52 MOFFATT RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
14 Board of Building Regulations and Standards CI I Y OF
j �Q SALEM
d9 Massachusetts State Building Code, 780 CMR Revised.Uur 011
.,
Building Permit Application To Construct, Repair. Renovate Or Demolish a
S� Otte-or Two-Famili,Dvelling
This Section For O ial Use Onl
Building Permit Number: to Applied:
Building Offimal(Print Name) Signatu Date
SECTION I:SITE INFO ON
1.1ert dre�ssT� / 1.2 A essors Map& Parcel Numbers
1.1 a Is this an accepted
id street?yes 1✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
%oning District Proposed Use Lot Area(sq It) Frontage 00
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p p
SECTION2: PROPERTY OWNERSHIP' C,y 2.J.a Q7n of Recoydx� u �c Sr4lP K /�rl 14 9ff 7 61
V Fb�2.le _ C_ t
N:mie(Print) City.State,ZIP
dd(Alt -7r 7V11--s313 c
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building S O OJ, 1. Building Permit Fee: S Indicate how fee is determined:
❑ Standard City/Town Application Fee
' Electrical S O ❑Total Project Cost'(Item 6)x multiplier x
3. 1'lumhing S SQJ, 2. Other Fees: S
3. Mechanical (IIVAC) S List: _
5. :\lechanical (Fire S 'total All Fees:S
Su r rressionl
Check No. _Check Amount: -----Cash
6. Total Project Cost: S 12 ow 0 Paid in Full 0 Outstanding Balance Due:
I
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
6:61- J �O/`Z CAS ____ License Nmuher licpiruliou D;ue
N:unc ol'('SI. Ifolder
J List C'SL'I)pe(sec below)
No. and Street '(ype Description
Si4/IPn /?" U/ 5 Sw U Unrestricted(Buildill s uo to 35,000 Co. It.)
Oilyfl"mm.State.ZIP R Restricted 1&2 Pmnil-Dtrcllin
M Mason
RC Roolin Cocerin
W'S Window and Sidin
1 SF Solid Fuel Burning Appliances
_ 1 luStdation
l elc hone limail;tddress D Demolition
5.2 Registered�7Home
/Improvement Contractor(HIC)
3 S//o
I
IIC' Re I IIC Registration Number Expiration Dale IIC Company N:une or gistrant Name
t r✓s b�o-3 c JnStR 9 YA uJ.C Nu utd SJrcey �7 / _
tizi, .SAb /;w 61�1 J 91YY-33s -,3pd 1 Email address
Ci /Town, State,ZIP Telc Lune
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........... ❑
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 Cff�J$
to agt my behalf,in al tatters relative to work authorized by this building permit application.
✓/ - S-S- a
Pnn caner s Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and curate to the best of my knowledge and understanding.
Print Ottner s or Authorized Agents Name(Electronic Signature) Dale
NO'PES:
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. 1 42A.Other important information on the HIC Program can be found at
y)t�t,m;i..,.�.ry ne❑Information on the Construction Supervisor License can be found at o\}Ak.n CIS:.yot Jp;
2. When substantial work is planned, provide the information below:
Total floor area(sq. R.) _(including garage, finished basement'attics,decks or porch t
Gross living area(sq. It.) _ Habitable room count
Number of fireplaces-__________ Number of bedrooms
Number of bathrooms .
_.----------------- Number ofhalf"Laths
1'y pe of heating System ------------------
- -__---- _--_-_ -- Number of decks porches
i)pc Of CUOling system Open -------...----
` ---.- .. -_._.---------- Inclosed _ Open
3. ••Total Pr>,ject Square Footage-may be Substituted titr"folal Project Cost'.
�+ CITY OF SALEM
PUBLIC P, . RUPRERTY
DEPARTMENT
.MV.a:l -
\I11,W
IdC WA}axNlilU.\ilvlL•T• Sd UtN.M.111.11.I It W 11\�177,^,
fld: 778.715.9i'd e 1 tx Y79.7/C•'lyla
Workers' Curnpensadon Insurunce .%t'B(lovit: Builders/Contractors/Electrieluns/Plumbers
ti 1 Illcrnt In urination
,,,, JJ PI •4x Print Le 'hl
V:IIT1C tlluwuc�sit)rganvatinNledrvuluull:_ C/'YIDS (-�y�,.�q- S
�tldress: S S PnNiSC� Sf
Ciiy,St:irc,%ip��h,.�y /Y>` O(�l ,i Phone 0:_':?7P — 33;5- 3rr�0i
.\re)nu an vwployor7 Check the appropriate box:
I I.0 I am a employer with 4. )Pit of Project(rayulred):
❑ I:un a general coutraelor and t
cnlpluycus(iu11 miyur part-lime).• have hired the sub-cuntraciurs ii' ❑Now construction
I am a tole prnpriurce or partner- listed on the anachcd.Avet r 7. dlcmaleling
ship and have no cinpluycay These sub-contractors have
working Air me in any capacily. workers'comp, insurance. 111' 0 Demolition
I NO wutiturs'sump, insurance 5. 0 We are a cniporetion and its 9' ❑ Dailding addition
3.0 ruyuirud.) otllcers have exerciscd their 10•0 Electrical repairs or additions
1 enl a hnmcuwnar doing all work sigh(of exemptilm per NICL 11.0 Plumbing repairs or additinrae
myselt iNo workers'comp, c. 152,¢1(4),and we hnv.no
insuranco rcyuired.J y employees.iNo workers' 12.0 Rwl'repoirs
com(t inurancu reyuind.J 13.0 uglier
ring.ggMcua ihW chacb bar el mum alw Jill uui iho"Clean behave amwia nnir wwIt 6 cum eua use
'1Jumx,w,wn whu udrmit this anrdeuir inAleatin t y e M ""I ,nriumwiwa,
•r,WIMIGW%Ihm ehesh this box mum attahud.W addeliuri l.'.�twwl Jtuwiity the uaine erlhis tus.emraeats as J their wuhan, alnJrvit in,ltualny.,nh.
/rim an employer that is pruvidlnx ivorkers'comprilraNen
lajurinuNna Gararnnca jot lilycrap/oyret Be/mv it/h /lay un%1 s
fte
In.vuranceCornpany Vnlne:
Policy All ur Sclf-ins. Lic.M: - —
•- Expiration Data:
Job Site Addre.s:
C'ny1slate/zip:
\ouch n copy Office workers' aired nsatlnn pulley deelaratlun page(showing the policy number and expiration date).
PJilure to wcuro cuvemga as required under Secliun 25A OI'NGL c. 152 can lead to the imposition or'eriminal penalties Ora
t7110 IT fin S 15tl0.00 and/ur Otte-year imprisoruncnt, ds well as civil(Knallics in the I'onn of STOP WORK ORDER and a fine
Drop ai i250.00 ll Jay ,yaiast the Violator. I Ie advised that a copy of(his slmancnt may be IurwardOJ to the UI'lice ur
InYcaliyauuna Ot16u 1)I,1 for ni+ur:o'ce covcnyu Icrilicanon.
/,la lierrby 1 erlij
uute y wider the point,arid pvnuh/er u/prr/ury that t/re iurmrNanjs provided above is true and correct.
l
//
- ' ` [).eta � J
I)//lcial rise an/y. no nor write in dill urea, to be rumpleted by wily ur town n//iviial
i
City ur Tnirn; _—_
iPunnet/Lltrnsr e _
reeving.\uthurily(casein anal;
II. ❑card ar Ilcalua 1. rhnidily Ikpartnunt 1. l:ir):'fotul Clerk 4. Clectrieal Inlpcctur 5. plumbing lueyceror
6. 0111vr
l'nil.lcl 11cnau: -_
Phonv J:
i
information and Instructions
v "son in the service of anu"her under any cumnct of hire.
dtu
�Lusasetts Ucneral Laws chapter I i2 rcy"urcs all unplo)crs to provide workers compensation "nett cusp he.
I'ursuaitt to tills."acute,an emplane is defined as"...e cry Ps'
c,prebs or implied, oral or written." or an two or more
�n e,npluper is defined as"an individual.Punnership.assoeianaa,corporation or other legal eascrified Y
a the I:,reywng engaged m a(win enterprise, and inc""Loa or othng the er legal enuty,employing em l cWtscilts"ves of 3 ployees.l However the
,ece"ver or Irubtee ul'.ut iudiv"Jusl, psrmcrbhtP,aisoc
g{house having{no more than three apartrnents and who resides therein or the occupant of
that
owner of a dwellin
,lwclhng house of another who a ploys pet) one 1 shall maintenance of sucA employment be Je med tk on ube in employer."
or on the grounds or building app shall withhold the Issuance or
�IGL chapter 152. 425C(6) also states thug"every state or local Usonslag ageaey
renews,of a license or poring"to Operate a business or to construct bu lith the ltd,ngs In she ce coverage
re for any
"pplicant wl"o has not Produced acceptable
c 7t sbleevidence of er the om nonw•ollnot lds nor,any of its political gsubdivisrons shall
AJJitionully, �IGL chapter l S_, G-
anger into any contract toe the performance ug'publiu work until accaptable evidence ui contpliu"ce with the insurance
requirements of this chapter have been presented to the contracting{authorit
Applicants `theboxes P to our situation and,if
please gill oug the workers' compensation affidavit goo)Com and phonnecnumber(s)slang,with their,ertiticute(s)of
necessary.supply subscontraclor(s)111wric(s),•address( )' Pemployees insurance. Limited Liability Companies(LLCw or orkers'te m pe ed trwuion insurance.(If an)LLC ornLLP does have
er than the
members or partners,are iced t ise�at his stAdavit"nay be submitted to the Depurtrnent of Industrial
employees.a policy is requited. Al171 aysure to sign and date the ultldavil. The affidavit should
\ccidents for confirmation of insurance coverage. ested to obtain u workers'
he rct""mcJ to the city or town that the application far the permit he law license
r if you are regested. nog the awor cts* o
Industral t�ccidents. Should you have any quasticas regarding
compensation policy,plea call the Deportment of
the number listed below. Salt-insured companies should enter their
self-insurance license number an the Appropriate lino.
City or Town Officials
Plense be sure that the affidavit is complete"I'd printed lof Inve The Department nt provided u sp u:a h mho bottom
Of the affidavit for You to fill out in he event the 011ice of Investigations has to contact you regarding the applicant.
lycwe be sure a till in the permlt/IICCIlaO nWllbef WhICh will be Used:1�a eferClmCC nutllbar. In addition,in is applicant
II"nt must submit multiple pennitllgcease applications in any given year,need only submit one affidavit indicating current
If the affidavit that has been afficiully stamped or marked by the city or town may be provided to the
Policy inl'wmation(if accessary)and under"Job Site Address"the aPPlicant should write"all lucmiuns in (city or
town)."A copyto,,permits at
ya rout each
tv�vherc a home ugwnergar ciid tizen is obta ring a ldavit is on rile for icense or permit not related to any business moavit tor comlium mercial venture
iced to complete this
I i.e. :t dog license or permit to burn leaves etc.)said person is NOT requ affidavit.
uebt"ons.
I he ,)(lice of Invcitigatiuns would llAc to thank you in advance for your cooperation and should ld yyouuhaw any 4
please du not hesitate to give us a call.
fhc U:panment's address, elcphune and Th Commonwealth of Massachusetts
Department of Industrial Accidents
OtRee of Invadgadons
600 Washington Street
Boston, MA 02111
'fen. # 617-727.4900 ext 406 or 1.877-MASSAFE
Fax M 617.727-7749
www.mus.gov/dig
CITY OF S.uy.,Nf, %L-kss k iUSETTS
Bl IL ILNG DEPARTMENT
120 W."jiL%IGTON STREET, 3i0 FLOOR
TM (978) 745-959S
FAX(978) 740-9846
KINMERLEY DRLSCDLL
MAYOR THoaua StPIEIuts
DIRECTOR OP PL13LiC PROPERTY/HCIIALNG COSMISSIONER
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 i 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit All 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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
S 4Le�^, 7 n Y S�
(name of facility)
(address of facility)
signature of permit applicant
date
I.bn vd.Lw .