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17 MEADOW ST - NEW EMPLOYEE RESTROOM The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of k 1 ) Massachusetts State Building Code, 780 CMR, 7"edition mamas Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two-Family Duelling ( _ This Section For Official Use Only Building Permit mber: 4 s IDate Applied: Signature: _f'Aa(4W—igz- Building Commissi e✓Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 17 NLt E.f 3) d rw S rt I.la Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: I CO P't ID, be e, „Z ` Zoning District Proposed Use Lot Area(sq R) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 6 is 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 16� Private❑ Zone: _ Outside Flood Zone? p J posal system ❑ Check if yes❑ Munici al id On site dis SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: No(ZMAA1 RFtt_Ly 1 ^7 1YAEAJ).L j S7`- Name(P nt) Address for Service: ii 78 1 - 317 - �J.SS Yg,ature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction[IT—Existing Building FIOwner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) d Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': RR ,M E rVEtcl Er PLOXFIF Q ST' 6ej j SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building S 15 0 v 1. Building Permit Fee: S Indicate how fee is determined: 2. Electrical S a 5 �— ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 1 e> e� e, 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees: S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S 1 7 5—D ❑ Paid in Full ❑Outstanding Balance Due: T7t-317 � SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 6 d b6 DS� .? l- O �•��A.. - TQo License Number Expirati Date Ngme u(CSL- F911der. ` List CSL Type(see below) ► T Description Address n" 1^-' ' U Unrestricted(u to 35,000 Cu. Ft.) ��•-- --� R Restricted 1&2 Family Dwelling Signature M Masonry Only !F7,q- ,3)7—SoZ-SS RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) D 5 L © 6 . s4 ( 6 9 S (.Registrant Ma a Registration Number HIC Company Name or HIC Registrant ame ( 971 / 6 q Address _3)7_k-,?sT Expiration Date Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 of the building permit. Signed Affidavit Attached? Yes ........... No........... O SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. Si nature 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 of Owner or Authorized Agent Date (Signed under the pains and 2enalties of r u 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 not 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 780 CMR Regulations 110.R6 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) S3 o u U (including garage, finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Habitable room count 91 Number of fireplaces Number of bedrooms IT> Number of bathrooms I Number of half/baths 1 Type of heating system Number of decks/porches Type of cooling system r Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALEM O PUBLIC PROPRERTY DEPARTMENT '.(111111`a LnY URI]C'-I I �Lt n 1a 120 WASHING I ON S I REST •SALrs4,M.,ysc i a si l is 01970 fla.:978-143-9595 • FAX:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Leeibiv NaMe (Busiluss/Organi 7atioNlndivalua4: (A)a-,., Address: .3 � Cao�— CilyrStateizip: 'Da---� Phone ".- it re you an employer? Check the appropriate box: "Type of project(required): 4. I :un a ocneral contractor and! G. New construction 1.❑ 1 am a employer with ❑ ❑ n,ployces(full antL'ur part-time).` have hired the sub-contractors 2.U 1 am a sole proprietor or partner- listed on the attached sheet. t 7. YfRemodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition 'No workers'comp. insurance 5. ❑ We are a corporation and its I P• 10.❑ Electrical repairs or additions required.] oRicers have exercised their 3.❑ 1 ant a homeowner doing all work right of exemption per MGL 1 LE] Plumbing repairs or additions myself. [No workers' comp. c. 152,$t(4),and we have no 12.❑ Roof repairs insurance required.j t employees. LNo workers' 13.0 Other comp. insurance required.] -.Any::pplicaul that ch:ccks box d1 must also till Out the sectlau Wow showing{lheir workurs'eumperaouion policy infurnutiun. '1lorn"'. fn who suhmif this affidavit indicating lhcy are doing ull work and then him outside contractors must auhmil a new affidavit indicating such. �Commchns that check this box must attached.m additional.,heel showing the name of the subcontractors and their workers'comp.policy information. l ant on employer that is providing workers'compensation insurance for my employees. Below is the policy and job site fofur n Insurance anct:Company Name:— Policy a or Self-ins. Lie. *: ___._... .(GLJ 6 d__F Expiration Date: f Job Site Address:=� 4 Ytae-ox-e`c-✓ /d/t (city/slat jzip: Attach It copy of Cite workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of 11GL c. 152 can lead to the imposition of criminal penalties of a tine up to 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the 011lce of Investigatiuus ul Lite DIA Ibr insurance covcra�c verification. l do herchy certify uader the pains and pe,udlies ofperjury that the information provided above is true and correct. Sienalnrc: �^""Y� , t:� Date: -3 tea :S Official use only. Do not lvrite in this area,to be completed by city or town official City or Town: _---. _ Permit/License -- Issuing Authority(circle one): 1. Board of Ilcaith 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector G. Other Contact Person: __.._ - ._.__ Phonefl: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an einplc lvee 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 a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of art 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." `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." .additionally, bIGL 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 nunmber(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 contintiation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be resumed 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 till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple pennidlicettse 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 affidavit is on file for future permits or licenses. A new affidavit must be tilled 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 bur leaves etc.)said person is NOT required to complete this affidavit. I he Otticc 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 Offlce of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY TMENT DEPAR 'd I 2C \\.\,I 11Nt ON S ISH T 4 SAI I M, N1\1i\( f: 'i I 4 1 \N: 978 174,.984t, Construction Debi-is Disposal Affidavit (requited flor all demolition and I_C110Vati0J1 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 M is issued with the condition that the debris resultin- from this work shall he disposed of in a properly licensed waste disposal facility as defined by NIGL c I t 1, S 150A. The debris will be transported by: _Wia gler) wanic I lie debris will be disposed of in Ele _ _ (tame of facility) (address of facility) siplatuipor1wrillit applicant