25 OAKLAND ST - BUILDING INSPECTION 1 1
J The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Code, 780 C'MR. 7ib edition
1 � g Huvin•<l hunarry
Building Permit Application To Construct, Repair, Renovate Or Demolish a
1, _008
One- or Two-Family Dwelling
This Section For Otflci s Onl
!!I
ermit Number- Date Appli
ilding Commissioner/ I for ol'Buildings Date
SECTION 1:SITE INFORMATION
1.1 Propert�Add es�' ^ S Y 1.2 Assessors Map 3t Parcel Numbers
„/ Ma Number Panel Number
L la Is thisan accepted street'?yes no_ P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy Il) Frontage(t))
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if Xcs0
SECTION 2: PROPERTY OWNERSHIP' /
2.l O nett of R cord 2{ f7k 4L,,J
S'c 5 r
Name( r t) y Ad ss for Service:
17? 213 z7`o
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) Alleration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
U// OLu
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: oMclal Use Only
Item (Labor and Materials
I. Building S �; p� I• Duilding Permit Fee:S Indicate how lee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier
3. Plumbing S 2. Other Fees: S
List:
4. Mechanical (IIVAC) S
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No._Check Amount: Cash Amount:__
6. Total Project Cost: ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.C,&r-Const)uctlyo Supenisor(CSL)
It(d�) �dV�( [�'Yj)l, dl License Number li.tpiratiun(late
Nwne WAS I lul er /� l.isl C'SL 1'ype(see below)
A ress I f� Description
0DResidential
15AO0 Ca Ft.)
! ricted 1.61 Famil Uwllin7Y �t'!i _ 7 z D� on OnlOdential Routin CoverinIblephone dential Windowand Sidindential Solid Fuel Bumin A liance Installation
Demolition -
5.21RAgIsterod,Ho Impr a CAntri rAll
(HIC)
I 11C Cump•ny Nay or f IIC c is ant Nape �/� Registration Number
_ �/ t 4
A fires L p
Expiration Date
Signature "reiephune
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7—OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CON RACTOR APPLIES FOR BUILDING PERMIT
I, 8 U J Sz ! tc 4I , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative work authorize by t is building permit application.
-/'--Z 6/7
St ature of Owner Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
l Lie r- M 1 ,acArMt 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. 146
' Print Na.T,
Signature r Authorized Agent Date
(Siloed under the pains and penalties ofperjury)
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 nu 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 790 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total Iluors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable 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 he substituted fir-Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
9 Boston, ALA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (� / 0 Please Print Legibly
Name(Business/Organization/Individual): �P Y t`'✓ /vl Lr Jt 1 v4 y,/1YI
Address:
City/State/Zip: Gvl Phone #: -24 3
Are you an employer?Check the appropriate box:
1.0 I am a employer with 4. 0 I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2..I am aselotroppictlm or partner- fisted on the attached sheet. 7. [] Remodeling
ship and have no employees These sub-contractors have g, 0 Demolition
working for me in any capacity. employees and have workers'
[No workers'comp. insurance comp.insurance.t 9. 0 Building addition
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their I L0 Plumbing repairs or additions
myself.[No workers' comp, right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp, insurance required.]
*Any applicant that checks box#1 must also fill 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 anew affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitles have
employees. If the sub-contractors have employees,they must provide their workers'comp policy number.
I information.an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
hisurance Company Name:
Policy#or Self-ins.Lic. #: 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
fine up to$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DiA for insurance coverage verification.
I do hereby c u r the ins id penal[ a perjury that the information provided above is true and correct
Si ature: Date oF/J�02
Phone#: !T� — , Y_t9 �� I
Euseonly.only. Do not write in this area,to be completed by city or town oJBcial
n: Permit/Licensehority(circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the Service of another under any contract of hire,
express or implied,oral or 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, 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 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,MGL 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 certifieate(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 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 fill in the permit/icense 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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 4-24-07 www.mass.gov/dia
1 • 1
CITY OF S'U1 &Nt, ,NLvL-kSSACHUSETI'S
BLLWLYG DEPAR71tENT
120 W.ssHLYGTON STRExT, 3iD FLOOR
T L (978) 74S-9595
PAX(978) 740-9846
Kl\®ERLEY DRISCOLL
MAYOR THO.uAs ST.PmR m n
DIRECTOR OF PuBuc PROPERTY/BUUMLYG COMMISSIONER
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 l l 1.5
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
I 11,S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
eP-14 v/
(name of facility)
( dress of facility)
signature o pe it applicant
02 �o
ate
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