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BP APP 11-892 SIDING
The Commonwealth of Massachusetts l Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Me SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.la Is this an accepted street?yes v 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes[] SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: qw 9�ro iI , W?' , o,, g70 Name(Print) City,State,ZIP No.acid Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work 2: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical ❑Standard City/Town Application Fee s $ 06 ❑Tot Project Costa(Item 6)x multiplier //rs — 3. Plumbing $ 2. Other r Fees: $ S 4. Mechanical (HVAC) $ List: !) 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount Cash Amount: 6. Total Project Cost: S 7 tlao,ol 0Paid in Full ❑Outstanding Balance Due: t SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ego n License Number Expiration ate Name of CSL l er ,/� _Yw List CSL Type(see below) No.and Street (J� , d—�-,+•f Type Description /} U Unrestricted(Buildings u to 35.000 cu. R. V .wtiat. 12 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Mason ry RC Roofing Covering /�—w• -' '[ WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) J©Q/G7 0 �CP'h HIC Registration Number Expiration Dote HIC Company N ne or 1-IIC�Name 14 No. and Street Email address �u�.-.-t `� a� 47�•7 of-sa'd2 City/Town, State, ZIP 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. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 hereby attest under the pains and penalties of perjury 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 N:une(Electronic Signature) Date 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(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 www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.i+ov/dns �. 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" CITY OF S.UE'Nf, A-kSS.ka-IUSETTS OI;IIDL%IG DEPARTMENT 120 WmHLYGTON STREET, 3"FLOOR TFt (978) 745-959S FAX(978) 740-9&% KIJ®ERIEY DUSCOLL MAYOR THo.+w ST.PmRtts DIREcroz OF PLEvc PROPERTY/a DLYG CONNISSIONER 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 c 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 defined by MGL c l 11, S 150A. The debris will be transported by: Lk —T (name of haular) The debris will be disposed of in �(name of factlity�— (address of facility) _ signature of permit applica t dare i CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT . Nr:aft Y;lMl�llgl \It11w IS:WA1t11.%ti lu^)latL•T BY 1-m. 'p8.7I3ov393 Ptx. 77x•?!C•'IY1A 1Vurkers' Cumpensat(on Insurance Af idavit: Builders/Cuntracturx/Electriclane/Plumbers %milleant Inrurmrlion (� Plcaxe Print Le Ihly Vnlnd IlAteilessit)raanlntinwlnJlvwluulC CityiStatc.%ipr Muni:Bill: F7e - 7Y5- -ssS, 2 .\re you an.ulployerl Check the appropriale box: IVal of pntjeet(rwlulreJ): I.IJp i:un a employer with 4. 0 I :un a gcocrsl contractor and 1 employees(lull and/ur port-time).• have hired the xub•cumracturs r'• 0 New construction �•❑ I:un a sole propricmr or partner. listed on the attached sheet. *- 7• ❑Remodeling ship and have no empluyecs These sub-contractors have S. Demolition working firr me in any capacity. Workers'comp, insurance. INo workers'coin , insurance S. 2 0 fluilding additiun p 0 We are s emporstinn and its rcquircJ.) alYlcers have exercised their 10.0 Electrical repairs or additions 3.0 1:an a humcuwncr doing all work right orexemptian per T 11.0 Plumbing rupuirs or additions myself. (Ko workers'comp, c. 152,§1(3),and we have no 12.0 Ruul'repairs insurance required.)t employees. (Ko workers' comp, insurance raquirLd.1 13.0 Other— •my.pphrud lh4 ewcks boa ill muu:dau till in,the%cnun meow awwine,heir wwkwi cunrpunueiun paivy utpinmaian --_� 'I tum.nrwmn who rnbmil this affidavit imt"line thug are Joins all wurk and lhca hue wBids cunrncr n; . m'•f..ntractun that ahaxt this ball MUM anshpl an aJdittwtal..h.�t duiwina live iunN oIIM rllb rs and thew ohuuhurs'tromrt�p rlKY n mrlrmlaritntk.am p' /fdr onnon employer that Lr prvvi✓ing rvurkerr'ru/npenrarlon inrur"uica jar"BYsinp/uyers. Below is the pullsy oil✓/ub,1'%le iojueion,Insurance C•umpany Vm Gne: cl 1 V_. Policy 4 ur Sclr•ins. Lic.n: C 1/6.2.5-y r'//b- Espirauon Date. Job Site Address: -a- `Y) P'1." a n (.. cilyrslateizip: Attach rt copy of Ill*workers'cumpen.tatlon polity declaration page(showing the policy number and expiration data). Failure to wcure coverage as required under Sccliun?sA ut'.%IGL c. 152 can lead to the imposition of criminal penalties of a r9nc up(1),51.5n0.00 ind/ur une-year imprismuncnt,is Wc11 as civil pcnallics in the I•urrn of a STOP WORK ORDER and a fine Af up fit i2s(1.00 a Jay against the violator. Ile advi.+cd that a copy urthil smicmcnl may be lurwardcd to the 011ice uf III\'��II�Jllytis of the I)IA for iitsuro:ce :,vcragc tcrilicanun. /✓u/h•rrby a.•rlijy under the polar un✓prnu/Tier u/•per/pry that the injunnrNan prvvi✓ d above is true unJ eorrvca Dart. rhl,l:e n q7d�- -7ySa �SY2 -t U/jle'ial tme only. no nor o•rile in dilr urea, to be runrplete✓by city of town u//irimi i ('irr of 1'111rn: Permit/lAvnxc is, J hvuing.\ulhorily (circle onc): I. Ihiard of IA•alth 1. Ihlildin� Dcpanulcul .1. (:ilyi than Clerk J. Electrical Inspector i. Plumbing inspector i G. Orttvr l'nllacl 1'c nuu: _ 1'hune•Y: Information and Instructions ,.I:uiadm:eus licneral Laws chapter I i2 equircs all employers to provide wurkers' COmPensahon thr heir employees. I'trrsu:uu to this +iatute,an empluree is defined Is,*...every person in he service of another umlet any contract of hire. c�prcas or implied, Ural Or written." or other egal critity.Or ally two tines regoingclinengaged in i j as ,an oint ei rprue�nd ,assincluding the legal cepeste nalivcs of la deceased employer,ortheore ant of the eceiver or uustne ul'.ut indivtJual, pesmenhip,asaoctatioa of other legal entity,cmplaying employees. However he CuP owner of a Dwelling house having not more than ons ro do nr hree ntenan crits e.construction eorlrepair work uerein.or the o such dwelling house ,Iwclling house of anther who employs pe . or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." �IGL chapter 132, Q23C(6)also stases chat"every state or local licensing al;ency shag withhold the Issuance or loca renewal of a license or permit to operate a business or to construct bonding$In he Commonwealth coverage re for any uppliesnt "lie has not produced acceptable evidence of compliance wltb the Insurance coverage required." ",dddwnally. IvIGL chapter 151 425C(7)states"Neither the commonwealth not any of its political subdivisions shall enter into any contract for the perfomtance of public work until acceptable evidence ufcompliance with the insurance requirements of his chapter have been presented to he contracting authority." Applicants Please fill out the workers' cumpensrtian affidavit comsles)and phone numbers)along with their cerr�cuteLsing the boxes that apply to your situation of nand if necessary, supply sub-contractor(s)name($),addr Limit and p with insurance. Limited Liability Companies(LLCworken'tcompensatioed Liability e insurance.(If an)LLC oroLLP does haveer than the inetnbers or pullers, are not required to carry employees.a policy is required. Be advised that this•affidavit tray be subtnined to the Depurtmettt of Industrial he rC�umeJ to the city or town that th ce covefolge. Also be appl cation for the peon eorolicense is being requed date the sted,ed, not he Dopartment of shouldigavil. The affidavit Industrial I.ellim Aeotile cis Should you hove any quesuaas regarding the low or if you are required to obtain a workers compensation policy,Please call the Depuranent at the number listed below• Self-insured companies should enter their self-insurance license number on the 2pproPnara lino. Cary or Town Omelets partment has provided u spree at the bottom please he sure that the affidavit is complete and printed legibly. The De of the affidavit for you to till nut in the ovens the OIZice Of Investigations has to contact you regarding the applicant. 1'I:usu be sue to till in he permit/license numtber which will be used as a reference numM r, In addition,in is applicant that must submit multiple PC applications in any given year,need only submit one at)idnvit indicating current policy information u if necessary) and under"lab Site Address'the applicant should write ,all locations in (city or town)."A COPY of tilt uftiduvit that has been officially stamped or marked by cite city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits Or licenses. Anew affidavit must mmercial venture be tilled out each year. Where a hone owner or citizen is obtaining a license or permit not related to any business or Commercial (i,c. a dug license or permit to burn leaves Cte.)said person is NOT required to complete this affidavit. I hen t)I IIce of Investigations would h'ee to hunk you in advance for your"Operation and should you hued any questions, please do nut hesitate to give us a call. the Dcpartlnet's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 t,..ocd 5 'tt-tis www.mau.gov/dia