50 ORCHARD ST - BUILDING INSPECTION (2) I 7 The C'onnnonsvulhh of Mussachusclts
�� y; 1►� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 C NIR SALEM
'Y//U1 'tip,•• R.ri,r�d.lhu•2W1
Building Permit Application To Construct. Repair, Renovate Or Demolish a
Ones-or Tis o-Funnily Duelling
This Section For Official Use Only
Building Permit Number: Dal • p I d: .
Building 01 iciai(Print N..une) rc , Dutc
SECTION I:SITE INFORMATION
I.I ProTl�.tdress:C r y 1.2 Assessors blap& Parcel Numbers
� A.tr�•f
1.Is Is this an acce fed street? 'es na Mop Number Parcel Nwntwr
1.3 Zoning Information: 1.4 Property Dimensions:
ZoningDistricti'n pu,ed(Ise Lot Area(sy Ill Fronlagc(Ill
1.5 Building Setbacks(h)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Neyuircd Provided
1.6 Water Supply:(M.G.I.c.40,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal )
Check if yes❑ P Wwl s stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owneri of Record:
N;une(Prnn)�`/ (uy.�tata,l.IP
01$ Sao 6..3
No.and Street rocphune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description ofPropgQs�ed Work : - wp..
w
SECTION a: ESTIMATED CONSTRUCTION COSTS
heat Estiniated Costs:
(Labor and.Materials) Official Use Only
I. Building S 52C)o , OD I. Building Permit Fee: f Indicate how tee is determined:
'. Electrical S ❑Standard City+Town Application Fee
50.vo ❑Total Project Cosli(Item 6)x multiplier
j 1. Plumbing S 3 SOv.t�r7 7. Other Fees: S P - -
4. .Vicehmiical III\'.\(') S List:_
S. \Icchanira) (Fin
Suppression) Total All Fees: S
Cheek No. ('lieek:lntuunt: (',lih \mount:o. Total Project Cnst: S Ll So. L) Cl P,lid in Full ❑Uutsrmding IlaLuIcc One:
tw l ic1L �iUC.-u L`
SECTION 5: CONS'I'RIIC'rION SF.RVI('ES
5.1 Construction Supen isor License
�- -- — - pi -
\ I �p
iansc NMuuhcr valuul Dale
Nvnc ol'_l'Sl. lolder
I ist('St. I)pc leec hclussl
I)PC Description
No. and Sucet
l l l4vestrictcd I Buddio gs 1111711 5.0110 eu. Il.l
OJ �• ._ O �� ,, itRearicleJ L@2 Tamil Dltellin
Cilsiroeo•Sl;llc.LIP M Masan
RC RlNdin Ctl�crin
%'S Windim and Siding
}� 9 .SF Solid Fuel Burning Appliances
(;"aaV `N-�,�QP� I Insulation
Iele hone Fnmiladdrem D Denwlilion
5.2 Registered llome Improvement Contractor(IIIQ \� ��� g f 7613
�--. I11C IL gistmtiun Ntnnher IfapiruUun Mic
I IIC'Con Nmn or HIC 1
1
4
1
1" Nam} �y � �
C i P �sPn� w Lev) ML F `6.u1(Slo'Z C c vs 4
No.Aid ' cet Email address f,j(, r
o�s V�- ick"V's-M Lk6V�
City/Town.State,ZIP Rc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.§ 23C(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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize V /
to act o y behalf,in all matters relative to work authorized by t s Widing permit application.
I' t aner's Nurne(Electronic Signature) Dale
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
containe in this application is true and accurate to the best of my knowledge and understanding.
Print(tner•i or Auduvired Agent's Name I I:Ieclnmic Signature) Date
NOTES:
7n ,,r who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
tered in the Hume Improvement C ontractor(HIC)Program),will 1 have access to the arbitration
or guaranty fund under\I.G.L.c. 142A.Other important information on the HIC Program can be round at
. y�l '�.I Information on theConstruction Supervisor Licensecan be found at�lw% ul.n:5:�1 �Ip.
bstantial swrk is planned,provide the information below;
a Isy. R.) - (including garage, finished basement attics,decks or porch)
Gross lit ing area l sq. It __._ habitable room count __. -... .
\umber of fireplaces Number of hedrounu
i \unlhoro(hathmunu \'unlberofhaffh;uhs
11 pc of heating syslent . . .. . _ \'umber ol'decki, parches
I 1\pC al CPP1alg is slelll 1"Ilclaied . ..
Open
i
1. "ralal Project Square Fool,t"',hilt) he auhilimled 11v"1'otal Project Cost" I
1
1
.r
CITY OF S.1i &M, ��L1SS.ICHC'SETTS
9LMDCVG DEP.m-naNT
120 WAIN NGTON STU=, )iO FLOOR
1tL (978) 7�5-9595
W MERLSY DRISCOLL FAX(978) 740-9946
MAYOR TtiG.►W ST.Ptatus
DptECSOfI OF PLO PROPERTY/at:RDNG CO- [OHSSIONEit
Construction Debris Disposal At-ttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cade, 780 CMR section
Debris, and the previsions of MGL a 40, S 34;
Building Permit M is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
I I I, S I JOA.
The debris will be transported by:
S �' aeXcTe(rams orhauler)
The debris will be disposed Orin :
------------
(name 0(r4t;jjjjy)
Pp- o 3
. 9oiL y� -
G9 Or r L
(iddreaorrivilify) 3
L-� I
fiynJN(e Or ~'�"�_
per f Jppiiunt
ary OF sivLEm, %L1ss:IcHUSETI'S
t BUILDING DEP.IRTME.VT
+ 130 WASNL�IGTON STREET, )�FLOOR
TEL (978) 745-9595
F.+x(978) 7411-9846
DRISCOI.L '
,VLAYo.t TTTmNw ST.Piling
DIRECTOR OF PCBLIC PROPERTY/BUMDTNG COSLMISSIONER
Workers' Compensation insurance AflTdavit: Builders/Contractorv/Electricians/Plumberx
Ah1111cant Infarmatinn x] Please Print Levihi
NillCflfu.fiiro,.vUrganiva(l�iomindividu:dl: � /���Df7fl �v Oly,\�C�aIL � SCi� �rApaL
Address: 51r ` t,%9$.S'y . -t, )
City/State/Zip: 'Qica- ,t.CN5 Vv� 00?, 3 Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6• ❑Now construction
ployces(full and/or part-time).* have hired the subcontractors
2. , 1 am a sole proprietor or partner- listed on the attached ihecL t 7. 0 Remodeling
ship and have no employees These subcontractors have it. ❑Demolition
working Isar me in any capacity. workers'comp. insurance. q• Building addition
(No workers;comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself (No workers'sump, C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.(t employees.(No workers' 13.0 Other
camp. Insurance required.)
•Any appli,•am dot eh.cka boa rl must also rill out the scuiue below hawing their workers'comparattun policy inrwmmion.
'I hvneuwners who uhmit this affidavit indicting they tin doing all work and then him""side contractors mien suhmit a new aMdavil indicting.tick
:Omnmton that check this box must auachod an.tdditiursd Awl ehuwing the nwna of the aaltaumrscWrs and their workers'comp.policy infomtaaon,
l tons an employer that Is providing workers'cumpe tsallon insurance for my employees. Below/s the policy and job We
information.
Insurance Company Name:
ll �
Policy 4 or Self--ins. Lic. 4: WC) —316 — �`100f.\rI —p L1 Expiration Dote: � � _D. � � ZZ&
Job Site Address: lc( OC&oaiAsk Citylstate/Zip: -S%\ei�., *Ac- 0 �Q123
\113cb a copy of this svorkers'compensation policy declaration pigs(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 an lead to the imposition of criminal renalties of a
rinu up to S 1,500.00 and/or one-year impriianment,as well as civil penalties in the form of a STOP WORK ORDER and it tine
of up to 5250,00 a day against the violator. Re advised that i copy of this statement may bo furwardcd to the Of rica of
n\'Cittgallooi ol'the DIA for insurance covcragc vCrillcatlun.
Ida hereby certify roofer that puins ultd petultles of perjury that the infurmullun provided above i.r true rind corritcl.
Lk v7
Oir ic•ial ri.+e wdy. Oa ant write in thiv area, rube cuurpleted by city ur town rr/jici it
City or fusvn: PermiUT.lccn1e4__. 71aspector
hauinKAulhurily(circle une):
1. IToard of Ilcallh 2. Iluildin; Ilcpuriment 1. Cltyirown Clerk J, Electrical Inspectur 5. Plumbi
6. Other
Cnulact Person: I'hnnc B•
I
(
Information and Instructions
Massachusctts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
t
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 fugal entity,or any two or more
of the foregoing engaged in ajuint 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 suih employment be deemed to be an employer."
NIGL 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 not 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 rill 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 date the affidavit. The affidavit should
he 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 nuinber on the appropriate line.
City or Town Ofnclals
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 till in the permitilicense 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 Cite 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 bum leaves ctc.)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.
]'he Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of favesdgatlons
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
;tee:i;cd 5-'_6-OS
www.mass.gov/dia