10 MAY ST - BUILDING INSPECTION (� V The C'onunonwealth of Massachuscus
Board of Building Regulations and Standards CI
UUUU���� �l•';, /9 Massachusetts State Building Code, 780 C•MR SALL.
Revive" or_'ill/
Building Permit Application TO Construct, Repair, Renovate Or •ntolis a
One-or Two-Family D ellin•4r
This Section For 011icial Use Only
�Buiillding Permit Number: _ Date Applied:
Y"l C ` 1 ITTZ-24L�. I&A' Z3
Building 011icial(Print Narre)l Si atu Ualc
SECTION I:SITE INF RIATION
I.1 Property Address, 1.2 Assessors Slap& Parcel Numbers
S_�
I.la Is this an acre ted street?yes no Map Number I'arccl Numtwr
I.J Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Uw Lot Area(sq fl) Fmnlage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:iM.G.1.c.40,§54) 1.7 Flood Zone Information: La Sewage Disposal System:
Public❑ Private O Z011C; - Outside Flood Zone?
'Cheek if vs❑ Municipal❑ On site disposal s)slcm ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record;
-To 07V �—
N;mte l Pnm) City.State,ZIP
/D */ �yg s�v _G7L7
Nu.mtd Strcet Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ ther ❑ Spccity:
Brief Description of Proposed Work': e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
item Estimated Costs:
Labor:md Materials) Official Use Only
1. Building S I. Building Permit Fee: S Indicate how fee is determined:
Electrical S ❑Standard Ciry/Town Application Fee
❑Total Project Cush(Item 6)x multiplier — _x
1. PlumbingS 1, Other fees: S
q. Mechanical nil\'.%(') S List: <
S, Mcchanical Wire .----- —._- -_— .__.---
Su,+ression) Total .\II Fees:
Check No. _ _('heck AmounC (',tsh \mount: _
e. Total Project Cost: i 6 O(j. O Paid in Full ❑Outstanding Bal;ulcc Due:
a ��
i
SEC FION 5: CONSTRUCTION SERVICES
5.1 Cm ruction Superviso License(C'SL) 6 Z yQ-7 G�
(G(-�� License Nunihcr fvpir; toil ale
Naneol'C'S1 1Ioalar ...._. _._.._.__.. _..____
�— I is(CSl. I)pe lscc hcluw)___._—..__.__—
3 -- - -- ---- 1) Ucxripliun
�;i„and Streel pe�------- ---- D
O, �.... I inrcictcd 1 I IhFaMi �s a to ly,000 eu. Il.l
N Rntrieted IS? fumil Dllellin
l'ilcil'aan..til;ita.LlP II Masonry
KC Nowlin C•ovcrin
._--. WS Window and.Siding
SF Solid Fuel ilurning Appliances
I Insulation
Talc Ihmo Fniail address D I Demolition
5.2 Reg��iisstLteredHome IIntl),a%eyme(it Contractor(HIC) /l / !/ � f �RE51)a1v
MYTS� OJI 't� IIIC It4isnutionn Nuail+ar Lsp
I11C'Company N;u n o IIIC !a ist •m N e
(�McctS�, Mo
No. and Stp;et a - I.
address
Ci /To5wn.State,ZIP t roe hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.4 2SC(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 of the building permit.
Signed ARidavitAttached? Y ... .. . No........... 0
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.
IMnt Owner's Nmne(Electronic Signature) D'
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering city name below, I hereby attest under the pains and penalties of perjury that all of the infornintiun
contained in this application is true and accurate to the best niy knowledge and understanding.
Ric-#&2U t e / Iry ,
Print Oancrt or:\uthorircd Aganl's Name(Electronic.•ignulurcl Matc
NOTES:
I. An Owner svho obtains a building permit to do his.her own work,or in owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor iHiC) Program).will no have access to the arbitration
program or guaranty' fund under M.G.L.c. 142A.Other important information on the HIC Program can be liwnd at
lilt%% Ka" L;n A I Information on the Construction Supervisor License can be found at tt+1+l con.+
2. \Phan substantial work is planned, provide the infurmation below:
fatal tloor area(sq. ft ) _ I including garage, finished basement attics,decks or porch I
Gross living area isy. Il.l ___. . _- Habitable room count
Numbarol'lircplaecs..._ ..._ Numherufhcdruums
vum her olbathroomi _ Numbcroflialfhaths
I\pe of heating sy stem Number of d"ks, porches
pe Ot cooling ilileni Lncloscd 011e❑
i
1. "fol;d Pnojcct Square Footage-maN he suh,litutcd t1u"I•otal Project Cost- -
CITY OFSALEM, Aw.wfi(:SETi'S
9LLLDLNG DEP.1R LLNT
110 WAiHLYGTON STRE=0 Jw FLOO7a
TLEL (979) 745.9595
K AMERLEY ORMOLL FAX(978) 740.9&W
MAYOR TNO..%W ST.pt8tttts
DInECrOlt OF Pt.SLIC P1t0PHItTY/8L anLNG CO\OOSSIONEI<
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 1
Debris, and the provisions of MOL c 40, S 34;
11Building permit q is issued with the condition that the debris resulting from
, S I SOA.work shall be disposed
1 1 of in a properly licensed waste disposal facility as defined by MOL c
The debris will be transported by:
(Hama of hauler) O
The debris will be disposed of in
(name Of
- f,facilityf
(�ddma of
u ynamre of permit jpplicant
da+a
'inn vd!.a
CITY vF S:u.ENls NLvL1SSACHUSETTS
BCRDLNG DEPARTdIENT
120 WASHLNGTON STREET, 3`o FLOOR
``�°•'�" TEL (978) 745-9595
FALX(978) 7.30-9846
KIMBERLEY DRISCOLL
INLAYOR T HOSL►S ST.PIEQ[t8
DIRECTOR OF PCBLIC PROPEflTY/aun.DSNG CO',WISSIONER
Workers'Compensation insurance Affidavit: Builders/Contractorn/Electricians/Plumbers
Amilleant Information Please Print Lepibly
Name lnusilwsi Ordan/ir� �n'IdndiwiJ�rr,�); _ �(0M
V
Address: �� L (JA /� �� �(
City/State/Zip: Phone At: J 7y' 7//-3 Y 7 ir
Are nu an employer?Check appropriate box. 'type of project(required):
I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑Now construction
employees(full and/or part-tune).* have hired the subcontractors
2.❑ lain a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling
ship and have no employees These sub-contractors have ll. O Demolition
working for me in any capacity, workers'comp. insurance. 9, ❑ Building addition
(No workers comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 ran a homeowner doing all work right of exemption per MGL i I.❑ Plumbing repairs or addition
myself.(No workers'Gump. C. 152,§1(4),and we have no 12.C] Roof repairs
insurance required) t employees. (No workers' I3.❑Other
comp,insurance required.)
•Aoy applicam dot ehceka box rI must also fill Out Ihv semen rm
below showing their worken'compenudun pulicy infoation.
'I Luneownen who mbmit this aRidavit indicting Ihry an doing all work and than him outride eonlraetOn must submit a new amdavit indicting each
:t'11Ml rylora that check this box must anachod un addiliural shmi showing the non,of the sub+eglrachrn and Ihell wurken'comp,policy infomumien.
fain un employer that is praviiBng worker'compeasadan Insurance for my ernp/ayees Below is du policy and fob Siff
Insurance
C / S
Company Name: _---'.-policy 4 or Srif-ins./ Mr"`7 L'ic. o%. � fq 7Zo 7Expiration Date: 4o�
Job Site Address: / 6 J'i" City/State/Zip: � ��M
,Attach a copy of the workers' c mpensatlon policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of STOP WORK ORDER and a line
of up to S_M.00 a day against the violator. Ile advised that a copy of this slatnmcnt may be forwarded to the Office of
Invcstigalimis of tlic MA fur insurance coverage verification.
I do hereby rify root JeR7 mud penalties of periury dr t the infonnallon prow'd J above i.v r e cord correct.
�IIft IllllrC' /•� �J I):11J: �� t Zi
Phone i• �7 g`_7V/-� _ /�-f
[C."
ial use Drily, no)cot write in Ibis area,to be completed by city or taws ojj7cia2
I
nrl'uwot Yurmitfl.lccnse,Y
ng Aut hurily (circle onc): i
ord ul Ilcahh ?. Iluiid(nq Ilcpartntcut 3.City(Town Clerk J. Electrical Inspector 5. Plumbing Inspector
her
act Pc rsuot _ . ._ Phone 4:
1
Information and Instructions
massachuseits General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to Lhis 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."
MU chapter 152, §25C(6)also states that"every state or local Ilcensing 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 sub-contractors)name(s), address(es)and phone iiumber(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
he 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. Sclf•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 die permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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 aMdavit 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 riot related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of[nvestlgatioas
600 Washington Street.
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/die