46 MEMORIAL DR - BUILDING INSPECTION The Conummwctlth of MaSS:IChnSCUS
t Bu:ud ul Budding Regulations and SrmJ.lrJs >Il plc ll'.V.I'I 1
t MJSschLISCItS State Building Code. 780 UN 7"' edition
a t'til'.
\ Building Permit :Application To C011.000t. Repair. RuWXS Ile Or Drmolish a R,i n J honatrt ,
(htr- or Ti o-Family /hrclling 'uuS
This Section For Oflicial Use Only
Building Permit Num Date Applied: -
Signature: - �—G�'-G Q U ----- --- --
Jill l mp C'onunn io / Inopecnor of Buildings Date
SECTION 1: SITE INFORNIA HON
1.1 Property Address: /J 1.2 Assessors Map & Parcel Numbers
I.Ia Is this an accepted street;' ye> no Map Number P:ucel ,,Cm nhrr
1.3 'Zoning Information: 1.4 Property Dimensions:
Zonis¢ District Proposed Use Lot Area(sy ttl Fronmge 111)
1.5 Building Setbacks (ft)
j Front Yard Side Yards Rear Yard
Rcyutied Provided Rey cued Provided Rayuired Pr111ide11
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? - -
Public ❑ Private❑ Check if ves❑ ibh�mapal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
y/
Nam, �t� Address fix Service: --
Signautrc Telephone
SECTION 3: DESCRIPTION OF PROPOSED NVORK'(check all that apply)
New Construction ❑ E.risting Building ❑ Owner-Occupied ❑ Repuirs(s) Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ If Other ❑ Specify: —
Brief Description Of Proposed Work: — —
�/
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (1_ahor and Mawri;ds)
I. Building S Q IJ e/� I. Building Permit Fee: $ Indicate how' fee is dc,cr III Led:
❑ Standard City/Town Application Fee
?. Electrical $ ❑ 'Total Project Cost (hem 6) % multiplier c
i
1. Plumbing $ 2. Other Fees:
1. Mechanical (IiV:1C) 5 Lisr — ---
. Nlechanic:d (Fire 5 --
Sup cession) Total .all Fees: 5
p��,�/,� Check No. ('heck Aimumt: ("ash :\mount ---. _
b. Total Project Cost: S O /v ( 0 Paid m Full 0 OubumJ11112' B:d:mee Doc: — - ----
SECTION 5: CONSTRUCTION SERVICES
r5-.1 L.icensed Construetiun Supervisor (CSL)
Licenx ::\' mberD;ne
nc of CSL- Ilolder
L.ut CSI_ l'vpe isce below) _
VJdrees Tv le Descn roan
1, l-nrestocied(up to 3�.000 Cu. Ft.I -
R Rcanctad I o-_' F;mnlN Duelling
Si_n:uure Vt Masonn Onh•
RC Residenual Roollnc ( mcrun,
Trlcphonr \\'5 Ke,iJenual \Vindu�� .md Stdine
SF Re,idrnlial Suhd Fuel Ihrnine \ it i.w.'e In,t.illaw u
D Residcnual Demohu,m
5.2 I3.y 1 istered home Itnprovel it "'untractur (LIIC) �a yks Z
/�i9 /o�p- il.
IIic Conq,.uty.,V15-;111 , ann or fI1C Registrant Name �yJ Registration Number
d o // � ` 3 " O
Add i Ad 1 ,.� e-l4 � 9'2,f p Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (NI.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pnnide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit .Attached'? Yes .......... yy 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 matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner Authorized Aggent li rehy declare
that the statements and information on the foregoing application are true and accural , ) Ito es o my knowledge and
beh
Signature of Owner or Authorized Agent Date
(Siened under the pains and penalties c4 er-urv)
NOTES:
1. An Owner who obtains a building permit to do his/her own woi k. 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. 14F2A. Other important informaion on the HIC Program and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5, respectively.
When substantial work is planned, provide the information below:
Towl floors area (Sq. Ft.) (including garage, finished basement/attics, decks m porch)
Gross living area ISq. Ft.) 1-1abitable room count _
Number of fireplaces Number of bedrooms
Nun)ber of bathrooms dumber of hall/h:uh,
Type of heating system Number of deck,/ porches _ _-----
Tvpe of cooling system Fnclosed _Opcn
1. I otal Project Square Footage- may be �tlbstrtuied for ..total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
h1111n RI'lf'f DgiSCVI I.
120 WAS Ili SAI.I'A1, MX. SA,:I[I-Sl''I'IS:i19iJ
ll:].: 978.735-9595 ♦ FAX: 978-74G9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
kpolicant Information Please Print Legibly
Name (Bus ine>s lAgani za(ion,I lid iv iduaal): .C/�2�"tl/ mEr-✓ ` /( /i7+-i
Address: ��/✓
City/Stare/Zip: //�� &�1 /� 1zQ S t i2. r O/9a3 Phone #: ? 2d 7y-
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
fin to ees full and/or art-time).' have hired the sub-contractors
� P Y l P' 7. ❑ Remodeling
1 ant a sole proprietor or partner- listed on the attached sheet. I
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
[ P
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL l L❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] 1 employees. [No workers 13. Other Urfi ,:, r
comp. insurance required.]
Any applicant that checks box 41 must also lilt out the section below showing their workers'compensation policy information.
t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContracims that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
fain an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
inforurntion. /' /
Insurance Company Name: (-� /L/atit,`F Policy #or Self-ins. Lic. #: �� ye, '/f� 0 7 Expiration Date: es" -
Job Site Address-: �d ///P/���L/�?�& City/State/Zip:,
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 S 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 LIP io S250.00 a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI.A for insurance coverage verification.
IF do hereby certi of pail s and penalties of perjury Nr the information provided above is true and correct
iFn Date:
1ialure:
Phone -':
Official use only. Do not write in this area, to be completed by city or town official
Citv or Town: Permit/License #
Issuing Authority (circle fine):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
%Iassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is de tined as"...every person in the sen ice of another under any contract of hire,
express or implied, oral or written."
:\n 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."
SK7L 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, NIGL 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 till 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 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
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 burn 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 Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
RIA ) HKCli I.
N I'%I g 120 W.N.S1]IN(,I ON S CIULT # SA I FM, N;L\SSACA ii ti1 I i S 0
11:1 978-74 9595 # FAX:978-743-9846
Construction Debris Disposal Allidavit
(required I"or 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 resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(name of hauler)
'I he debris will be disposed of in
(name oil C ty
(address of facility)
4�''' //A /�
signature of permit applicant
5 lf
(late
acoRn_ CERTIFICATE OF LIABILITYINSURANCEIssUED ASAMATTP�ER�OFINFORMATiONL/07
WDUCEK ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
an Hurley Insurance Agency HOLDER.THI5 CERTIFK:ATE DOES NOT AMEND,EXTEND OR
hestnut Green,- Suite 24 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
even Federal street
#
anvers MA 01923-3620 ,-. AFFORDING COVERAGE
.hone,.978-777-9394 ram:978-777-3306 ININSURERApreferred Mutual L5024
SURER INSURER B' Granite State
Rileyp Brothers Construction sava+ERc
Bartholcm0w Riley DHA o D_
56 Conant Street ----
Danvers MA 01923 Re
.OVERAGES ABOVE FOP THE POLICYPEN100 INDICATED.NOTWITHSTANDING
THE POLICIES OF INSURANCE LISTED BELOW"AVE SEER
ISSWO TO THE MUNED NONTRACT OR OTKER � §PECTTO WHICII TICS CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT,THE SURANCCAFFORDEDBON OF THE POLICIES DESCIMOM H(SER IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDHIWIS OF SUCH
MAYCIES,AGREATEL NICE AFFORDED
POLICES.AGGREGATE LRAT59DNR MAY HAVE BEEN REDUCED BY PAD CIAILiS LOTS
TR
TYPE OF INSURANCE POLICY NUMBER OaTEIMBi� DATE R - HwI OCCURRENCE s300000
NSR ��
GENERAL LIABILITY S 100000
4 X c0NMERmGENERALLIABNRY CPP0140564252 10/16/06 10/16/07 ME ) t5000
CLAIMS MADE XX OCCUR PERsowusaoaf SLIURY F300000
. L;ENERALAGGIIEGATE S 600000
PaDmTcrs-caurGPAGG s 600000
CENL pLXfEGAIE LRBT APPLES PER'
X POLICY ¢OCR LUC
AUTONOBeELWBLTfY, (EC alxefMapM�EtWN § _
ANY AUTO
BODILY INJURY
§
ALL OWNED AUTOS lPN 9ersmm9
SCHEOIAED AUTOS
BODILY INJURY §
MNEDAtIT05 - (�=ckiw)
NDN'OWNEO AUTOS PROPERTY DAMAGE §
(Per Trc�
ALTO ONLY-FA A:CIOENT S
GARAGE LIABILITY ORER THAPI EAACC §
ANY AUTO AUTOONLY: AGO S
EACH OCCURRENCE $
IOICEssANNNELLA LIABILITY AGGREGATE S
OCCUR CAMS MADE S
S
DEIXICRBLE S
RErEW H S X IORY LINsiS ER
VWRKERS AIM AND 06/z0/07 O6/20/08 EL.EAtx ACCIDENT $100000
EMPLOYERS LIAfNIRY WC2407407
$ ANY FROPRISO PARTENexECITiTVE El DISEASE-EA EMPLOYEE $100000
OFFNZeRYEISILR E=inED? SEE A'1°PAL�f» IAORE E.L.DISEASE.POLICY LSNT $500000
�CIAL IaS EMNN
OTHER
OE ON OFOPERATOUSf LOCAIONsfVESGESf EXCI.USImSS ADO®BYg I SPECIAL PttDVImN§
CANCELLATION
CERTIFICATE HOLDER ,WOULD ANY OF THE ABOVE�W PamES BE CMICEUM 111307E THE ETwrtaLTWN
FORUM 6LT@TT .TFE l43UYSGN NR1.1310EAv@t7DMAL 10 DAYS riRTTEN
For information Purposes Only. No=To THE fBiRRCAMHODER NAMM TO TE LEFT,BUT FAILURE TO GO SO SMALL
Please contact agency for NLPOWROCEJ MINmURSI 'OFANYURm UPON'RLE INSURER ITSAGENTSOTL
individual certificate. "INEL
AtfnLua>m
Daniel J HTlrl ®ACORD CORPORATION im