30 MOFFATT RD - BUILDING INSPECTION file Commonwealth of Massachusetts
Board ol'Building Regulations and Slandards CITY
Massachusetts Stale Building Code. 780 C'MR. 7'edition OF SALEM
19 Revised JarnarrP
Building Permit Application To Construct. Repair. Renovate Or Demolish a ), :01AV
One-of Two-Fumily Dwelling
(Y� This Section For Official Use Only
Building Permit umber: Date Applied: /G GCS
Signature:
Buildin CommissioneN Inspector of Buildings fate
�SSEC/T�ION 1: SITE INFORMATION
1 3/)Property / �% 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning lnformation: 1.4 Property Dimensions:
Zoning District Proposed Use Ld Amn(sq 11) Frontage(11)
1.5 Building Setbacks(11)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.2 Sewage Disposal System:
Public❑ Private❑ Zone' _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow gr'pfRLE:ClAk .30 /v/ Or�A � 8-0
Nome(Pain/t)(( Address for Service: L
SAZLn
Signaum Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(cheek ag that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) IV I Alterations) ❑ Addition ❑
Demolition ❑ I Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
eYvd
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omclal Use Only
Labor and Materials
I. Building S Q 0 I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
J. Plumbing S 2. Other Fees: S _
4. Mechanical (ffVAC) 33
S List: �d
J. Mechanical (Fire S
Suppression) Total All Fen:S
Check No. Check Amount: Cash Amount:
6. Total Project Co ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7 92 J )-- 0�
CS (To-9� I.iccnsc Number Hspintion bate
N: pl'C51.• luldet / us1CSL f)pe(se'e below)
l' ✓I�./ Gu-t�1+ f Ikscri ion
Address U UnrestricteJ to 33.000 Cu.Ft.
R Restricted IR2 FamilyDweltin
Sigrulure M M (Hal
RC Residential Routin C'overin
I'cicpft) a WS Reiidential Window and Siding
p•A /'3� L���- SF Residential Solid Fuel Burning Appliance Installation
o (( b aJ D Residential Demolition
5.2 Registered Home lmprovemest Contractor(HIC) 43-0 /o5'
l IIC Cumpan N or 111C Registrartl Name Rcgistralion Number
/✓rcirl arm fs ln /Jx96 c 3��2Q /X!2
Address S.p 5 4 Es irstion Date
Signature to 44 _ rc ephune
SECT ON 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a ISL f 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 Affidavit Attached? Yes ..........O No...........O
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.
Si umofowmr Date
TI SECON 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1. as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are we and accurate,to the best of my knowledge and
behalf.
Print Name
Signature o(Owner or Authorized Agent Date
(Sisitted under the pains and penalties or perjury)
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 gd have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 IO.R6 and 110.RS,respectively.
2. W7�' P"
ntial work is planned,provide the information below:
Total f (Sq. Ft.) (including garage,finished basement/attics.decks or porch)
Gross (Sq.Ft.) Habitable room count
Numbeaces Number of bedroomsNumbeoms Number of half/baths
Type oystem Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Syuare Footage"may he substituted for"Total Project Cost"
MANH'S HOME IMPROVEMENTS
MANH NUYNPI
26 SPENCER ST LYNN MA 01905
781-632-0577
LICEN#CS 99237-FULLY INSURED
HOME IMPROVEMENTS CONTRACT
JILL LECLARE
30 MOFFATRD
SALEM MA 01.970
WORK TO BE PERFOMED AND MATERIALS TO BE USED
Replace old deck and install new deck floor trex composite decking [ 8'by 8' 1 and 4
steps
Total material and labor cost$4200
SIGNATURE
Hoommowner Signature; Contractor's Signature;
Date..0.S1,2 /& Date..0 (/ .lf./.a1/.
, 1
, �
f
Zv �r
.�,
CITY OF SALEM
=� PUBLIC PRoPRERTY
r = . .4 :.
DEPART'.MENT
Construction Debris Disposal Affidavit
(required lbr all demolition and rcnovatiun work)
In accurdance ill, the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisiuns of:ti1GL c 40, S 54;
Building Permit tt is issued with the condition that the debris resulting from
this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c
11 J. S 150A.
The debris will be transported by:
I name of haulcr)
I he debris will be disposed of in
(narrle of facility)
(address of facility)
,IL;IIallll'C ut I)i fllllt ,1111)hlalll
date
y CITY OF SALEM
A,, __'„ ; ' PUBLIC PROPRERTY
`'` r DEPARTMENT
RI r.l•!)It ISCOIL.
MA)OR 1200 WASFaNGIONSTREET♦S, LEM,Msssnca it, rn G197.^
1ba.:978-745-9595 0 P:\x:978.740-9S46 -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A 3 )licant Information /\ Please Print Le ibly
Name (13ucincls/orr..anizatiorrrvindivvi,luual : ` 1
City,Scale,Zip: L /jl A-- 0C Phone ''.'
Are you an employer! Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 fi. ❑ ew construction
employees(full and/or part-time).' have hired the sub-contractors 7. Remodeling
2.❑ 1 ant a sole proprictoi or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have K. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
No workers'com insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required] officers have exercised their
right of exemption per MGL 1 I.❑ Plumbing repairs or additions
3.El I um a homeowner doing all work g P
myself LNo workers' comp. c. 152, §1(4),and we have no 12.0 Rotaf repairs
insurance required.] r ctttployces. LNo workers' 13.0 Other
comp. insurance required.]
-.4ny up l licaui that clucks box rtl must:llso till out nK wcoon Wow sJiownta Ihcir workws cumpcnsatiou pulicy iolinmvtion
r l lumcuwnen who submit this affidavit indicating they are doing all work and lien him outside cunrmctors must submit a new affidavit indie ling such:
-C,,nlmdurs that check this box muss attaehsd on additional shs-el showing the name of the sub.conttactors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for sty employers. Below is the policy and job.site
Insurance Company Vm lA ne: � (�d1p� � -_l `=-._�� �C / �
Pulicv 4 or Self-ins. Lic.r: Ld - '-�..0 . ._.._— Expiruiion Date:�'
Job Site Address: �M (9/C FA 1/ 4n - City;Stateizip:
:%ttach it copy of the workers'cwnpensation policy declaration pale (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ul':vlGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment, as Weil as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a Jay against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
III\'iatlgarU.ltli of the DIA for insurance covcra,c vciiticalion.
Ida herehy certify under the pains and pen hies ofperjury that the infuriation provided above is truea/nd�Jcorrect.
Sienau nurc: Date' d / /
Ofjlciul use only. Do not'tvrite in this area, to be completed by city or ratan official.
C'ityorTown: _ Permit/Licenseq__---_ __
Issuing Authority(circle one):
L Board of Health 2. Building Department 3. Cityffowu Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other --- _
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree is defined as"...every person in the service of another under any connect 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 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.rounds 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, NlGL 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 rill 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 confimtation 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 till 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 pennit/lieerse 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 filled out each
year. Where a home owner or citizoi 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 Off ice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call
The Dep:rnnent'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
Rcviscd >-2G-OS Fax #617-727-7749
www.mass.gov/dia
/ 66ard of Building
_ ti.Re;�ul:rtions and Standards.
,ConStructibnr Superviscir. License
License: Cs 9M7
Restricted to 00
MANH' HUYNH
-28 SPENC.ER 3T 1 _4
LYNN, MA
Expiration: 4PSW12
r
( nuninsi ner+ '' Tr#: 99237
`?� GT'C'e•"�wmvnso'ru�ealo� o�✓C(oe��,�
Offlceof Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
i - Regis
traUon1p0405
Expl�tlo t Tr# 292830
i TYpe ItMjyi .;.o
MANH TRUONG'
MANH HUYNH �i°i - N Nlv
26 SPENCER STRET� f
LYNN, MA 01905
' '' ----------
Undersecretary