1 ORANGE ST - BUILDING INSPECTION �a
� .� The ('qmmonwralth of Mussxhusetts ',
. � Buard uf f3uilding Rcgulations unJ St�ndards I c�K
� �Y''� ,j Massachusetts State f3uilding ('ude. 780('MR. 7"' editiun ' �il'vll'IP.�I.I'll I
d� ,.� s i�si:
� Ciuilding Pcrmit Application To Cunstruct. Repair. Reno��tr Or Demulish ❑ Kr�isrJ l,un��u, I
One- ur T�ru-f�umilr rllin,G l. 'ur�,1'
This Seciiun F Of'firia Use Only
l3uilding Pennit Nwnbrr. ❑t p lied: --_
Si_�nature: "'�"" '" �/ �/��------
HuiWinECumnu�siun�r/ Insperturu(Buildings Ua�c �
�
SECTION L• 517'F. INFORMA'f10N �
Ll Proper )' :�ddress: u� l d 1.2 :�ssessors 11I�p & P�ml Numbers ,
/ �l�LA�LAP �� � —
l.Lt I5 Ihis an :icce ed slrce[7 yati l� nu_ Map Numhcr Parcrl \umhrr
I1.3 Zumng lnfurm•rtion: 1.4 Property Dimensiuns:
� Z:�,�;:�� ni,�.,,_; pronused Use , Lnl Ana Isu ft! Fronlage I lil
1.5 Building Selbacks (Pt)
Frunt Yurd Side Yards Rcar Yurd
! Reyuired Provided Reyuired Proviued Rcyuired Pruvidrd
�
1.6 Water Supply: (M.G.L c.10. §51� L7 Flood Zone Informatiun: 1.8 Sewage Disposal System:
Zone: Oulside Flood Zonc'? ,�.1unici �I ❑ On site dis�osal ti sicin ❑
Puhlic ❑ Private❑ Check if yes❑ P � ��
SECTION 2: PROPERTY OWNERSHIP�
�'2.1 Own� f Rec�o�d:/ // � e
��� �.f� ,' �l r �' � '
Nmne i PrinU . ` Address(or Service:
�-�_�� - 77SS^ -
Signaturc Tclrphone
SECTION 3: DESCRIPTION OF PROPOSED �4'ORKZ(check all [hat apply)
New Cunstructiun ❑ Esisting Building Owner-Occupied ❑ Repairsls) ❑ Alterution�s) Addiii�ro ❑ I
Demolition ❑ Accessury Bldg. ❑ Number of Units Other ❑ Specily: '�
Brief Description uf Proposed Wurkz: --
I — --�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
I � em Es[imuced Coscs: Official Use Only
If_ubur:md Marerials)
I. Building $ �p a^> �� duilding Permit Fee: 3 Indicate huw kt is Jetermincd: �
❑Standard City/Tuwn Application Fee
?. Elecvical � ❑Tutal Project Cost� (Item 6) x multiplier s '�
3. Plumbin � � �
�. g ?. Other Fees: $ � I
1. Merhaniral (HVACI '6 � � �"�' �� I
�. Mechanical IFire ,� — �
Ju� ression) � � Tutal All Fees: S .
Cherk Nu. Chtck :�muunt C:uh :lm��unc _ I
Ib, '1'otel Project Cost: $ ❑ pald m Full ❑ Ou[stanJing B:il:ince Uue:_____ �
� �
�� � ���
SECTION 5: CONSTRUC'PION SF.RVICES �
5.1 Licenscd Construclimi Supervisor(CSL) ��� �� �
e - N h. Lictnsc Numb� lispir:viu U:ur
Namr ul C �I.- lul r n . '�� .
/ �1�_�[Q,�1 l A / �,Vl_� �'•.�� �tit CSI_�P�pc uac hclo��1 _ . 'y
/� �`L—
- dre+.� . T ' c . Desrnilion
l'.. l'nreslncleJ lu tu i5.(p)Q('❑. PLI
' Rcsu�ictcd I�C'_ Fandl�' Durlline
i�nuturc �,v�� 7 �1 �fasunry Onlv
9 J� 7�_7�0` RC Ra>i.lential RuoGnc C'o�.rrin_
T�•Irphunc \1'S . i;e�id:mia! \Vu��Ju�.c :mJ Siihn_ _ '�
SF Rc�iJrntial So�id Pu�l Burnme :\ >>lianrr In.i.ill.w��u
D Kr.i�cn�ial Drmuhuun
5.2 J�gislered �lomel iprov enr�n[r�ct r (FIIC) ' /ya//
��_� Co I
HIC Cum� i y N� c ur C R� �slr n Ii �mc . Rcgislratiun i\'uinbrr
�Jr•» � �C���"�`� �. .
--- tf Ex i �uun a�c
' awrc � Tel��hunc I � I
—1
— _ — �
S.'3C:::,N ti: WORKERS' COMPENSn`f10N INSURAYCE AFFIDAVIT(M.G.L. c. 152. § ?SC(6)) I
WurAers Compensation Insurance attidavit must be c�rmpizted and sub;nitted w�i[h �hiti applic�tiun. F.iilw'r tu pruvide 1
this uffidavit will result in the denial uf the Issuarce uF[he buiiuing ;zcnnit.
Signed Aftiduvit Attached'? Yes .......... ❑ No ..... . . Q� �
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLE't'ED WHEN_ �
OWNER'S AGENT OR CONTRACTOk A-"r??.IFS FOR Bi_iii.,7ING PERMIT
�, � ,____________, as Owner of the suhject properry hereby �
authorize _ ._._._ -- to ac[on my bahalf. in :dl m:it�ers �
� rela[ive to work authorized by this building pr:mit applir.�tion.
Si namrc of Owner ---� L'�« ----�------ ----__�
SECT(ON 76: OWN�it' OR .4UTHOrZIZL� AGF,NT DF.CLARA"ftON .
___"' .._--_'." —_____—" y
I
� �` ----- __, as Owner ur .�uthorized Agent hereby c'erl:ire j
tha[ the stacements and informatiun un the foreeoing �pplication are true and accurate. to the best of my knowledge ar�d i
behali'. I
�
Print Name
Sienature of Owner or AulhorizeJ .4gen[ Date �
ISi neJ under tlle ains�nd enalties o1 er u )
IYOTES:
L An Owner who obtains a building permit to do his/her uwn .curk, ur an uwner who hires an unregistered run�ranur
(nut registered in Ihe Home Impruvement Contractur(HIC) Prugraml, will ��ot ha��e acress to the :ubitr:uiun
. program ur guuranty fund under M.G.L. c. 1�13A. Other impurtant intiirmation on the HIC Prn��r.un :md
Cunstructiun Supervisur Lirensing (CSL)can be fiwnd in 7S0 CMR Regulations I IO.R6 :md I IO.RS, respactn�ely.
; _'. When substanual work is planned, pruvide the inti�rmatiun below:
ITutal flours area(Sq. FLI lincluding garage, finished bustment/at�irs, Jtrks ur purrhi
I Gross fiving �rea �Sq. Ft.) Habitablz roum u�unt _ '
Number uf fircpl:ices Ninnber uf bcdru��ms __
Number uf bu[hruums Number��f h;ilf7baihs ___
'fype uf hea�ing sysmm �lumbrr uf Jecks/ p��rches - - -- i .
'�Ype uf cuuling system Lncluaed (Jpen .
3. 'Tutal Project Squ:�re Fu�im�t' may be aubstiiuted fi�r 'Tuwl Pruject Co,t"
CITY OF SALEM
a '
PUBLIC PROPRERTY
DEPARTMENT
. Iii l-'�--a;. ,.r . I ��. •:rg_v: ;� ,
Construction Debris Disposal Affidavit
(rcyuired liu all danolitiolt and renovation work)
In accordance ith the sixth edition of the Statc Building Code, 780 Cb1R section 1-11.5
Dcbris, and the provisions of.1v1GL c 40, S 54; M
Building Permit is issued with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The dehris will be transported by:
name of hauler
I he debris will be disposed of in
t
(name ul laohty)
Iuddres. of lanlily)
GWtale otl nmt .pphcant
( tl'
rn
CITY OF SALEM
ru irk) PUBLIC PROPRERTY
*', DEPARTMENT
R-6
'wl\IU;Kf YY JKNCk Q.I.
\L\1H( 12^_WASHING TON 5'I KEL•T• SALL\4,MA&S.x(J II's1%I i s GI970
'Cels:978-745.1595 • I:AX;978J4C-')846
Workers' Compensation Insurance Affidavit: Builders/Contractors/El Pease Print m ers
:'Ltlicant Information
ibly
V IMM 11)usiocss/Or�aniz:uinNlndrvi<luaq:
City,'Stareizip! f Phone
Are you an employer? Check the appropriate box: '1'ype of project(required):
I.❑ I am a employer with 4. ❑ I am it general coutractor and 1 6. ❑ New construction
ell
(full andor part-time).' have hired the sub-contractors e ❑ Remodeling
2.0 ant a sole proprietor or partner-
listed ort the attached sheet. 7.
ship and have no employees These sub-contractors have Ii. ❑ Demolition
workers' comp. Insurance. q, ❑ Building addition
working for me in any capacity.
[No workers' comp. insurance 5. ❑ we are it corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL i L❑ mplumbing repairs or additions
3.❑ I ant a homeowner doing all work g 12.E] Ruofrcpairs
myself. (Ko workers' comp. 152, 1(4),c. 152, � and we have no 12.
insurance required.] t employees. 1No workers13.❑ Other
comp. insurance require'd.J
-Am:gtplicaut that decks box BI must:dso IIII out the waiun below showing their wurkus'cumpensation policy inliutrmtiun.
,I Iumeuwlu:rs vhu submit this affidavit indicating they am doing all work and then hire outside cwumetors must auhmit a new arrdavit indicating such.
that check this box must auxhLd:in additional sh o ct showing the name of Ito sub-contractors and their workers'comp.policy information.
1 aur un eurpfuyer that is providing workers'c•ompensn
aan insurance jar uty eurplayecs. Below a rhe policy and/ab irte
infuriation.
InNUrallee Company Vmne:
I'olicv a or Self-ins. Lie. r: .. _... _ ....-_---
Expiralion Date:
City,State/Zip:
Job Site Address: —
Attach it copy of the workers' compensation policy declaration page(showing;the policy number and expiration date).
Failure to secure coverage as required under Sectiun 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/or one-year imprisonment,as well as civil licliallics in the furin of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. He advised that a copy of this statement truly be 1'urwarded Io the Office of
Inc zligalions ul'thu DIA for insueuxe atveragc veriticatiun.
!do hereby certify under rhe pains and penalties ojperjury that the information provided above is true and c•orrec•l.
Date
Phi arc F%:
ofkcal use only. Do not ivrhe in this area, to be completed by city or town official.
Pcrmit/License
City ur'fon•n: .-- - _.
Issuing:%ulhority (circle one):
I. Board of health 2. Bllildiu' DcparUncut 3.Cily/Tonn Clerk 4. Electrical Inspector 5. Plumbing Inspector
h. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enhplayees.
Pursuant to this statute, an emplot•ee is defined as"...every person in the service of another under any contract of hire, ' 1
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.-rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
:`1GL 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, 1MGL chapter 152, 525C(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 lilt 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 nnnber(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 confimmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he.retrmheLI 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/license number which will be used as a reference number. in addition,an applicant
that must submit multiple pennidlicense 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he 0i'icc of luvesti.-ations 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
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
itcviscd 5-26-05
Fax # 617-727-7749
www.mass.gov/dia