36 NORTHEY ST - BUILDING INSPECTION r _ fhe Conunonwralth (it Massachusetts —
yI Bouid ul Building ReLlulatruns and Standards t )u
Massachusetts State Building Code. 780 ChiR. 7"' edition III Nli 11 I l 1
a13ui ldi ng Permit Application To ('onstruct. Renosale (h Demolish a Rci nc,/l uu n
Oire- of Tit o-F )av Dtr /hc ).l' -'!"s--
phis Se on For O(-cial se Only
7
Building Permit Nu her: ._ a Ap ieJ: --_—_—_--_ I
Signature: / �• D 9_1 - . --__.-.--
Budding Conuun.wneu Inspector of uJdmgs Date
SECTI N 1: .' : INFORINIA'HON
1.1 Properly Address: 1.2 Assessors .Nlap & Parcel Numbers
_
L
I.i Is Ihi",m -tccr ed street ' Yes Ot ."•lap Number t'.accl NumhvrZoning lnfornlationc IA Property Dimensions:
ng District Prupised Ilse I_ol Area(sq it) Frontage tit)Building Setbacks(ft)
Front Yard Side Yards Rear Yard
I Required Provided Required Provided Required Prat iJcd
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone7 ,tiiunici al ❑ On site Jis wsal ,ysirm ❑
Public Private ❑ Check if yes❑ p I
SECTION 2: PROPERTY OWNERSHIP'
2.107 2 o eco9
U2Zr� JG /ca: , Sr (. yt ✓1
Name AddressoSv iPrino iQ {j
- 1
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check II that apply)
New Construction ❑ 1 Existing Building ❑ Owner-Occupied ❑ 1 Repans(s) Alterations) ❑ A.1Jitiun ❑
Demolit Gel ion
Accessory Bldg. ❑ Number of Units Other ❑ Specily:
Brr�1+ Description of Proposed Work'': e- 2 -ppyy.._ (Yt use _
i _Yr!1901t
SECTION J: ESTIN TED CONSTRUCTION COSTS
T(L
item abor and Materials)Estimated Costs: U OV(J Official Use Only
_
1. Building .`$ I. Building Permit Fee: $ Indicate how tee b Jaternuncrl:
❑ Standard Cily/Ibwn Application Fee
'_. Electrical S ❑Total Project Cusl' (Item 6) x multiplier x
3. Plumbing S 2. Other Fees: S
J. Mechanical MVAC) S List: _
5. Mechanical IFne
Su m resslon) Total :111 Feed: 5
( heck No. ('heck Amount ('.ish to n ti n
b. Total Project Cult ❑ Paid in Full ❑ Outstanding Bol:mce Due _--- -.-_---.
r
SECTION 5: CONSTRUCTION SERVICES
_ - -t
5.1 Licensed Construction Supervisor tCSI.1
6 Al
aoc�
'p— Lis ens un�her Il,hl .ui�❑ :
I \ame ,lI Csl. Holder l\C. last l Sl_ pe i,ze hrlu"I . U
_ Lrnco��L4ve M� C —
oe>.�......
\,1Jir>• t l'nrcslnc0.•J nl,to t;.INIU lu hl i �
R ReNlrlc led IR_' f'.I llllb D,—llnnl
ili_ st�u�n7• iO,C �.,'/�� 11 \l:umn Unh __ __.-�
_ 6(_[— p���� Rl Iir,iJrnudl Rulinc ll, rrin
frlephunr - \\S R:aJt wial NuiJ,", .'nd "I'll III-,
— SF Re,iJrin i,ll SIiJ I •.irl ISuinin,_ \ „hew: Iml.il l.il ism i
D Re,i Jew"ll Dellluli!ugl
5.2 Rey�istered Ilome hppLLtpro\ men[ Contractor(IIICI
L. '{ �'wAlTh�tbOYl — —__ -1—__ _ ._—
i IIC Comp:ury Nanm or IIIC Re eu rani Nam• Rc�sarauul �ubcr�__ -
Addr1 r S oLG---
Stgna le Telephone .�
rSECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (!FI.G.L_ c. 152. § 25C(6))
r Workers Compensation Insurance affidavit must be completed and submitted \vnh this applicafloo F:mlllre a, pl o\!de
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... ❑ No - - 0 _
SECTION 7a: OWNER AUTHORIZA'i'iON TO BE COMPLETED WHEN
1., ''� OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _
,lp� f. ___ _—_ as Owner'it the SUh)e-cI property hereby
x}' authorize Ll (� -_ ____--_ to act ull my behalf. ill .ill mat
;ciao ve to work authorized by th building pmit applis ication.
�Slunuwrc ul'Oancr _ Dute
SECTION 7b: OW'NEW OR AUTHORIZED AGENT DECLARATION
1. as Owner or Authorized lgent hereby declare
that the state nts and information on the foregoing application are true and accurate, to the best of my knowledge and l
� behalf.
t C 20 _.
Print None
S121latAlle of Owner ur Authuri zed Agent on,
ate
(Signed under Ilse pain,and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do hi,/her own work, or an owner who hires an unreLlaerrd contrrcn"r
(nut registered in the Hume Improvement Contractor (HIC) Program). will rat have access to the :ohnralinn
program or guaranty fund under M.G.L. c. 11_'A. Other important intorrnauon on the HIC Program and
Consuuclion Supervisor Licensing (CSL) can be ;irlmd in 7SO C'NIR Regulations I IO.R6 and I I0.R5. respecroely.
' When ,ulistantlal work is planned. pruv ice the Information below:
Total flours area ISy. Ft.) (including garage. finished basemen U:utics. decks or porchi
! Gross living area lSq. Ft.I Habitable room count
Number of fvrpluees Number lit bedroom, __
! Number of hal L'hxhs
Number of bathrooms — — --- ---
1\pe of heating Nv,tem __-- Number of I"k,i por,hcs ------__.
I ,pe of cooling ,\,Izm _ Enclosed --
z. `Turd Prnjzct Syuarc Footage" may be substituted tier 'Tnlal Proj"I C—I" ___�
[
c
CITY OF SALEM
/r PUBLIC PROPRERTY
DEPARTMENT
,t4lf:K:I'Y:)K IKC, 1 v�
\[XYUN l-��\v A`iHI\ti i J:;S'ia LLT 6 SAL I`..U,M.\,%.\CI iI it:'I'I\u1970
- 'f-.1: 978-745-9593 • FA x. 979-741^'1g46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
- ) )licant Information Please Print Leeiblv
V 81Ts: 113u<incsvQr;;anir:uinnrindtvuluall: // -
}�v esvn
Addre,s: 9. - tench Awe \
City,State,Zip: M � iQ1� MA06JlYS Phone it: Lk-0 95U - 36k-]
I Are sou an employer:'Check the appropriate box: 'Type of project(required):
1.El I tun a employer with A. ❑ I :un a general contractor and I 6. Q Ne construction
ploy ces(full anWor pan-time).• have hired the sub-contractors 7. emodeling
2 1 :un a sole proprietor or partner- listed on the attached sheet. : ��
ship and have no employees These sub-contractors have K. LlQ""nolifion
working for me in any capacity. worker' comp. insurance. 9. Q Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
1 rcquircd.] officers have exercised their .,
right of exemption per MGL I LQ plumbing repairs or additions
3.❑ 1 am a homeowner doing all work c 152, §1(4),and we have no 12.❑ Roof repairs
myself. [No workers' comp.
insurance required.l t cmployccu tic workers' 13.0 Other
comp. insurance n:quircJ.]
/\n0.1pphlinl that checks box ill n1uv:IISU IIII UUI IIn:ticIIull h,luw shuwing their workcls'cumpensarion pulicy hll lmuiwit,
' Ilomeuwrcn w'hu slbmil(his affidavit inuic:uing they are doing all work agog ncun hire outside cununetors mint euhmil a new a1 f:14avi1 indiuhng.rch.
-C' m 'tun that check this box must atlwhal an additional wheel showing the name of Ill,sub.ontracturs and their workers'comp.policy infurmatiun.
l tun till empfuyer that it providing workers'c•ooipensation insurance•for ury employers. Below fa tree polity and job.Nile
iufurnaiion.
I tnurance Company Name:
Policy is or Self-ins. Lie. *: ... ...._ Expiration Date:
Job Site Address: _.___ City,'Slate/Zip:
.\ttach it 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>IGL c. 152 can lead to the imposition of criminal penalties of a
tine op to S1.500.00 indlor one-year imprisonment• as well is civil penaltics in the form of a STOP WORK ORDER and a fine
Of up to S250.00 it day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
I❑\'i sllfall Otli oI the 01A for imur;uxe covcragc \ciilication.
l do hereby ccrtijv under the pains rued penullics of perjury that the iufonnation provided above is true and correct.
official u.se only. Do not nvite in this area, to be cuanplrted by city ur town ojjicia/.
Gly or town: --- .. Permit/License 4_ _ ..
issuing Authority (circle one): -
h. ISnarJ of Ilcahh ?. 13uildin:; Ueparunent .l. Cily.rlown Clerk 4. L•'lectrical Inspector 5. Plumbing lu+pector
6. Other _ -- -
Contact I'cnon; ..- - __. Phone it:
Information and Instructions
\lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
PUNU:mt to this statute,an etnploree is defined as "...every person in the service of another under any contract of hire,
evpress or implied, oral or w'r itten."
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
recetver 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
nr on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter M. §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, hIGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ot'public work until acceptable evidence of cunipliarrce 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) namc(s),address(es)and phone number(s) along with their certificate(s)of
instance. 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 rotumed 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used is a reference number. In addition,an applicant
brat MUSE submit multiple pennit'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 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.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he i)Dice of Investigations %could like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department',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 # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
., �tii:n.rr
III 'f'8-.'4;-1;4; Y: 'i'8 V4_ 98h,
Construction Debris Disposal ,affidavit
(rcrluired lur all demolition and renovation work)
In accordance ill, the sixth edition of the State Building Code, 780 C NrIR section 11 1.5
Debris, and the provisions of v1GL c 40, S 54:
Building Permit it is issued with the condition that the debris resulting front
di
this work shall be sposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of\in
(name of taalffy)
' laddrcss of l9cilifvl
lie
R
�ignutur� n pr fit applicant
/p p�
Jae ���
Board of 1°Building Reguiatio sand Construction Supervisor Supervisor License
License CS 98808
Expiration 61y2011 Trtl 98808
Reshlction g4i
JASON DICEY
22 LINCOLN AVENUE.
MARBLEHEAD,MA 01945 Commissioner
4e �am>naru�ie�rlr/ C�aaui�.�+tom
p� Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:. 159609
Expiration: 5/152010 Tr# 268264
Type: DBA
ELITE CONSTRUCTION.
JASON DIXEY
22 LINCOLN AVE. � \
MARBLEHEAD, MA 01945