31 ORD ST - BUILDING INSPECTION The Commonwealth of Massachusetts
v Board of Building Regulations and Standards Town of
CC ' Massachusetts State Building Code, 780 CMR, 7'"edition Wilbraham
\u Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
U One-or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Co t
i er/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
T
X / o_� fT _
1.1a 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 Ft) 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
✓ 2.11 Owner'of Record, ?r Dk2D S J
/� LtIJP ,
Name(Pr_int)) Address for Service: o 6 I
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑axdisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Aiteration(s) )I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 7 e U 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Applic Lion Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ —
Su ression Total All Fees: $
` Check No. Ci eck mount: Cash Amount:
'X\ 6. Total Project Cost: $' ?a��, 6 ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) D66/ J
�ti � n �O
License Number Expiration Date
Name of CSL-o2 r �. __ �� List CSL Type(see below)�_
�r c Type Description
Address U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature // M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Were �rovement
ere�rovement Contractor(HIC)
HIC C.Ompan N me or}jIC Regi tr ut Name r, Registration Number
lao el?
C
Address / 3
3 ;/3F7 ration Date
Signa 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 he.building permit.
Signed Affidavit Attached? Yes .......... No........... ❑ -
SECTION 7a: 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: OWNER[ OR AUTHORIZED AGENT DECLARATION
1, �� ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are truz and accurate, to the best of my knowledge and
behalf.
Zee _
Print Name
Signature Owner or Authorized Adent Date
_Signed u der the pains and penalties of er u
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.R6 and I IO.RS, 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"
I
. JXBoar o m dmg�lat•Ions nn ' tan ards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 100733
Type: Private Corporation
Expiration: 612 312 01 0 Tr# 267195
A. B. CARNES, INC. — ---
Barry Carnes —— ---
30 Arrowhead Farm Rd.
Boxford, MA 01921
Update Address and return card.Mark reason for change.
Address ❑ Renewal Employment Lost Card
oascnt a so•+mmr-xe�so
anard fS ogrxar.w,wl10"2 ntl Sr�an0 rdds
COOetrllclton Supervisor License '
'L+icense: CS
Expiration: 1/14/2010 Tr# t2607
9 Restriction: 00 t
'n
KENNETH R CARNES
GRQVELAND.MA 01834 Commission-'/'_ I,
a MB4 CERTIFICATE OF LIABILITY INSURANCE DATE z; '
PROB(IC.ER (781)438-5000 FAX (781)438-SO28 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
New &oiand Heritage Insurance Agency Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
335 Main Street HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Stoneham, MA 02180 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIL#
wauaw A B Carnes,Xnc. ILSUREtA- Essex Insurance Co.
30 Arrowhead Farm Rd. INSUIIEReR AIG AMERICAN INfERNL GROUP INC
Soxford, MA 01921 aeL�ea
a
v�e
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED-NOTWITHSTANDING
ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORD BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS-
MR POUCYEFFOCTIVE POUCYOUPWATION
ITR TYPE DFp�A� FOLI;YNINMo LIMIrs
GIDIERAL LIAwLIT TBD 63/18/2008 03/19/2009 EACHOCcuRRENCE $ 1,000,001
X COMME CI ALGHNERALLIABEJTY DAMAGE TDWWVD s SO,OOI
CLAIMS MADE ❑X OCCUR aEnEm lA�y o„�pa- S S,001
A PEeSONALSAMILIIRY $ 1,000,001
T7
GENERAL AGGREGATE S 2,000.00
GENL ACGR8G-TE LIMIT APPLIES PER: PRODUCTS-COMPATP AGG S 1,000,001
POLICY LOC
AUTOMOBILE LIABRnT
ANY AUTO (Ea SINGLE LIMIT S
ALL OWNED AUTOS
BODILY p I IURV $
SCN®IA.EDAUTOS SPe*Cason)
HIRED AUTOS
BODILY IDURY S
NON14)WNED AUTOS Der acodem)
PROPERTY DAMAGE $
(Per aaiEaa(
GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC S
-
AUTO ONLY: AGO $
EXCESSND�LIABILITY EACH OCCURRENCE $
OCCURO aCLAIMS�E AGGREGATE
DEDUCTERE
RETIRETENTIONS s
WORKERS COMPEN ATaNAm MC 844-90-76 03/31/2008 03/31/2009 wcsrATu OTW
EMPLOYERS LIABILITY
B o�E� � - El.EACH ACCIDENT S 1,000,00<
El DISEASE-FA EMPLOYEE S 1,000,00(
OTHER PROVISOOMblow EL DISEASE-POLICY LIMIT s 1,000,
DESCRIPTION OF OPERATIONS/LOCATHONGI VE ICLES/Exa>mONs AVOW BY ENDORSEMENT ISaPECIALPRovlsroMS
ontractor Subject to terms, conditions, endorsements and exclusions on the Policy.
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE BRIM POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN INDUCE TO THE CMITIHCATE HOLDER NAMED TO THE LEFT.
MR FAILURE TO sum.SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
"PROOF OF INSURANCE COVERAGE ONLY" OF ANY HIND UPON THEINBUR13k ITS AGENTS OR REPRESENTATIVES.
SPECIMEN COPY ONLY AUTHOR®REPRESENTATIVE
William Kell
ACORD 25 I2ODIMS) elarnon rnoonoAyinu 4AAn
CITY OF SALEM
PUBLIC PROPRERTY
' DEPARTMENT
!1M v
i
t•,. I t\ 'i'9 V_ vi lip
Construction Debris Disposal Affidavit
(re\luiICd litr all demolition and renu\ation \wrk)
In accurdance \%ith the sixth edition ofthc State Building Code, 780 ChIR section 1 I 1 5
Debris, and the pro\ isiu[Is of b1GL c 40, S 54;
building Permit t is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported
by:
manic of hauler)
I he debris will be disposed of ink:
de/
^^��-- (ta rul laulily)
`
I ,rldrri.ur I�rJnvl
.Icnamic of p.nuu .ytphcant
dale
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,I V It;g[1'1':)KISCI-1 1
\l.\lott 12'-WANHl\G ION S't'X LET • SA E.M.M.\ss.\a IS]
.'I'11 G197�
Tel.:978-745-9595 • P.\X. 978-741V9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers -
,X r tlicant Information
Please Print Le ibly
V nlmt: llluciucty OrganiratioNlndlvuluul):�
City;Sta[ -%ip
Phone /':
Are sou all yer? Check the appropriate box:
type of project(required):
i 4. ❑ 1 Inn a general coutractor and 1 6. ❑ New construction
L toll a employer with
have hired the sub-contractors ❑ Remodeling
7.
employees(full antL'ur part-oars).' listed on the attached sheet.
2.❑ 1 ant a sole proprietor or panncr-
sltip and have no employees These sub-contractors have 8. ❑ Demolition
workers' comp. insurance. 9. ❑ Building addition
working for me in any capacity. 5. ❑ We are a corporation and its
lKo workers' comp. insurance officers have exercised their 10.❑ Electrical repairs or additions
required.] 1 1. Plumbing repairs or additions
right of exemption per MGL ❑ b •p.
3.❑ 1 ant a homeowner doing all work c. 152, §1(4),and we have no 12.❑ Roof repairs
myself. re workers'comp. cinployces. iKo workers'
❑
insurancee required.] 13. Other
comp. insurance required:J
•one uppbcam Ihut checks box dl must also till our the+ucrian twluw showing their wurkui eumpensatiou pulicY intiutrlation.
' I lomcnwrwrs vhu rubmil this al7davil indicaung they are doing all.work alul then hire uulside cunuxmn mart submit a new alfda'Ibc infotrtnaaun.
d'.mlrxurn that check this box must aowit ci an additional.cheer showing the name of the sub-contractors and their workers'eornP P Y
employees. Below is the policy and job vile
• but is providing workers'cmnpenvnliwi insurance ja•my
/tun air roydaycr t p
inforularion.
Imurancc Company Name: ----..... ..d(.(, �f�'r
g /? to. __ Expiration Date:-1
1'nlicv a or Sclf-its. Lia 1=: - c/�
Job Site AtlJress:�� ----
City:State/ZiP
Attach a copy of the workers' compensation policy declaration page (showing;the policy number and expiration date).
hailure to secure coverage as required under Section 25A ul'\IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to SI.500.00 and/or one-year imprisonment,as well as Licit penalties in the form of a STOP WORK ORDER and a fine
of till to S250.00 it Jay against the violator. Ile advised that a copy of this statement may be forwarded to the Oltice of
Inccsu�•auons of the MA for insural:cc coverage \critic. m.
l du hereby terrify under the pains urtd pens tics jperjury that the injurinution provided above is true turd c'o't't'ty-
Date'
I'h�n:er:: �/ l0
Official rive only. Do not n•rire in this area,to be completed by city or town a ficiuL
Cilv or fmwn:
_ Permit/l.iccnse 9._ .. _.
Issuing :\Whority (circle one):
1. hoard of llcallh 2. Building Department 3.CitJ'rfo\\n Clerk 4. Electrical Inspector 5. Plumbin); Inspector
4. Other _ -- -
Phone q:
Coutact Pcrsont
Information and Instructions
,Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empluyees.
Pursuant to this statute, an einphgyee is defined as "...every petxon in die 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
,it the 60regoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of am individual, painiership,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 shalt not because of such employment be deemed to be an employer."
IIGL 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, NlGL chapter 152, �25C(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 ol7compliance 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) namc(s), address(es)and phone nuniber(s)along with their certificates)of
inswancc. 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 of idavit 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 number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of rile affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Phase be sure to fill in the permit/license number which will be used :is a reference number. In addition,an applicant
that must submit multiple permiUlicense 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. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I Ile Of'icc or Investigations would like to thank you i❑ advance fur your cooperation add should you have any questions,
please do nut hesitate to give us a call. -
rhe 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
2.viscJ i-2ii-05
Fax # 617-727-7749
www.mass.gov/dia