18-20 ORD ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
t t Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7" edition Wilbraham
Building Dept
Building Permit Application To Construct air, Renovate Or Demolish a 413-596-2800
One-or Two- roily Dw ling Ext 118
This 5ection For Qfficipp Use Only
Building Permit Num r. a plied:
Signature:
Building Commissioner nspecto of Buildings Dale
SEbTIOX-tePTE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes y no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(fit)
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 n site disposal system ❑
Check if yes❑ p ~
SECTION 2: PROPERTY OWNERSHIP'
2.1 caner'of Record:
JbaiJ k C ar�5n (R - DO e) C4 &1ree4
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)X I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': 0 1 E `
o va. nlr
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ �-
4. Mechanical (HVAC) $ List: (�
5. Mechanical (Fire $
Suppression) Total All Fees: $
C o-� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ /0 �� x 0 Paid in Full 11 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /`,^�-]SSS3 DY 08 'pof
C r
E+t t� R, l��✓�C C/ License Number Expiration ate
Name of CSL-Holder q List CSL Type(see below)
.
Adder T Description
U Unrestricted(u to 35,000 Cu. Ft.)
Restricted 1&2 FamilyDwelling
Signature M Masonry Only
Via"uhN_" PLO RC Residential Rooting Coverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement ontraetor(HIC) 13 o n t
���1 R �..f -4mr 6r 7
HIC Company Name or HIC Registrant Name _ Registration Number
Address
tl t��d fV Ez iration ate a
Signatu Tclep one n
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... No........... Ct
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, f36bc k iL c ar���. ,r as Owner of the subject property hereby
authorize b0 11 Q C{� �' I�145C zsaSJv SPc (df 9 to act on my behalf, in all matters
relative to work au honzed b t budding permit apnli�t '
Signature of Owner Date
SECTION 7b: OjjWNEW OR AUTHORIZED AGENT DECLARATION
as Owner Authorized eby declare
that the statements and information on the foregoing application are true and accurate Agent
, '5'est of my knowledge and
behalf. —
1
Print e _ /,O i (D dA
_ 6 I
Signer r o rize Agent Date
Si ned under the ains and enalties of e J
NOTES: J
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 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 1 I O.R6 and I I O.R5, 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 SALEM
PUBLIC PROPRERTY
DEPARTMENT
i
III '��5 ';i '�+•�j I \";'V.'A. L,
Constrtiction Debris Disposal Allidavit
(re�luired titr all demolition and re10vation '01k)
In accordance ill) the sixth edition of the State Building Code, 780 CMR section 111.5
Witis, itnd the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
t 11. S 150A.
The debris \\'ill be transported b 0j ^
(name of hau r)
I he debris will be disposed of in
(nainr ul Iaeihty')
aenatwc of pcnna applicant �,
� )C
late
CITY OF SALEM
PUBLIC PROPRERTY
?P;-
DEPARTMENT
_
,I Ill;M:I % IINIi(.11I 1
M\,\ta 12L W,\stur.o It^S l set a • au 1'\I,M.\n.u.IIt it I rsu197C,
ll,l: 779-715-9595 • 17.\s. 97s.71CC9846
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
1 ylicant Information Please Print Leeibly
Name (13uuucevl)rgamrationVindjs ldual): M ST
ddress: F1d*cL -e cSLee.L i 4/ fop
City,State,Zip: l�� ��� 1(/ Phone r!: l �917� 6 0 -7d ly
Are you an employer? Check the appropriate box: - Type orproject(required):
1.4 1 :uyt a employer with 4. ❑ I am a general contractor and l /I. ❑ New construction
ens tloyecs Cull antL'ur art-ume).• have hired the sub-contractors
1 ( P 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on The attached sheet.
ship and have no employees - These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
Ko workers' cons 5. ❑ We are itcnrporation and its
P' insurance officers have exercised their 10.0 Electrical repairs or additions
I required.]
ri�h[of exemption ..r MGL 11.❑ Plumbing repair or additions
3.❑ 1 am a homeowner doing all work c y152, i 1(4),and\v have no
Myself. tNo workers' comp. 12.❑ RuuCrepla\lrs
insurance required.) t uinp. inch. nc workers' 13.[RUlher 4sf5R�I'�
comp. insurance required.]
-4m .,ppbcanl Ilut checks bus OI muss alw rill out the µcoon bcluw showing their wurkws cumpen Wiun policy mfurrnatium
' I lomauwmm whu.ulbmit this affidavit indicating they a c doing ull work and then hire uulside contractors must auhmit an.afl"davil indiuling omh.
-C.,nlrxasn that dwck this boa mW Jnwhod an acditiunal Jua:1 showing INC name orthe sub"comraciors and their workers'comp.policy mfurmamm
/uttt an employer that is providing workers'c•onipensntion insurance for my emtp/uyecs. Below is the policy andlob rile
hiforinution.
Insurance Company Vmne: _...---------
r� A p 1 �y
I'nlic_v 4 or Self-ins. Lic. *c: AWC 701303_(1, (DPI d- OO o.. -- Expirulnun Date: S r/ //
Jul) Sitc Address:
IV' do arj S) frl CityiStatci"Llp: �len /dC/4
Attach it copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
pailure to secure coverage as required under Section 25A of>lUL c. 152 can lead to the imposition of criminal penalties of 3
- t m of a STOP WORK ORDER an
d a fine
) f anJ,'or one-year ins risonmcnt, us \yell as civil penalties m he iul
rime up at Sl.S(O.NI y P ,
. o of this,ialement ma be lumarded to the Uflice of
�" To -250.00 a du against the violator. Ile advta:d that❑copy Y
, top � Y 6
Inc:,trSa sons ul the DIA for Inslsr:uxe av\cenge \ecitie.u;on.
/Jo hrrrhy ccr o Id rhr n )rs onJ nllics jpejury thus de urjunnuttan provided above is true nod correct.
hcbEy/ -wia
OJfic•iul use only. Do nor write itt this area. to be completed by city up town official.
City or fawn: --- . -- Per mitll.iccnsc
Issuing; Aulhurily (circle glue):
1. ISuard of licallh 2. Building Mpartlncut 3.Cili font Clerk 4. L•'Icctrical luipec nor i, Plumbing; Inspector
6. Other
Conlael Pcnuo; _. __ I hone r!:
Information and Instructions
\IaLs.acllusens (3crleral Laws chapter 152 requires all employers to provide workers' compensation for their cnmployces:
Pursuant to this statute, an empluree is defined as"...every person in the service of another under any contract of hire,
cypress or implied, oral or written.''
An eiriployer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more
of the l;uegoing engaged :n a joint enterprise, and including the legal representatives of a deceased eniployer, or the
receiver or trustee of in individual, pamnicrship, 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 erountLs or building appurtenant thereto shall not because of such employment be deemed to be an employer."
..10GL 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 "Ito has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally. :bIGL chapter 152, §25C(7)stales"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable ec idence ol-cunnpliance 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 nmllber(s)along with their cerrificate(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 confirlation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
Lie 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 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.
Pl:a-se be sure to till in the pennittlicense number which will be used as a reference number. In addition,an applicant
iliac must submit multiple penniolicerise 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 is proof chat 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 h: 1)dice of Invesrigations would like to thank you in advance fur 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
Otflce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
y T1. &.�.a ��zla�aaG,�ra
Board of Building Regulations and Standard*
Construction 3upervisorLicense
_ ' Licenae� CS- 75553
BlrtGdate: 4/8/198T
Expiration=-'4/8/2009;' Tr# 140W
Rsstrktlon 00 J
{ DONALD R WHITE JR" +`fr} �•
13F 88 LINDEN ST �L`a '';5 �-•� �-?"
SALEM,MA 01970 . Commissioner
I
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