10 ORCHARD ST - BUILDING INSPECTION L
ITh Commonwealth of Ma�� ` � e Massachusetts
Board of Building Regulations and Standards CITY
.� u, OF SALEM
' ' Massachtuetts State Building Cute, 780 CMR, 7 edition
Rrvisrd Janosrry
Building Permit Application To Construct, Repair, Renovate Or Demolish a I• :(NAY
'One-or Two-Family Dwelling
This Section For ORcial Use Only
Building Permit Number: Date Applied:
Signature: /4 1 I-0.
Building Commissioner/Inspector u ur dings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map d) Parcel Numbers
I.la Is this an accepted street?yes ✓ no Map Number Parcel Number
IJ Zoning loformatba: 1.4 Property Dimensions:
Zoning District Proposed Use - Lot Am(sq 11) Frontage(11)
1.5 Building Setbacks(R)
nOPriyawaylIM3
rd Side Yards Rear Yud
Provided Required Provided Required Provided
1. .G.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Dbposal System:
L Pu Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
D n iv r+L l9 .Cis Lc-�t2 c. /0 O/r.c. ./
Nome(Print) Address for Service:
,
Signature Telephom
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building O Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ AdditioJ103
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work": c-_4--.• A!," -4-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building Is 1 1. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S 1
❑Standard Cily/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S 0 0OV,00 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 0�2C iF G 5
I.icense Number F%piraliun Wit
Name of CSL•l lulder 0 IJA CSL Type(s. below)
J L f I Description
Address U I unrestricted(up to 35,000 Cu.Ft.
� ""' "� ���•' R I Restricted IA2 Family Dwelling
Signature M Masonry Only
C7k- --7 s"Stla- RC Residential RoutingCovering
I"eleplhme WS Residential Window and Siding
Sf Raidenlial Solid Fuel Bumin Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company ur HIC Registrant Registration Number
Addrea l
7�-'7YS-sag Expiration Date9
Signature Telephone
SECTION 6: WORKERS'C MPENSATION INSURANCE AFFIDAVIT(M.G.I.c. ISL f 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 ARdavil Attached? Yes..........O No...........O
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ee r l ,as Owner or Authorized Agent hereby declare
that the statements information o4 the foregoing application are we and accurate,to the best of my knowledge and
behalf.
)e/4r Pli' C
Print N0.me
tret4'+t-�sf.+i
Signature o Owner or Authorized Agent Date
iSiatted under the oains and penalties of 'u
NOTES:
1. 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 ayg 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 1 IO.R3,respectively.
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
). 'Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR"I'MENT
Construction Debris Disposal Affidavit
(rryuircd lire all denwlition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNfR section I 11.5
Dcblis, and the provisions of'v1GL c 40, S 54;
Building Permit N is issued will,the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I t 1. S 150A.
The debris will Ile transported by:
Utomc ut hau cr)
I lie debris will be
disposed of in
(mine ul facility)—
(address ul,facility)
.Iguatme urp nit applicant --
/0
.late
CITY OF SALEM
a PUBLIC PROPRERTY
_ lr
`—� DEPARTMENT
J NI I::M:rY:)nisCN n.t.
LN n to 12C W Mkii u:I ON Six E1:T •S.Nt itsr,M.Ns_SA0 It-%I 1 S 0197C
Tr.1.:978-745-9595 • f.Nx.978-74C-9x46
Workers' Compensation Insurance Afridavit: Builders/Contractors/Electricians/Plumbers
f llicant Information Please Print Leeibiv
Name tBusincsslOrganiutioNlndtvlduu4:
Address:
City Srare,lip: Phone id:
Are you an employer? Check the appropriate box: 'Type of project(required):
1. am a employer with
4. ❑ 1 general contractor and 1 New construction
[�I �-,_ tun a ge 6. ❑
employce+(full and/or part-time).• have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet. r
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building udditiun
No workers'coo 5. ❑ We are a corporation and its
l p insurance officers have exercised their 10.❑ Electrical repairs or additions
I am acd•] 1 I. Plumbing repairs or additions
3.❑ f am a homeowner doing all work right of exemption per MGL ❑ b P'
- myself. (No workers' comp. c. 152, y`1(4),and we have no 12.0 Roof repairs
insurance required.] r employees. [No workers' 13.❑ other
comp. insurance required.]
-Any:1ppllcaut that chccks box al must also till out the section W-uw slwwing(heir worked cumpcnseaiw,pulicy inlirtrtuliun.
' I lomatwnen who atbminhis affidavit indicating they ate doing all wade mid then hire uulside ecallmnom must submit anew affidavit indicating etch.
:Comrxwn that check this box matt at1whal on additional.daet showing the name of Ito:sub-comrxtom and their wuherx'comp.policy information.
1 aar mr employer that it providing ivorkers'compensation insurance for my employees. Below is the policy and job.Nile
infurinution.
Insurance Company Name:
Policy u or Sclf-ins. Lie. it: C cl(,F 2S4 9 JG ___...... _ _ . _._.._ Expiration Date: 3�.2�I1 t/�,r,,
Job Site Address: 1G �i✓c�.a-,-�(' .l�" ._ CityislardZip: r�Gas.,, '
Attach 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 NIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 it day against dle violator. Ile advi.acd that a copy of this statcmcnt may be forwarded to the Office of
InNvcstlgauons ul'the DIA for ut,uruxc covera.-c vcritication.
l do hereby certify wider the pains mad penahicv ofperjury that the information provided above is true and correct.
Date- /01c 116
Plume
Official use only. Do not write in this area,to be completed by city or fovis Official
City or fawn: _ Pcrmit/Licenxe X----___.- _. . .
Issuing;Aullturity (circle one):
1. Iloard of Ilvaldr 2. Building Department 3. City. foesn Clerk 4. Llectrical luspecfor 5. Plumbing; Inspector
6.01tier -- -
ContactPetsulr __ . .__. Phone#:
Information and Instructions
,,\lassachusetts 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 :m 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."
`iGL chapter 152. g25C(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, y25C(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 GII 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 dale 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. Salf-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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense 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.it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I tic i)t)ice of lnvesrigations would like to thank you in advance fur your cooperation and should you have any questions,
please do nut 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
Itcvi.ed ;-26-05
Fax #617-727-7749
www.mass.gov/dia