4-6 MOUNT VERNON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
+ hoard of Building Regulations and Standards CITY
t m O ReviseF SALENI
Massachusetts State Building Code, 780 CMR, 7 edition
t d Junowv
y
`. Building Permit Application To Construct, Repair, Renovate Or Demolish a l• =o2v
1! One-or Tnw-Family Dwelling
This Section For Applied:
Use Only
Building Permit Nu er. Date Applied: 2 ,C O
Signature:
Buildit g Commissioned Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: .2 Assessors Map& Parcel Numbers
l.la Is this an accepted street?yes r/no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District proposed Lim- Lot Area(sq It) Frontage(11)
I.5 Building Setbacks(R)
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 Zone? Municipal❑ On site disposal system ❑
Public❑ Private[3 Zone:
if yes❑ P P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Name(Print) Address for Service:
Signature Telephone
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 Propose Wo/r�kA': , _
O �.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IiVAC) S List:_
5. Mechanical (Fire S
Suppression) Total All Fees: S
pr, Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 'n 2" Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES w
5.1 LicenseddConstructi supervisor(CSL)
Gt
(��� . Gj(/� Livens•Number f:\ imtiun(Ualc
Name of'C ' .-I folder 1f
List CSL Type(see below) �® n
Address 7 �t Description
/ �/yRCI`t'F � U Unrestricted u to 35,000 Cu.1:1.)
1
Restricted 1&2 Family Dwelling
Signature )� � N1 I Masonry Only
RC Residential RootingCovering
l'ekphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
9 �OC.� 1) 1 Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Company Name or HIC Registrant Name Regislmliun Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(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 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
I, as Owner or Authorized Agent hereby declare
that the statements and information he foregoing application are true and accurate,to the best of my knowledge and
behalf. E A 2—a--
Print Name
Signature ot'Ownefoq(AuthQim gent Date
Si med under the ns and penalties of er'u
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(FIIC)Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. I J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, 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.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted fir"Total Project Cost"
CITY OF S.U.&Nl, .L-kSSACHCSETTS
• BUILDLNG DEPiRTMEZNT
120 WA,HNGTON STREET, 3"FLOOR
TEL (978) 74S-959S
RVc(978) 740-9846
KIMMUEY DRISCOLL
�1TAYOR T FLO.�[AS ST.P[ERRS
DIRECTOR OF PUBLIC PROPERTY/Bt:MDLNG COMMISSIONER
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 111.5
Debris, and the provisions of MGL a 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 defincd by MGL c
111, S 150A.
The debris will be transported by:
S
(name of haule
The debris will be disposed of in
(name of facility)
(address of facility)
signa re 4ermitl cant
/( TO
date
Jchnvlf J„:
11 - CITY OF SALEM
_.�., fr; ' PUBLIC PROPRERTY
!' moo DEPARTMENT
J%II X:I:Y:)X ISC ul I.
\1 m K I1C WASHING IU.V SiXELT 1 SAIFNI,M.U}.\<:11t if I is 0197..^
'I.1:1.:WS-7I3-9595 • FAX,9711.74V M46
Workers' Compensation Insurance Affidavit: Builders/co n tractors/EIectrici ans/Plumbers
%n )licant Information Please Print Legibly
V81TC (I)u:iut�stl0r�anbminNlndlv�duup:Address: I7 1
/?,4R-6 y
y
City,Stafc;%ip! l'�/9Gv�`l �6Q t'honcil:�lI���J t` yt9laG
Are you an employer'.' Check the appropriate box: 'Type of project(required):
4. ❑ I :tin a general contractor and 1
1.❑ I am a employer with 6. ❑ New construction
employces(full and/ur part-time).` have hired the sub-contractors 7. D'Retnodeling
2.❑ 1 till a sole pmprictcx or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have S. ❑ Demolition
working Ibr me in any capacity. tvorkers' comp. insurance. 9. ❑ Building addition
l No workers'comp. insurance 5. ❑ We are a enlporation and its 10.❑ Electrical repair or additions
requircd.) officers have exercised their
3. 1 ❑nl a homeowner doing all work right of exemption per MGL It.[] Plumbing repairs or additions
myself,LNo workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) I employces. LNo workers' 13.0 011ier
comp. insurance inquired.)
-Ally ap pheuut that checks box BI musl also IIII Wt the section Lvi,w diowinif itmlr wu(k,x* ,un,pcnuaiw)puIiey inliartt di,^
'I lumatwmn whu stanmil this affidavit indleaning Ihv-y are doing all work aild Ihcn Ain uulside cwnrxtors must suhmit a new affidavit indiW ing Stich.
-('omrwutts Ilml check this box must anxhcd an addiliunal Auvol ahuwiny lhu name of the sub-contractors and their m'udten'comp.policy information.
fain tin employer thus ix prurfdin,K rvorkrrs'contpcnsntian inruranee/br try unp/ogres. Belnry is the pu/icy and ji bafle
infUrntutiUK
. Insurance Company Name: .. _.. _..---._.----_--
Policy is or Self-ins. Lie.11: __.. ....__ Expiration Date:
lob Site Address: _ City;SlatdZip:
Altach It copy of Ilia workers'cumpensati in policy declaration page(showing the policy number and expiration date).
Pailurn to sucure coverage as required under Section 25A of IIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.5110.00 and/or one-year imprismmncnt, us well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 if Jay against the violator. lie advised that a copy of this statement may be lurwarded to the Otlice of
III\"istigjimns ul due DIA Ibr Insurance cOVCrage\el'IhettiUn.
/(lu herchy a erd under ds nr'tv and pet a/ties of perjrtry that the information provided above is true and correct.
7�
Si,:l;mlre / Dot•: P (/
Official use unly. Do not irrite fit this area. to he curaplerred by city or tasvn ojJiriaL
i
ity or Town: .._ - Permit/l-icensc 0._.
(circle one):
[[I.stuingAuilaurily
. ihtard of Ilealth 2. Iiuilding Department 3. Glvi Ibsen Clerk 4. L•'lectric:d Inspector 5- Plumbing; Inspector
. Other
Clrltact l'crsuu: _ - .. I'honc :Y:
Information and .Instructions
,\lassachuscus General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplgres is defined as "...every person in the service of another under any contract of hire,
eapress or implied, oral or written."
An employer is defined as"an individual, partnership,:association,corporation or other legal entity,or any two or more
,it the 6xegoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of .m individual, pa rnership,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 ground-c or building appurtenant thereto shall not because of such employment be deemed to be in employer."
SIGL chapter 152, p25C(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, bIGL chapter 152, 325C(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 confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he 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 fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pennitdicetuc applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and tinder"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 ter 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.c. it dug license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
I he r)i l iev 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 Uaparnnent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
itcviacd ?-h_ti-(15
www.mass.gov/dia