96 ORCHARD ST - BUILDING INSPECTION 4 �
"file Commonwealth of Massachusetts
—' Board of Building Regulations and Standards CITY
t m OF SALF:M
A(' f Massachusetts Slate Building Code, 730 CMR, 7 edition
Rrvi.red Jnnu<irv
jJ
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. '008
One-or Two-Family eWeking
This Section Fgr,6fficialkse Only
Building Permit Number: / Date plied:
Signature: Xa-�
Building Commissioner/Inspector of Buildin Dale
SECTIOPK. SITE INFORMATION
1.1 Propyrty Address: 1.2 Assessors Map & Parcel Numbers
N(i (2fchiic S4-
I.la 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 It) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
L,2t.-s 56
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) [21 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 6 _ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ t
❑Total Project CosC (Item 6)x multiplier���x
3. Plumbing $ 2. Other Fees:
4. Mechanical (FIVAC) $ List: /
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S b l �� 11 Paid in Full 0 Outstanding Balance Due:
� � 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) Sltfl�-�i tl�d IN
License Number Fxpiration Date
Name ol'CSL- I[older List CSL I'vpe(see below)
ne (_ LAtiL 9A P/f
:\Jdress Or rN,oc Description
-_. U Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
Signature I- I-I-
M Mason Only
�GG_� RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Register d Home Improvement Contractor(HIC) ` I Q
F' r;ce r rye 0
1-IIC mpany Nam HIC Registrant Name Registration Number
VL..9.
AJJrrss /
Expiration Dale
Signature Telephone
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 .......... Nu........... ❑
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.
Signature of Owner Date
�S7E�CTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
:]�rt,S-,N ,as Owner 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
beha'
ate=
Print Name
Signature of Owner or Authori-ed Agent Date
(Signed under the pains and nalties 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 trot 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 780 CMR Regulations 110.116 and 110.115, respectively.
2. 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S�UZ"\i, 1rL-kSS.ALCHUSETTS
• BUILDING DEPARTMENT
130 WASHINGTON STREET, 3' FLOOR
I'm (978) 745-9595
FAX(978) 7443-9846
KI.NfBRRr EY DRISCOLL
MAYOR THO!►tAs ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BCII.DING CO.\LMISSIONER
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 It 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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
CA: ._.�___
(name of facility)
S ;, R-L SA(e.• 1
address of/facility)
signature of permit applicant
date
dcbnialyde:
CITY OF SM-EN12 ANSSACHUSETTS
BUiLDLNG DEPARTSIE.NT
• 12
0
WASHINGTON STREET, 3"FLOOR.
la,e TEL. (978) 745-959S
F tax(978) 740-9846
Kl%fBERLEY DRISCOLL THOMASST.PIERRE
MAYOR DIRECTOR OF PUBLIC PROPERTY/BL BDI.NG CONL\tiSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t Iicant Information Please Print Legibly
Nalllc(tlusiixSLOrganiratiOmindividual): �F - Q r✓ icor �� c
Address: TY P, I ;h� s
City/State/Zip: eAt. t D 15 to Phone #: 9��" f31 766?
Are you an employer?Check the appropriate box: Type of project(required):
I.CTI-am a employer with /1 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractor
P 1. ❑ Remodeling
2.❑ 1 eon a sole proprietor o partner-
listed on the attached sheet. :
ship and have no employees Them sub-contractorshave g. ❑ Demolition
working for me in any capacity. workers'comp. . 9.k ' insurance Building addition
❑
[No workers comp. insurance 5. ❑ We are a corporation and is,
officers have exercised their 10.❑ Electrical repairs or additions
required.) I I. repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOC ❑ Plumbin•b P
myself.[No workers*comp. c. 152,¢1(4),and we have no 12.❑ Roof repair
insurance required.)t employees. [No workers' I3.❑ Other
comp. insurance required.)
-Any'appbe,sm that Musks best/1 must alas,rill uut The section below slowing their workers'compensation policy mfumnatioa
I lomewvraxs whe submit this affidavit indicating They am doing all work and then hire outside contractors must submit a new aIT:Javit indicting such
:Cumraotor than check ibis bos most attached an additional Aml showing The name or the sub-comractor and their worker'camp.pul icy intormaTian.
l am an employer that Is prapfding workers'compensation insurance for my employees. Below is the policy and job site
iuformasion. n _
Insurance Company Name: GQ Yfo °✓` SI a
Policy 4 or Self-ins. Lic.N: h t"r C 4 ��7 9 6 a' Expiration Date:
r�hr+r/� J'- Cm fW1 a L 9
Job Site Address: 96 0 CilylState/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number a expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Ofrwe of
Invesliguliolut of the MA for insurance coverage verification.
I do herrby c ertify at or the pains and penalties of perjury tlrat the Information provided above is true and correct.
S. Data:
Official use only. Do nor write in tiro area,lobe consp/eted by city or town ofpciaL
City or'fuwn• ____
l%suiag Authority(circle one):
1. Board of lleallh 2. Building Department J.Citylfown Clerk a. Electrical Inspector 5. Plumbing 6tspeetor
6.Other
Contact Person: _ . ._.. ... Phone M:
Information and Instructions I. ,
.issachusens General Laws chapter I J2 requires ate ell'players to provide workers' commpensalion for their e'inployees.
Pursuant to this minute, an employee is defined as"...every person in the service of another under any Contract of hire,
c\press or implied, oral it written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
a the 6)regoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
t eceiver or trustee uI .ar individual,partnership,association or other legal entity,employing employees. However the
uwner 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 maintenunce, 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."
NIGL chapter 152, .j25C(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."
Additiunully, NIGL chapter 152, )25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ufpublic work until acceptable evidence ofcumpliunce 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 nuniber(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 icnimed 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(lie number listed below. Self-insured companies should enter their
self-insurance license number on the approprirtc line.
City or'rown Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space ut the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pl.asc be sure to till in the permit/license nionber which will be used as a reference number. In addition,an applicant
than must submit multiple pernitllicense applications in any given year,need only submit one affidavit indicating currant
policy information(if necessary) and under"lob 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 file 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
f i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lie t)l lice UI Investigations would like to thank you in advance fur your cooperation and Should you have any questions,
plca.%e do not hesitate to give us a call.
fhe Dcparuncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
OUke of Investigations
600 Washington Street
Briton, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Rai:i+cd s-zG us Fax # 617-727-7749
www.mass.gov/dia