4-4 1-2 NAPLES RD - BUILDING INSPECTION 1 a� The Commolnve:d(h of Massachusetts
Board of Building Regulations and Standards CI"1'1'OF
1 p'yp MaSSnchtl5C`US State Building Code, 780 CNIR SALEhI
C / �I li • Revised.Ilar 2011
a,,..
Building Permit Application To Construct, Repair, Renovate Or Demo ' a
One-or Two-Famill Dn ellin,q
This Section For Official Use Only
Building Permit Number: to Applied: j
Building Onfcial(Print N;pne) Signature pale
SECTION I: SITE INFORMATION
I.I Praper�Address: 1.2 Assessors Nlap & Parcel Numbers
I.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Usc Lot Area(sy It) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Reyuircd Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone.
Check if 'es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
150me �SALE.M,MA Ul9�a
Nanie(Print) Uty,Slutc,Z.IP n
y NAPc�S 2d� SAc�rJJrr/.y
No.and Street Telephone Email Address
SECTION 3: DESCRIPTI N OF PROPOSED WORK"(check all that apply)
New Construction❑ Existing Building T1Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': r p` L/CAE oGJ�hf�.t.
Mee � Z LZ} c L r E Ji
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item JEnCost'sals) Official Use Only
y
I. Building I. Building Pemtit Fee: 5 Indicate how fee is determined:
2. Electrical ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier e
?. Plumbing ?. Other Fees: S
4. Mechanical 111\:\ List:__sleeit (Fire Su i ireuiun) Total All Fees: S
Cheek No. Check Amount: _ _ C':sh Amount:
(,. Total Project Co ❑Paid in Full ❑Outstanding Bahmce Due: -
r ,
SECTION 5: CONSTRUCTION SERVICES
5A 'onsiruction Supervisor License(CSL)
-__4.Ln! License Number f_cpaliol Dale
p/
LisI CS1.1)pa(see below)&
+�� 'E -------- ------ 'I)pe Description
No. and Street
np [IU nrcstrieleJ I Iluildin,s ti to 35,0110 nl. tl.l
Y R Restricted IM Famil D%tellin,
C itcrfoan.S te.ZIP M 7,1—.11111ry
RC Roofink C(nerin
. - W:S Window and Siding
![ SF Solid Fuel Burning Appliances
I Insulation
'I'cic hone ('.mail address D Demolition
5. Registered Home Improvement Contractor(HIC) Id
1,4AJ )-f ( may gy iY-TC�s HIC'Registration Number lis vuti n Uutc
IIiCrS pK) Name or'HIC(.f�AL/✓LfiRcS r �ame
No.andAtreet AW 14 A Email address
City/Town. State,ZIP Telephone
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 Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owners Na ne(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
containe in this application is true and accurate to the best of my knowledge and understanding.
Print Oancrb or Atitlnrizc Agent's Name(Ficctronic Signature) aW
NOTES:
i. .1n Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(H IC) Program),will Trot 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
wwq naps Information on the Construction Supervisor License can be found at 1;o\ 11p,
2. When substantial work is planned, provide the information below;
Total fluor area(sq. ft.) (including garage, finished basement'attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
\unlberoffireplaces- __._ Numberofbcdrooms
Number of bathrooms Number of half bade
f)pe of heating s)stem - -- _ - __- - -- _ Number of decks, porches
1's pe ol'cooling *stun - _. .._ . 17 ncloseJ —Open
t, "Total Project Square Footage-may be Stlbsllttlled for ,rTotal Project Cost"
CITY OF S'U.E.`I AxSSACHUSET B
• BLILDCIG DEP1IM(E\T
t 120 WASHNGTON STRErLT, Y°FLOOR
TEL (978) 745-959S
FAx(978) 740-9846
KI1C3FAf Y DRLSCOLL
.MAYOR IHow�s Si.PrEats
Dimcrot OF P sue PROPERTY/HCILDLNG COS12MISSIONER
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 1 11.S
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
Ns 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:
ON,ere 0 W4406
(name of hauler)
The debris will be disposed of in
(name of facility)
�ls�oy m 4
(address of facility)
signature of p m pplicant
,-n r
X/
ate
-icbllylrt•IG
RECEIVED
INSPECTIONAL SERVICES
7011 JUL -I A 11: 3 b
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.�11C.■:Ir)XI-A\nt
11C WANtfl.\G HI.�$ivtk)' •S,tU N,M.\wat.ut st I Iv u177C
1'1..1: )747ii'Iin3 s Fox Y7s4tC•'ta4e
Workers' Cumpensation Insurunce :UQduvit: Builders/Contractors/Electriclans/Plumbers
fi I )llcant Inrtmnation
_ Plc4s tint Le 'bl
V:tlnt Ilhnuwva t7raanvaoio VlnJivuluull:_ Nr{9 t/J f l/ /il jll,�r, 1�19-V
Address:. �� /t . [w�/4/�l1/cl( S`T e/
City,State,Zip- /1lA Q Phone it: . C7�- 3/ —// �
\re u000 in vugiloyer?Chuck the appr°prlute box:
II IJC t ;tin a cmpluyve with 4. ❑ 1 ;un a general cuutractor and 1 I ype off project(nqu(rrd):
mnploycus(full in4Yur part-time).a huvu hired the sub•mmtractors to. ❑new Construction
-'•❑ I .tut a solo prnprictor or partner• listed on the attached sheet ❑Rtnnodeling
ship and have no empluycctt These subcontractors have d. 0 Demolition
working fin me in any capacity. workers'comp, insurance.
I No workers'comp. insurance 3. ❑ We ars a unparalian and its 9. ❑ DuiWing addition
3.❑ nyuirCd.J )tylccrs have ewrciscyl their I o.Q Electrical repairs or additions
1 ant a homeowner doing all work right oretemption per hI IL 11.0 Plumbing repairs or additions
inyselL (No\vorkcn'comp, C. 152,¢I(4).and we hnve no 12.[�Ruufnpuin
insurance required.] r onplupwit. (No worked'
comp, insurancu rcyuind.J I7.Q Other
•.\'y.,pphca,A it'd ehcke tong ill mug'a1w till uw the\loaders follow awwinx likhr.wwtui cunipessg'iun Iwlicy uirurmuiiwa
'I Worw.wnrn wttw 41.1mck ills this affidmum iff Indtcatine tlwy.ue Juiny ell wurt any ihen hire 4wtaide eunrfstete mwt.uhnir a nwY aln4evit indi.aa:ne volt.
f,.ntrwn,n ihg'eMct thin toss mug anahwl�w aaaioiuu,il\hwtt vluwinx iMf nairW 4d iM no� outraaracnxs and thew.voters'comp.l"Iny mrurmg'lm
or non on roeployrr that le provld/nX lvarkar'ruonpenml/on inlwrvnurlora Lrwmnrefor ray rloplaayrrr. Bela le is the pulley endlab.cilw
Insuraucu Company Vane: /� �J(ff-(��}L /Hfs•
Pnhcy a or Suir•ins. Lic.n:— LAJ61-33S•33350 (-G
E><piruuon Date: Q /1
lob Sole Address: 7'N/�Q(� /c
city,JtataZip:��/
.�ttacA a Cupy or the workers'eumpensatlon pulley drelarutlon page(showing the policy numbur and aspiration date).
Paduro w sauro wveruge a4 required undocr 3ccliun 251%ul'SIGL c. 132 c44 lead to the imposition oferiminal penalties ora
tine up oil it 500M and/urune•ycar hnpros.nuncnr,av wcll4-1 civil pcnalucs in thu f'onn ofa STOP WORK ORDER and a fine
of tip to) S250.00 at Jay.iguinat file violutar. lie advi.4cd shut a copy urihis..fulcmuni may be lurwarded to the 011ice ul'
Inviallgallulb ul the DIA IOr nt.ur:mcc cnvcragc\crilicalant.
/Ja/q rvby t:rri/y f older Me paint ur perrwhiev to/perjury that the iu/aroneNon pravided bure is true flood cornice
; tier• /���� /;
Data
r=M
r)!/Iriu/fur uro/y. Da rtnt Icr/rr lot INY area, to he ramp/arrd by airy w totrn a//lriuL
( ,. or fn\rn; Pcnnit/Lh:vmwy
I\vuiny .\whurily (circle one);
iI. IL.arJ �Ir Ilealtlt 1. IhoLiioC 11cp;irnneul I. t:it)r'funn Clerk 4. C•'Icclric.tl hispcclor 5. Plumbing Invpceror
G. t)ther
l'�,iu.4el 1't nuu: . I
Information and Instructions
son in the service of another un,ler any cuntr of hire,.
�Lusachu;etts lJenenl Laws chater i2 p I rcywrcs all enyrloyen to provi de workers' compensatun ti>r theiret of employees.
I'unu:uit totius aatuea,an rmp10 ed is dclined as"...every p'ar.
,.press or implied, oral Jr written." or an two or more
allun
An ewpluyer Is dctincd as"an individual,Patti inc, thing he legal
represent ti tes O Iebal eanry, Y
m em la «s. However the
,t the (JregJliig engaged m LL iWnl enterprise,and iiltladlltg the ICgaI representatives
Jf] deceased inlplJyetl ur the
acmver or trustee ul'.ul individual,piumenhip,asaoolatoo par or other legal a resy.ides
employing ' P Y
owner of a dwelling house having not more sthan Illans to do maintenance.
ents unhuu��neurhepuir work ancsu h dwelling house
.Iwclltng house Jf another who employ Pe
or Jn the.,rounds Jr building appurtenant thereto shall not because of such employment be deemed to be An employer."
\IGL chapter 132. §35C(6) also states thug"every staff Of loeai licensing agaaey shall withhold the Issuance or
r
gumption"with ghelnsurance coverage required:'
renews)of a license ur p+rnslt to operate•busing,or to construct building,in the eommoeweulth or any
applicant who has not produced accaptabl+evidence of
\dditionrlly, �IGL chapter l 52, 323C171 wares"Neither the commonwcaldt our any of iq political subdivisions scar
anger into anyIGLccontract for the pertormance of public work until acceptable vidence ofcumPliurrca with the insurance
requirements of this captor have been presented to the contracting authority.
Applicants s that pp to ur situation and,if
Please rill out the workers' compensation apfldavit c nspantdlYhoM checking
)a ong with their certificau(s)of
necessary,supply sub-contractor(s)name(s),address( )' P with
insurance. Limited Liability Companies(LLCw Or orLiimited Liability sagioe insurance.((f ao)LLC oroLLP does have
employees ar than ills
neanbars or purtnan, Age not required to carry be submitted to the Deptuamant of Industrial
employees,a policy is required Be advised that this affidavit may
he re.Neciran ed to die confirmation ry or tow Ifth uppl colon for the peon Ito be ce coverage. Aeoral'icensanrs being trcquened,inot the lhPaRmam Of
t ndustriai Aecidents. ShoulJ you have any questions regarding the low ur if you era required to obtain a workers'
ensation policy. Please call the Department at the number listed below. Self-insure
cuinp d companies should enter their
self-insurance license number on the a n riutc ling.
city or Town Orneteu Ivit
plicaru
plena Lin 3
r sure
it at the you to till nutainethc event th+Otri a mplete And printed otl[ovestigrtiony. The his to cunrtment trct`yuu regarding the provided U space at iapplicant.
I'I:use be sure to rill in the permitllieatse numb''ons in anich y
been ee s�eedonlycsubmitunur. t+�itt davit nd indicating current
Y t) Y
that,nmt submit multiple Pennio'licettse applications provided to the
piilicy inform4ti,m(iftha necez
ufllduviet hu has been offic ally stamd tinder"Job Site ped or markadiby�tileuc y oreiowe nay tbu D in teary ur
Out each
town)." \copy
yes on fild for
rr1 ant as proof hag a Where a coins own+rlor ciid tizen isdavit iobta obtaining a license or peermit not related to y busiinessavit tor comust mercial 1 venture
t i.e.. to burn leaves ete.)said person is NOT required to complete this affidavit.
dug licence or permit uesnous,
investigations
r hat)trice Jf would like to thank you in advance :m
for your cooperation and should you have Y q
please du nut hesitate to give us a call.
the U.p:utincnt's address, telephone and fax number:
The Commonwealth of Massachusetts
DepaMcIlt of industrial Accidents .
0Mce of lovesdgadons
600 Washington Street
Boston, MA 02111
'f ei. q 617-727.4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.man.gov/die