12 ORD ST - BUILDING INSPECTION r The Commonwealth of Massachusetts
4 Board of Building Regulations and Standards Town of
' Massachusetts State Building Code, 780 CMR, 7'"edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Tiro- P welling Ext 118
This,86cuoifFor O rcial Use Only
Building Permit Number: D e Applied:
Signature: I l]
Building Commi loner/Insp for o i s Date
SEC N I- SITE INFORMATION
1.1 Pro ert Address: 1.2 As Map& Parcel Numbers
!� fact 5-t.---
L 1 a Is this an accepted street?yes_ V no Map Number .Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
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:
� PP Y�( 4 ) g P Y
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑ _
SECTION 2: PROPERTY OWNERSHIP'
.t Ow �of Reggord: I'1 on;Q 5..r,
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ 1 Existing Building dW- Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
�. — � o --
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ r'
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
� �1 Check No. Check Amount: Cash Amount:
6.Total Project Cost: S -3'W1Vr 000 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) '?y 6/S o1 0 O
fZ obe TT- nq(yn n�l License Number Expimtio Date
Name of u,CSL-+He A older U
(I �
8 G�r ale OC( f J/) List CSL Type(see below)
AddrpS� / � /� � � 6/8�3 Type Description
/ `�7� _U Unrestricted(u to 35,000 Cu. Ft.)
�[ �/ l �•(�✓/"� L R Restricted 1&2 Family Dwellin
Signature M Mason -Onl _
272 -36o-s93� RC Residential Ro_ofin Coverin
Telephone R'S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Reg ristered Home Improveme°�Contractor(HIC)
Pe c�st��n c'ctrn. f1c • l57[,S(o
yIC� Company Name or HIC Registrant Name Registration Number
L7E�C' 6,.I� r�M� ^ �iEy_�8.�3 9/to,/0C)
re s P/Z Expiration Date
Signature Telephone
SECTION 6:WORKERS' OMPENSATMN INSL:i<ANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance aftidav it must be cort ietea and sLicuted with iris application. Failure to pioNide
this affidavit will.result in the denial of the Issuance o` he bu ldu y}. . t
Signed Affidavit Attached? Yes ......... No ❑ —
SECTION 7a: OWNER AUTHORIZATION TO BE CONI?LETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I
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 applicction.
Signature of Ov.ner - Datc
SECTION 7h: OWNER_OR AUTIiORIZED AGENT DECLAR kTION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are,Cuc and accurate, to the best of toy knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed_under the Fains and penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an tu:registered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will not 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 I I O.R6 and 110.R5,respectively.
2. When substantial work is planned, provide the information below:
Total Floors area(Sq. Ft.) (including garage, finished basemenUattics, decks or porch)
Gross living area(Sq. Ft.) Habitabie 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 SALEM
, ..� PUBLIC PROPRERTY
_ .. � ' r DEPAIZ'I �tENT
64�
.. •.I . .I: I_„ A \ .III\i.. '•:ll:;lli � 1.\II \I, \I \ .\I I _I'I _
III '1'S '4. );�r
Construction Debris Disposal Affidavit
(teyuireJ fix all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CNIR section I 1 1.5
Debris, and the provisions of IAGL c 40, S 54;
is issued with the condition that file debris resulting front
Building Permitf
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c K }
I 11. S 1 50A. t"
The debris will he transported by:
Utamc of haul�r)
r
The debris will be disposed of in
mew sw�s� 1
tmm�r ul Indrty)
6ZT l 33 C�nl�ief�wn Mf} / 3 3
Iaddresv of racllnvt
♦IL'IWIUII' nt prnuu .ytphmnl
/7 ' 8
1, JW
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I\:, It ILL Wd1t Ij.%G JON SI:t LL f • S.\In'\7,MAYS.\e.111 it'I Is0177--
11,i. )78-7s5-93 t5 • P.\x 978•74".9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
\ ) )Iicant Information — Please Print Leclibly
V.11Tt lau.uxsvt�rganv:uiaNlnd uluoll; 151Uf-N (771C(J a� �-1�Ro6-t1-00c n'?5
AddrCss:��(nn G%nrJP/1 Gi) C
City,Statc,%i(t �J1�lJTGPtCZ&j0 (�A (J'/�.��Monei': 9�� �60- 5�1 3a
Are)ou an cuiployer? Check the appropriate box: 'Type of project(required):
i4. ❑ 1 :fin a general contractor and l 6. ew construction
1.❑ I :u)r a employer with�_ have hired the sub-contracors
2. en11,a sale
(lull antor r papanrtner-
� 7. ❑ Remodeling
❑ 1 ;fin a sole proprietor or partner• listed on the attached sheet.
,hip and have no mnpluycos These sub-contractors have 8. emolirion
working liar me in any capacity. workers' comp. Insurance- q. ❑ Building addition
No workers' comp. insurance 5. ❑ We arc it corporation and its 10.❑ Electrical repairs or additions
I re(juired.) officers have exercised their
right of exent lion r MGL I I.❑ plumbing repairs or additions
3,❑ I ❑ a homcuwner doing all work c 5152. g 1(4),and we have no 12. Rout repairs
Myself. lKo workers' comp.
insurance required.) n crnployccs. (To workers' 13.❑ Other
comp..insurance required.)
•any,,,pbcant Ibot checks box rll mint also till sun the wclmn Inlow;hawing their w•orkus�cumpuns:aion policy ioliumatium
` I lomeuwm r%tvhu submit this ofridavit indicming Ihc)ate doing all work a1W dmn hire outside cwurxtun muss suttmit a nesv al'Cdavit...Jimmy such.
-f r trxhgh Ihal thcck this box must antwheli on additional.Awvi shuwiny the name of the
sub<omracWrs and their wurkun'comp.rydicy mformanun.
fain fill eugtloyer that is pruriditgf workers'curnpenvation insurance fur my eanployees. Below is the pulicy and)ob site
iujunnarion. �` �}
lit,urancc Company Narne:jr1UV h t- �nbS • Criros,5. Put,_O_f_�_ 1AS.
W rz�Ja7B o�.0 0 . _.- Expirallun Date:_! d
I'ulicv 4 fir Sclf-ins. Lic. �: C -_,
Job Site Address: AIOfd tit . _c,�L•.t',r�rr--+^ T. Ctty;Slatei'Llp: S4I�M M�
Attuch it copy of the workers' cotnpensation policy declaration page (showing; the policy nuruber and expiration date).
I'ailarC to secure coserage as required under Section-25A ul'.%IGL c. 152 can lead to the imposition of criminal penalties of a
tine uP I„S1.500.00 and/or une-year nnprisomncnt, as%%ell as civil penalties in the lunn of a STOP WORK ORDER and a fine
Of up to S250.00:t day against the violamr. Re advised that a copy of this,mtcntcnt may be lurwarded to the 011ice of
Inc:�m,a u�ms ul the DIA :or inrwarcc p,vcrago \critic.lnun.
l do herrhy�crtifv under the pains anal pena/tiev ufperpnry that the atfornnattan provided above is true and correct.
-
I'l,,.re
O/Jicial use undy. Do not nvite in rhi.v areu, to be cutnyleted by city fir toivn oI)icial.
Cily or Town: Pcrtnit/License 4,_ _
issuing Authurity (circle one):
L Roard of Ilv;dth 2. Building Dcpar incol .1. Cit)r-fown Clerk 4. Electrical Inspector- 5. Plumbing Inspector
6. Other . ..
Contact Mrsou: -- __ Phone tt:
Information and Instructions
Massachuscits General Laws chapter 152 requires all employers to provide workers' compensation fir their employees.
Pursuant to this.statute, an emplgrre 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 tither legal entity, of any two or more
of the Gtregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or tru]tee ut .or individual, paltnershlp,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."
MGL chapter 152, §25C(6)also states that "every state or local licensing agency shall withhold the issuance or
renewal of u license or permit to operate a business or to construct buildings in the commonwealth for any
applicant wlm has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, hIGL chapter 152, a25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of puhlic work until acceptable evidence ufcompliance with the insurance
requirements of this chapter have been presented to the contracting authority."
t
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) name(s), address(es)and phone nunrber(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 maybe submitted to the Department of Industrial
Accidents for confimnatiun of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
be retunxd 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 it workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number tin the appropriate line.
City or Town Official
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant.
. 11Isue be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicease 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. ❑ dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he i)dice tit Invesrigatiuns wuuLd like to thank you in advance for your cooperation and should you has'o any questions,
please do nut hesitate to give us a call.
The Ucparoncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel- N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia