14 MONROE RD - BUILDING INSPECTION 7-1 , s2-1-1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards SALEM SALEME
Massachusetts State Building Code,780 CMR
Revised'M.2U
01d _ i 12 P 4 9
Building Permit Application To Construct,Repair,Renovate Or Demolish a D J
N One-or Two-Family Dwelling
This Section For 61I1cW Use Daly
If) Building Permit Number Date lied;
Building Official(Print Name) tgnatur batete/
t SECTION 1:SITE INFORMATION '
L1 Property�//�Address: �� 1.2Assessors Map&Parcel Numbers
/—r
].la s this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use - Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front 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: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zoye?
Public Private❑ Check if yeol Municipal f�On site disposal system ❑
SECTION 2t PROPERTY OWWJNEERSBIP'
2.)rQ0.�r1ofRecs: /. �/lLt�bYl " �j 77�1�� _
rr ���('' G� t�tJ N 2 r
Name(Print) City,Stat ,ZIP
14 Monroe. q44-q0ql- 13ys Da�ct�Ufva �AInP� �'• ot�
No.and Street Telephone T Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check al"hat
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) - "IfAddition ❑
Demolition Irl Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: ir
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 8 I. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
r6.uTotal
r ession Project Cost: $ /a e,Qa Check No.
Check Amount: Cash Amount:
PE
❑Paid in Full 0 Outstanding Balance Due:
S E'K) O To 11-o 'L-o 1-1NX' Nor-,
v
.1.. . SECTIONS: CONSTRUCTION SERVICES ,
'SX Construction Supervisor License(CSL)
`44G re- Lr-175 L't License Number Expiration Date
, 'Name of CSL Holder
ZF��
�� List CSL Type(see below)
W`L./, iP� Dasealption,.-
No.and Street
tRm—
WSestricted uildin u to 35,000 w.ft.
Rtricted 1&2 Famil Dwe
City/Town,State,ZIP Mso
RCdondSdow and SidinSFd Fuel Burning Appliances
I lalion
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC
i y� T�i F/�✓/ HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
mac.,1 / i
No.and Street Z� 1/+��,/G Email a s
Ci /Town,State ZIP Telephone
SECTION 6..WOREERS3 COMPENSATION INSURANCE AF MIAVIT(M.G.L. c 152.§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 Tat OWNER AUTHORMATION TO BE COMPLETED,WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR$ ' pDVG PERMIT
I,as Owner of the subject property,hereby authorize/,1 C C /
to act on my behalf,in all ma re ative to work authorized by this building permit application.
at�-i&V",N,..e/ � MAGI 1 �I t.
Print Owner's Name(Electronic Signature) I NTl Date
SECTION 76:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(E nic Si Date a
NOTES:
1. 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 can be found at
jnvw.mass.gov/oca Information on the Construction Supervisor License can be found at wnvw.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor 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 bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
�\ iOffice of Consumer Affairs&Rusiness'Regulatien
HOME IMPROVEMENT CONTRACTOR
t Registration j84319 Type:
• 'Expiration-_ 2P301.7 Individual
1
MICHAEL F.�GRIFFI
- MICHAEL GRIFFIN -
180 LORING AVE
SALEM; MA 01970 --
Undersecretary y
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor -
License: CS-083459
cF:r I ti OF.
Michael F Griffin `` '-• �'f.
180Lorin¢Avenu6 IMF 5
Salem MA 01970 lam)
ao
Expiration
Commissioner
12/13/2016
QTY OF SALEA AWSA(HUSE M
BuzDD cDsPaa'ne?arr
IM WA9MWXWSMW J;WR OM
TiL(978 745-9595.
Fiuc�78 74498�6
BII�ERLEYDRISOL?LL
MAYC 7)KNMS7.PM
Construction Debris Disposa/Afdavit
(required for all demolition and,.renovation work)
In accordance with the shah edition of the State Building code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL 00,S 54; Building Permit B is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111,S 156A.
The debris will be transported by:
60221,z all, TtC4474
(name of hauler)
The debris will be disposed of in:
/,�G�2��� l� c4dl //1G.+.f /�c✓L. , JT/�os•�
(name of facility)
(address of facility)
Signat cant
06-0/—
Date
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114 2017
www.massgov/dia
NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians)Plumbers.
TO BE FILED WITH THE PERMTPING AUTHORITY.
A licant Information Please Print Leidbly
Name asiness/ —(B Orgatti2atiotr/fadividual):
Address:1SC� 1!��
City/State/Zip: S /f &YoPhone#: �
Are you an employer?Check the appropriate box:
E
of project(required):
1.❑I a employer with employees(full and/or part-time).•
2. 1..
am a sole proprietor or �Ej�coustruction
partnership and have no employees working Corte in lin any capacity.[No workers'comp. insurance required] g
3.❑1201 a homeowner doing all work myself.[No workers'comp.insurance required.]1 olition
4.❑I am a homeowner and will ix:hiring contractors to conduct all work on m fR
ding addition
y property. I willensure drat all contractors either have workers'compensation insurance or are sole trical repair&or addition&
proprietors with no employees. tbIng repairs or additions
5.❑1 nor a general mmtmcror and I have hired the subcontmctom listed on the attached sheet.
711ew subcont actors have employees and bare workers'comp.inamurmt repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy hdamstion.
t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such.
IContracmrs that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub=conraums have employees,they most provide their workers'comp.polity nurnber.
lam an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$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 up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify undecthe pains andpenaNp ofperjury that the information provided above is true and correct
Signature, ate:
Phone#:
FF
only. Do not write in this area,to be completed by city or town ofcial
n: Permit/License#
ority(circle one):
ealth 2.Building Department 3.City/I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector
on Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee 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 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."
MGL 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,§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 fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with then 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 appropriLte 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 fill 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 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.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02 1 14-201 7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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