80 MOFFATT RD - BUILDING INSPECTION (5) Zk The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
VIV Massachusetts State Building Code, 780 CMR, 70,edition OF SALEM
Rewsed Jamatrs-
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 2141
One-or rwo-Family Dwelling
�— This Section For Official Use Only
Building Permit Number: J Dale Applied:
Signature:
Building ComnAssioncri Inspector of Buildings Date
SECTION 1: SITE INFORMATION
A TPro A re+ ,�
1 1.2 Assessors Map& Parcel Numbers
.11 a is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Am(sq 11) Frontage(it)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Requited Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Infortnotlon: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zom?
Public Private 0 Cheek if es0 Municipal O On site disposal system O
SECTION2: PROPERTY OWNERSHIP'
RI Owner'of Record: r,
Kcne.na"to n o rn n r n �O M i+fck+ R-A
Name(Prins) 1 Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing Building O Owner-Occupied Repairs(s) 0 1 Alteration(s) O Addition O
Demolition O Accessory Bldg.O 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work:
11
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCIaI Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
?. Electrical $ p Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (flVAC) S List:
S. Mechanical (Fire S
Su ression Total All Fees:S
Check No. Check Amo t: Cash Amount:
6. Total Project Cost: S r7 S'OO O0 ❑Paid in Full O Outstanding Balance Due:
z- �-o v�lr -
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 16 'Z IS Z 01 )
I.iccruc Number Expinliun Date
Name O'CSL- I IulJer I.161 CSL Type IsK below)
G .� YV1 Gf•��Qb y {' f 11 s.ri ion
AJJre U IInmoricted Qp 1u 1`1 000 Cu.Ft.
R Restricted 1A2 Family lywellin
'..-alunr M masonry Only
(7�� C1117'� 3 RC I Residential Rooling Covering
fdcpMme WS Residential Window anal Siding ,
SF Residential Solid Fuel Rt ning AoDliance Installation
D Residential Demolition
5.2 Registered Home lmproremeSt Contractor(HIC)
S �e
I IIC CO pany Nam or IIIC Registrant Name Regislrali Number
—
`y i 1 � 617011
,A s (ryT.;) c-I.fy—gt�Ct-� Expiration Date
. Siww Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.f 23 ON
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 7n: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: OWNER'OR AUTHORIZED AGENT DECLARATION
1, aLi? l Jkm kJ 1 6a,I<< r7 e1 ,as Owner o �best
ereby declare
that the statements and information on the foregoing application arc We and accurat , knowledge and
behalf.
ST a'K.S ril
Print
�las�2ol�
Signature of ner Ihorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will Zg have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of Is
Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Ftwtage"may be substituted for'Tu1al Project Co'I.
CITY OF SALEM
PUBLIC PROPRERTY
DEI'AllT'NIENT
1 {Vr
r. 1
J . 'u
I I I' 'I';I �I;.1j4j ♦ I \�.'i':L V:'/.iln
Construction Debris Disposal Affidavit
(n.'yuired li)r all demolition and renovation work)
In accordance \\ith the sixth edition of the Statc Building Code, 780 CNlR section I I f .5
Dcbris, and the provisions of AGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
I11. S 150A.
The debris will be transported by:
I name of hauler)
I he debris will be disposed of in
(mine ul facility)
a= 6� 'na
laddr s ullucJuv)
.Ip uuuc ul pcnnit .yrphcant
Mate
�I;tssachusctts - Depallincnt if Public Safch�
lit,
I B"ited'iif Building Rc ufationvaut6Stundardv i
- Construction Supervisor License
License: CS 50166
Restricted to: 00
at
STEPHEN W CHAISSON I
PO BOX 1062 i
MARBLE HEAD. MA 01945 S
Expiration: 2i'l W2011
(lnnmi..i„nrr Tr#: 11240
Ae
seam of tl IOg —91A. 11 t��1-fd%0
HOME IMPROVEMENT -
Registration_ 145292
Explra6ori: 1/6I2011 Tr1R 279157
lug
Type: DBA.
i "
CHAISSON CONk&REMODELING
STEPHEN CHAISSON ;. `
165 GREEN ST
MARBLEHEAD,MA01945'" Administrator
f
I
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.IUna N:1 1':)A lsCs-I.n.
\i.,vu,a I2�W,,sruvu;ao.N S(setn' • 5ALEM,MASSACI n sH I� 0197^Z
fi,i.:778-'45.9595 • p.,x: 978.74Q 78i6
Workers' Compensation insurance Affildavitt Builders/Contractors/Electricians/Plumbers
ko )licant Information n - Please Print Legibly
Vitlme lliu<hh s OrBaniratioNlndtvlduu4: r hn ` (0Q 1<C c24
Address:
City,State,zip: PA"6/')2jA wmisfl Phone il: Poo II q7 a - 599 Z
j :\re you an employcrY Check the approprio e b x: Type of project(required):
4. I :un a general contractor and 1 6. New construction
I.❑ I am a employer with ❑
unpioyccs(full and/or purt-6111 ).' have hired the sub-contractors 7. M Remodeling
listed on the attached sheet.
I ant a sole proprietor or partner- t
.ship and have no einployccs These subcontractors have 8. ❑ Demolition
workers' comp. Insurance. 9, ❑ Building addition
working for me in any capacity.
INo workers' comp. insurance 5. ❑ we are a corporation and its It).❑ Electrical repairs or additions
required.] right
have exercised their
right of cxcnn tion per NIGL 1 I.❑ Plumbing repairs or additions
3.❑ 1 ant a homeowner doing all work - S P P'
myself. LKo workers' comp• c. 152, j 1(4),and we have no 12.❑ Roof repairs
insurance required.] t employee.. [No workers' 13.0 Other
comp. insurance requircdJ
•,4ny:5gthcaut that chucks box el muss:dso fill uut the xclion b low showing their wvrkux'compens:aion puticy inliumatiun
' Ilomn,wrors who sohmil this affidavir indicating Ihcy are doing all work and then hire outside coeurmtors must suhmit a new alrdavit indi"mg stteh.
:( t vas Ihal check this box must allwhcd.m additional shoe)showing she umlu of the sub•contraeturs and their workers'comp ptdicy information,
1 run tin e)upluyer that is providing workers'c•onpensatioil insurance ja•my employees. Beloly is the policy unrl job site
iujurntution.
Insurance Company Name: ...
Policy A or Selr-ins. Lic.>:: .. . ._____ Expiration Date:
Job Site Address: city;State/Zip: '
\ttach it copy of the workers'compcnsatiun policy declaration page(showing the policy number and expiration date).
s•cure coverage as required under Section 25A ur:v(GL c. 152 can lead to the imposition of criminal penalties of a
Puiluro to secure b 9
well ll as civil penalties In the lurm of a STOP WORK ORDER and a fine
imprisonment, ax vl
( or one-year !k ,-
tine up h>51.500.)0 end/ Y
Of up art 5230.00 it day against ille violator. lie adviscd that a copy of this slatelncm may be Iorwarded to the Office of
Invcaugaunns ul the DL\ for insurance coverage verification.
l do hereby cer y s nJer the pains and penuldes of perjury that the itrfonwuNon provided above is true and correct.
St tot Datc' `0I2 $ hr) IQ
r .
I'hul:•ti: 7 1 CI I � '
OlJic•iul use only. Do nor Ivrite in this area, to be co tpleted by city or town oJJiciul-
City or Town:
Issuing,:\ulhority (circle one):
1. livard of Ile:llth 2. Buildio,, DcparUncot 3. Cityi rowu Clerk 4. Llectrical Inspector 5. Plumbing Inspector
6. Other -- -
(.ulttaCI 1'crsort: _--_ Phone Y:
Information and Instructions
,,\lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an errrphtree is defined as "...every penxon 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
or the foregoing engaged in ajoint enterprise,and including'the legal representatives of a deceased employer,or the
receiver or trustee of at 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, MGL chapter 152, s§'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 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-insurisd companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he 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 fill in the permit license ntanber which will be used as a reference number. In addition,an applicant
that must submit multiple pennitiliceasc 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 die 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 citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I tic Office Ice of Investt.anons would like to thank you in advance for your cooperation and should you have:my 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
OtHee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Itcvised 5-20-05
Fax #617-727-7749
www.mass.gov/dia