7 OLIVER ST - BUILDING INSPECTION Hie Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
Si\LEM
d
Massachusetts State Building Coe, 780 CMR
Revised.1lur 2011
Building Permit Application To Construct, Repair. Renovate Or Demolish a �
One-or Two-Family Dteelling
This Section For Official Use O
Building Permit Number: Date Appl'
7
Building Official(Print Name) ignatu - Da e
SECTION l:SITE 1 ORN TION
1.1 Yerty Address: 1.2 Assessors Map& Parcel Numbers
O/%vti sT -��
I.I a 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 II) Frontage(II)
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:
Zone: _ Outside Flood Zone? Munich ❑ On site disposals)s stem ❑
Public El Private❑ al Check if yes❑ p p y`
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownertoff�ecord: Ol
Nu •(Print) City.State,ZIP
7 &3a
rr�r/ T 7f YS - /
%� s
No.and Street 'telephone EmailAddress
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ecify:
Brief Description of Proposed Work-: AVCk /t�
K
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
'_. Electrical S
❑Total Project Cost (Item 6)x multiplier x .
3. Plumbing S 2. Other Fees: S
a. \leeh:mical tit\':\C) S List:
5. \Iechanirul IFire S Total All Fees:S -- --
Su sassionl
Check No. _('heck Amount: _ C;uh :\nxnnd:_-- '
6. Total Project Cost: S �� ❑ Paid in Full ❑Outstanding Balance Due:
� I
LV
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL) /0-rla va
_ License Numhu .cpirali t Date
Na to of CSl. 11uldcr y
UiJ�/-e " List CtiL I)pe(see below)
No. attd Street type Description
lnrestri-led lBuilJin s u' 10 35,u1J0 cu. R.)
C'ily/loon.Stale.ZIP F=t� R Restrict ed IK?I�antil Dwellin
M Masan
RC Roolin C'overin
/ W'S Window and Sidin
7 Sl/� ��'iO r/ SF Solid Fuel 13urning Appliances
I Insulation
'fete hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC ompan Nance or I IIC Regi trunl Nume I IIC'Registration Numher s ation Dale
t u and Street
aw_r--Cl�'lj Q/f/ 7 .2 Email address
Ci /Town,St te,ZIP fete hone
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 .......... 15-� , 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.
�t<�a,,.� 7 <a <l
Print Owners Name(Electronic signuturc) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this a #ication is true gaj3ifaccurate to a best of my knowledge and understanding.
��
Print r' r Authori benl's Name( �.lectr nic Signature) Date
NOTES:
I. ;\n Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contactor
(not registered in the Home Improvement Contractor(HIC)Program),will no!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
t1)U1-JII I��5un Alc,I Information on the Construction Supervisor License can be found at t%%t tt.n glss.g��t Up,
i When substantial work is planned,provide the information below:
Total floor area(sq. ft.) _(including garage, finished basentent'atties,decks or porch)
Ciruss living area(sq. ft.l_—_ __ Habitable room count
`'umber of tircplaces___—__—__—_ Number of bedrooms
unthcr of bathrooms -----------------
Number of half,baths
1')pe of beat
PC System -----
` ----_._-_-- Number of decks,porches--
F)pe urcouline Svstent ------------
-..__. -_.----_---_-- Enclosed __---Open
?. . 'rood Project Square Footage-ma)' be substituted litr"rot:d Project Cost*'
b CITY OF S.UY-.,Nt, .LL-kSS.A cHUSETI'S
OI;tLDLVG DEPAR-MENT
120 WASHLNGTON STREU, 3iO FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
Kl1BERLBY DRISCOLL
MAYOR TkcimuST.PtT m
DimcroR OF PL'BL c PROPERTY/11UMMSIG 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 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 facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debriswill be disposed of in
/ (name of facility)
(address of fa ility) '
ignatu rmit applicant
Jate
I.bn aJ(bw
•� • CITY OF SALEM
././' PUBLIC PROPRERTY
DEPARTMENT
\r 11,41
11:\VA1rnA,llu•\ilBtay f $dlt.u. h1.1\14111t V I nJl'77:
11a. n}7tini'ri,f ps.r vly7uC•'IYM
Workers' Cumpenaallon Infurunce \Iflduvit: Builders/Cuntracturs/Eleetriclana/Plumberf
% ) )llcant In ormatio
//f� PI •r� tint Le 'hl
�1;IITIe Illua,k,y OrgrmratinNlndlaJuull:_ Gr-�/ s✓��2 y w�� � /
Lam. / / /r�✓S I"
Address: —
Cily,Smrc,7ip: v Phone it:_
tru),ru�lurinployor7Check eapproprlelebox:
lama employer with e. ❑ l'!Par of prof eet(reglrlred):
employer and
es(full and/urpart-tiute).f hove hired the ruh-claitnlra�u n) h'
❑New culwtrticuun
?.❑ 1•un a sale prnprictor or partner- listed on the anached sheet r 1. ❑Remodelin`
ship;utd have no cmpluyuvnl These subcontractors have
working hir Ine in any capacity. workers'comp Insistence. d' Nnicalirion
INO workers'sump. insurance J. ❑ We are a eolporstion and its 9' ❑Building addition
).❑ squired) utllcers have cscreiscd their 10.0 Electrical repain or additions
I unl a ham, varier doing all work right of o.rclnption per W(71• 1 I.❑Plumbing rupoirs or additiorty
myself.(No workrs e 'comp, c. 152,¢1(4),and we hove an
insurance required.) t .mpluyces.INO workM' 12.(]Ruul'repuid
comp insuratim squired.J I7.0 Ot1lm
•.��9.•,;9dwud thel"Crab t7w of mull:Jw till w,the•acuw,4hrw amwuq their wulkuss cum
'l lumu,lrnerf who„dine/this amafWr inulralin 1 r+nuulun Itdiry tvfinlnf,iurr,
th andC•wlrnntn M vM•,'�this Cot Rust arraeh st rill 3 ad tine" tNfl.Anwina then I$of ft/u►"aw1,anon and thew a now alRafvil inJ(udin
y.,it.
/roar uhim
n vurployrr thud lr pravid/ny ivorkors'rurnprnrnr/oa httarunce w ro efn u, +n .poky mtbntaliva
illlyftnYlirlq � Jr p/J raid Br/uw lr tM pu/Isy mid/u1 aiq -
ImuranccCompany.Name: AdlQNz�.t��
I'ulicy a or Sulf•ins. Lic.it: 4
�4,p�-
7c
_ EApirauon orate: C�
lob Situ�\ddresv:__ � r V L � S /
City,5late z p:
NtaeA n copy,or lho workers'cumpenratlon pulley duct lratlun page(showing the policy number and esplratlun data).
I+allure to secular cuveruge u required under Section'L\ul'.tIGL c. 152 eau lead up to the imposition'oferiminal yenaltia of a
tine er StlO.iLtln und/uruna-year intprisnumenr, of well us civil 1wrialttcs in the Penn Ora STOP WORK GIRDER snd s fine
n(up to i150,M a Jay tduinsl the viul:uar. Ile advt.,cd thut a copy urthls.,lulclnunt may be lurwarded to the 011icu vl'
tnr,anyaut nlf of lhu OL\ ;of insur:mcc coverage sal iriv lure.
/du herebycertify Im a ninr surd pan, '• u rr/nry fhur the in ur,nudest/' provided ubu •e it uue lard rorrvrR
�/7 ) ell �
II r)/Jlriul rnr u,dy. l)o nor wriu in thG drt•u, far hr rurnpleted by city us.tolvn,r//I,'iuL
(irrur fnlrn:
- Vrnnit/Lltvnra 1
Issuing .\Whnrity (circlo noel;
I. I6,ard of Ilrahh 1. Ihuldiu� Ikp.lrtlurnl G thher I. ('h), Ia,ul Clerk J. Ucctrical Insperrur i• plunlbiny Inseorye
l'��nt.rct I',r,url: I
__ I'Aunc 9• �
I
i
Information and Instructions
1 con m the service of another under.illy :ontrict Of hire-
�lassachu:aus licnenl Laws chapter I i2 lcywres all employers to provide workers' wmpensalum for theta cnlployees.
I'ur>u.uu to liars%taluoe, an rmplat're is de fi Ile J as"_.every pc'.
press or unplieJ, oral fir wntten." two or more
partnership,.1160clatlod-corporation ur other legal entity rn a11Y c.r Or the
\n etnpluyrr n dclineJ U"an mJtviJual, p to in ant loyees. However the
a ,hc t�lregJmg engaged m a Imm cnterpnse, and 'nuluJing the legal rcpreseuutives of a deceased emp oY'
,ecewer or trustee of.an individual, p
sumenh,p, as locmlioa or other Icgal entity,cmp Y e ' P ant of that
owner of a dwelling house having not more than three apartmenu and who resides therein,or t I occupant
thereto shall not because of such employment be deemed to be:m employer."
.Iwelltng house of anathar who employs persons to do maintenance,cultatructin r repair work on such dwelling ouse
or Jn the ground+Jr building appurtenantshag withhold the Issuance or
�tGL chapter I32. t)13C(6)also states that"Ivory dsro or local trust buildings
lessee wltb the Insurance coverage required:
renewal of a Ilccase ur perntlt to overate•buslaou or to construct buildings lathe commaawaultb or say
t3C(7)smogs"Neilher the commonwealth not any Of its political subdivisions shall
applicant who has not prof acceptable evidence Of eutnp
Additionally. SIGL chupter I S-• i-
cncer into any contract for the performance
an P tlo the cote act {aluthorityv mince ofcwupliarlca with the insurance
requiramcnls of this chapter have been p'
Appllcastts the boxes that apply to your situation and-if
nsation atYtdavit completely,by checking with their cartiticute(s)of
Ple;lsa lilt Jot the workers' cumpe as hone nuntber(s)aloes with via om loyces Other than the
necessary, supply sub-contracror(s)name(s), •address( t P partnerships(LLP) P
P
workers' compensation insurance. if as LLC or LLP does have
insurance: Limited Liability Companies(LLC)or Limited Liability
,nembers or partners, art not required to carryrallyempin Of industrial
yers,a policy is required. Be advised that thu�l�bait I to yl{ I and
dais he OI'Bdav�lt•rttTit*li lidav t should
lication for the pannit or license is being requastad, ao1 the Department of
�ccidenu far contlrmatiun of insurance coverage uired to obtain a workers'
he returned to the city or town that the upP uestions regarding the law Of if you are rc4 alias should enter their
industrial Aceidents• Should you have any 4 ant at the number listed below. Self-insured comp
colnperuation policy,please call the Depalm
self-insurance license number on the appropriate lino.
('try or-rows Officials
Please he cure that the affidavit is cumplete and-Printed legi The Department has provided u spun at the bottom
bly.
of doe aifidrvit for you to hill out in the event the Ofiiea of Investigations has to contact you rcn addition,
the applies
applications in any given year,need only submit one arfidavit indicating c`een'
I'I:usJ be sure to till in the pOrmiViicanse number which will be used as a reference nwubor, in udJition,an applicant
that must Submit multiple Pennib'and un app Provided to the
policy information I il'necessary)and lender"lob Site Address"the applicant should write";all lucmiuns in Y
town ty be
town).",\COPY,,(the affidavit that has besot officially sun'comas oo or r marked cen es`ItA nowd city �affidavit mus be tilled out each
applicant as proof that a valid affidavit is on role for Notice pto any business of
�dile. �R a home
permit.or citizen is to bum leaves ate.) Jining a Dars�or
NOTtrequired to complete omplate this affidavit.mlttereia venture
enso tit
I he ,)tile¢ ui Invecligatiuns �wuld like to Jwnk you in advance fat your cooperation and shuuld yuu haw,uoy yuesuons,
Idease du nut licsitato to give us a call.
nci: Ucparnncnt's address, telephone and fax number'
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of favtrsdgadons
600 Washington Street
Boston, MA 02111
'fee. p 617.727.4900 exit 406 or 1-877-MASSAFE
Fax M 617.727-7749
d <.If,.us www.mw,gov/die