: e7 � f
D 4(
Address: 12
36
City1 Scact:rY.ip:
Are too an tuyiloycr'! Check the appropriate bus:
"Type of project(required):
i 4. ❑ I run a general contractor and 1 6. ❑ New construction
I.❑ 1 ant a employer with
have hired the sub-contractorsILE 7. ❑ Remodeling
il n a sots(full rietor part-time).' listed on the attached sheet. t
i ;tin a ale proprietor or partner-
ship and have no employees- These sub-contractors have 8. ❑ Demolition
working for me in any capacity. \vorkzrs' comp. Insurance. 9. ❑ Building addition
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required]
workers' comp. insurance officers have exercised their
� rcquircd.] I I. Plumbing repairs or additions -
3.❑ 1 ant a homeowner doing all work right of exemption per MGL ❑ b "'P
myself. [No workers' c[anp. C. 152, §1(4),and we have no 12.❑ Ruuf repairs
insurance required.) } c (ICo workers'
13.❑ Other
coomp.mp. ices.nsurancc required.]
•nu. phcuW tlwt cha:cks box rtl muse also rill uw the secrian hcluw showing(heir a-urkui cumpensolion pull y inturrtwrium
' I lumuuwnen h,'hu mhmit this atYdavil indicating they ure dung all work alai then hire outside umumcton must.uhmit anew al'rdavil indiu[Ing.uch.
.( t that check this box must allwho l an additional.sl ••I,ht wing the name of the subcontractors:cod their,vurkers'comp,policy informadun.
l ant ant employer that is providing workers'cumperrsanon u).curauce for trey eutpluyees. Below a the policy and/ob s e
information.
Imurancc Company Name:
Policy A or Self-ins. Li0. *: ------ Expiration Date:
C'ityStateiZip:
rub Site :\[Id[css: ---
Attach ,t cupy of the workers' compensation policy declaration page (showing; the policy number and expiration date).
Failure to secure coverage as required under Section 25 A of.>IGL c. 152 can lead to the imposition of criminal penalties of a
tiny up to 51.500.00 and/or une-year imprisonment,as ,yell as civil penalties in the furm of a STOP WORK ORDER and a fine
of till to S250.00 it day against the violator. lie advised that a copy of this siatcmont may be furwarded to the Office of
III\'Call�al U)Ili ul till' DIA or instu arce coverage verificauon.
l do hereby certify under the tins u d pen«lrrcc of r rry that Nm arfunnulron provided a ve rs rue and correct.
g V 6 g
Ph,wc +.
of/ie•iul use only. Do not write illthis area, to be completed by cily or tolvn li ficial.
City or Fown: -. Permit/License x"_ _ ..
Issuing .\W purity (circle one):
1. Board of ltzalrh 2. 13uildilty Department .3.City;fo,vn Clerk 4. L•'Iectric:d Inspector 5. Plumbing; inspector
6. 0ther _ ---
Cmutuzf Penotc -_ - _-._ Phone tt:
f
,.Information and Instructions
,Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an einpluree is defined as"_.every peson 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
„t the (oregotng engaged in a Joint enterprise- and Including the legal representatives of a deceased employer,or the
receiver or trustee of.in individual,paitnership, 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. NlGL chapter 152, §25CM states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of puhlic 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 nuniber(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 Depurtment of Industrial
.accidents for continnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retuned 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 arc required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self insure)companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pennit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pennidlicese applications in any given year,need only submit one affidavit indicating current
policy intormation (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 tine 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he r hfncc of Investigation) would line to thank you in advance fur your cooperation and should you have any questions,
please do not hesirate to give us a call.
The Department's 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
R;vised i-]G-U5 Fax # 617-727-7749
www.mass.gov/dia