35 NORTHEND AVE - BUILDING INSPECTION a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 780 CMR, T"edition
' Revised Junnurn•
Building Permit Application To Construct, Repair, Renovate Or Demolish a I. zoaY
/0ne-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/Inspector of Btrildi4p Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
7i IVet,:y J.4az
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 11) Frontage(tt)
1.5 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?
Public❑ Private❑ Check if es0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owners of Record: r
N e int) Address for Service:
Si ore Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': v4� 13, %•�// ,•f •t — 8 , ? �.
SECTION 4: ESTIMA`•ED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 2C'X.7 I. Building Permit Fee:S Indicate how fee is determined:
?. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S � ( 3—4. Mechanical (IIVAC) S List: P_
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S Z60 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5A Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of C'SI.• I Iulder List CSL Type fsee below)
HDResidential
Description
:Address
,ricteJ u to 33.000 Cu.Ft. .
cted IR2 Famil Uwellin
Signature OnI
ential Rootin Coverin
I'clephone ential Window and SiJin
ntial Solid Fuel Bumin A liance Installation
Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Company Name or 111C Registrant Name Registration Number
Address
Expiration Dote
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 Issuance 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
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.
SiartaturcofOwner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
(, 'JDa n,Q I O-"t+"t' 4 v'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.
pi. ? aC ;"ek ..
Print Name
Signature of Owner or A horized Agent Date
(Sianed under the pains and penalties of '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 IHIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I l0.R6 and I WAS, 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.) 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 SALEM
yr , PUBLIC PROPRERTY
DEPARTMENT
\I `,t�tlf � '� \�',\iI II]t.:i IN 1'41:1-T • SAII III. \'L
Construction Debris Disposal Allidavit
(required lirr all demolition and renovation work)
In accordance wvith the sixth edition of the State Building Code, 7S0 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it - is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal lacility as defined by MGL c
1 11. S 150A.
The debris will be transported by:
S� ITS
(name of hauler)
The debris will be disposed of'inl:
(nain
--e
^v
taddress o(I'acility)
signature of permit applicant
/ /O
CITY OF SALEM
, i, j PUBLIC PROPRERTY
DEPARTMENT
:J]ll;:a(EY Ja1SGd tl.l.
12C WASHING ION S'I'aELT • SALIEM,MASSACI It Si41'ISO 197C
TL,i,978-745-9595 • 1'ax: 978.74C.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Au llicant Information Please Print Le ibly
ValnC lBusincss OrganizatinidIndividual): �^h I r� 1)
Address: ?J� � ��" et11�
CitylSlatc/%ip: X, (`i �� Yl1-41r o 140 Phone i.--:
:\re you an employer?Check the appropriate box: 'Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
em Flo ces full and/or art-time).` have hired the sub-contractors
l 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
To workers' cum insurance 5. ❑ We area corporation and its
l p• M E] Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL I I.❑ Plumbing repairs or additions
3.�1 am a homeowner doing all work g P P•
myself. [No workers' comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t umployccs. LNo workers' 13.❑ Other
comp. insurance required.]
-Wiry applicant that chucks box ill must:dsu till out the.secutin hclow showing their workers'cumpenwtiun policy information.
`t lumeuwnera who submit this affidavit indicating they are doing all,writ and then him outside cuntraeton must euhmit a new afrdavit indicamg;such.
-Gmiraeturs that check this box must artachcd an additional ahoel showing the name of tho subcontractors and their workers'comp.policy information.
1 am mt employer ilrat is pruviditig nvorkers'conipettsatiun irisuratnce fur trty employees. Befow is the policy and job site
information.
Insurance Company Vane: --.__. _-. . ...-. -
11olicv is or Self-ins. Lic. *: —---- ._ .____---_-_ Expiration Date:
Job Site Andress: City/State/Zip: ,I
.ILttach a copy of life workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of�IGL c. 152 can lead to life imposition of criminal penalties of a
fine up to S1,500A0 and/or one-year imprisonment, as well as civil penaltits 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
invcstigatiuns ul'tha DIA for insurance coverage verification.
/do hereby cc ua cr he n'ns a, p aLirs of perjury that the information provided above 's tore and correct.
`) j ,
I h u r
Qfjiciul use only. Do not tvrhe iu this area,to be cumpleted by city or town aJjicial.
City or Town:
Issuing Aulhorify(circle one):
1. Board of licallb 2. Building Department 3.City/rosin Clerk 4. Electrical Inspector 5. Plumbing; Inspector
6.Other --- —
Coulact Person: _ Phone N:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursu:mt to this stutute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral it 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,Pat mership, 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, b1GL 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
l'I::ase be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pertnit/licemse 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 ffi adavit 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. it dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
The Olf tcc 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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax #617-727-7749
www.mass.gov/dia
CITY OF S.XLEM
PUBLIC PROPERTY
DEPARTIMENT
K1fOlkirLY
MAVO< 130 wA9uN[.-ro"STMW•&M2^MAnA04.'sorts 01970
if19"9-7IS-9S" • FAx 978.740.9*4
HOMEOWNER LICENSE EXE.MMON
Please Ptrist
Date
Job Location 3J /Uv r ' " n 'AQ e �u�E[N. VW E�
Home Owner Address
Home Owner Telephone o ,i `-I — +a
Present Mailing Address •-je-
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
him who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official, on a form acceptable to the Building
Official. that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedur 1d r quire a ts.
HOMEOWNERS SIGNAT[. tk
APPROVAL OF BUILDING INSPECTOR
See other side for state code
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