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3C NIMITZ WAY - BUILDING INSPECTION The Commonwealth of Massachusetts i Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR, 7" edition ' ' " fit NIt SE`i I I ' D W Building Permit Application To Construct. Repair, Renovate Or Petnolish a Re,oc/Ammi, One- or Tit if v-Futnv Dm elling ) \ This Section For Official Use Only \ Building Permit Number: Date Applied: WJ`� Signature: \ Building Commissioner/ inspector of Buildings Due SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Nlup & Parcel Numbers I.la Is 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 It) Frontage(it) 1.5 Building Setbacks(it) 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? Public❑ Private❑ Check if es❑ Municipal ❑ On site Disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner,' f Record: Name(Print) Address for Service: 373 ?on c7 ©b Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building ❑ Owner-Occupied ❑ I Repairs(s) Aiteration(s) ❑ Additwn ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': .P� � e o/d Fop x SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OMcial Use Only (Gabor and Materials) I. Building S Ow-vos 1. Building Permit Fee: $ Indicate how flee is determined: ❑Standard City/Town Application Fee ? Electrical S ❑Total Project Cost' (Item 6) x multiplier x 3. Plumbing $ 3. Other Fees: S 4. Mechanical (HVAC) $ List: — S. Mechanical (Fire S Total All Fees: S Su ression) Check No. Check Amount: Cash amount: 6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due: SECTION5: CONSTRUC2ilONIIERVICES 5.1 Licensed Construction Supervisor(CSL) The Chimney Guys License Nurnher F..apoauun Datc Nanoc ul'CSL I u1 e7 0% Peabody,MA 01.960 Liu CSL Type (scr hclow)' 978-977-99UU T Description >JJress U I Unrestricted (up to 15.000 Cu. Ft i R Restncted 1at2 Faind Dssellut Sign Alason Onl RC Residential Rtwtin Cosrnn telephone \V$ Residential \Vmdo,s and Sidin . SF Residential Sohd Fuel Burnie A i thami In.iallauun 0 D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Nine or HIC Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 5 2506)) 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 1 , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print,Name - Signature of Owner or Authorized Agent Date (Si tied under the putns and penalties of perjury) NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contracuor (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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5. respectisely. 2 When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics.decks or tx)rrhl Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of hathrooms Number of half7baihs "Type of heating system Number of decks/ porches Type of cowling system Enclosed Open j 3. 'Total Project Square Footage" may be substituted for"Total Project Cost" ' l CITY OF SALEM PUBLIC PROPRERTY m; DEPARTMENT i',AIM-KIL- DKI.SGt'I I. Nfsn'It 120 WASI HNG n IN S I1U,E I ♦ SAl FAI, M.\Sti V I It'Serr, 1970 I'm.: 978-7i5-9595 ♦ Fsx: 978-7J0-98i6 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers lnnlicant Information Please Print LeaiblY V;Iltle t Bust ncss,organ izatioNl rid,vidual): The Chimney Guys P.O.Box 4074 Address: Peabody N4A 01466 978-977-9900 City/State/Zip: Phone #: :\re you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction m to ees full and/or art-time).+ have hired the sub-contractors P Y ( P 7. ❑ Remodeling 2 I :un a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These Sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition No workers' cum insurance 5. ❑ We are a corporation and its [ P� 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, SS'1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. l ant 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. #: CJ 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Im cstigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si,,nmure: Date: Phonc #: Official use only. Do not write in this area, to be completed by city or town officiaL Citv or 'fown: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: r '• Information and Instructions \lassachusetts General Laws chapter I52 requires all employers to provide workers' compensation for their employees. I'ursuant tO this statute, an rtnplgree is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An entploYer is defined as "an individual, paruiership, association, corporation or other legal entity. or ally two or more of the foregoing engaged in ajoint 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,.nut becaute,u.fluch 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'io construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, NIGL 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-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-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 die 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 permidlicense 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 Office 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 Department's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www,mass.gov/dia