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4 ORLEANS AVE - BUILDING INSPECTION (3) The Commonwealth ol'Massachusetts Board of Building Regulations and Standards CITY y ) Massachusetts State Building Code, 780 CMR. 74,edition OF SALEM "'wwwar Reru"rd Jmman• Building Permit Application To Constru 1.Repair, Renovate Or Demolish a /. :TRAY One-or rwu-F milt/Dwelling This S on Fw Official Use Only Building Pernik Num r. Date Applied: 0 Signature: 22 � missione Iropectw of 8uildinya Data " SECTION 1:SITE INFORMATION 1.Lrperty IAdd� J 1.2 Assessors Map& Parcel Numbers 1.I a Is this an accepted street?yes no lmapNu;;Wr Parcel Number IJ Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Fronrage(tl) 1.5 Building Setbacks(0) From Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.1 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2.( pwr rtneI Trdllrn ec N 4 Orleans Age. Nu�c 1 'no) Y�—I nT— Address fw'S'eervice: //��}/( / /� signal n: Q �Y Ml — ` ' 6' —I Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(check al that apply) New Construction❑ 1 Existing Building Owner-Occupied OQ Repairs(s)A I Alteration(s) ❑ Addition ❑ Demolition Cl Accessory Bldg.❑ Number of Units—J I Other ❑ Specify: Brief Description of Proposed Work': e w,C)�, SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials 0111c1a1 Use Only I. Building I S /00 0. oc-) I I. Building Permit Fee: f Indicate how fee is determined: 2. Electrical s ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x J. Plumbing S 2. Other Fen: S 4. Mechanical (FIVAC) s List: / 5. Mechanical (Fire s ^ Suppression) Total All Fees:f Check No. _Check Amount: Cash Amount: 6. Total Project Cost: S /.QU D 0 Paid in Full 0 Outstanding Balance Due: SECTION S: CONSTRUCTION SERVICES 5.1 Licensed Constructions Supervisor(CSL-)1 +Dz kca 2 07�r2 20 rn�j-i�e.� 1 a L?,&es 6 Vv I.iccrue Number Expiration IYute Name ul'CSI.- Iluldct .c { 1 I.is1CSL f)pe lsce below) `►�3 2 .�c�v n vtn P�S 1 �yn�t �, �l(F f I)escri ion WJre �_ D_ - — U Unrestricted too to)3.000 Cu.Ft. R Restricted Id2 Famil Ihvellin signs Sg Q6 C '7 M M -1 R'7 Y3 RC Residential a"""' C'overin I dephnte WS Residential Window and Sidi" SF Residential Solid Fuel Bumin A liarwe Installation D Residential Demolition 5.2 RegVtered Home Improvement Contrsclor(HIC) 1 R 1B s [ Mai 7)L�1 ) ('C..4 tM�Sa 1 �O° v�S F. �r�C. Registration Number 11� Zpan Name or HIC Registrant Name (� �� 7 �wrw e.n 0 T LYAI n c 1�2L4 AJJre Expiration Date Signature Tcleplwne SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. IS2.! 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. FSEECTION Affidavit Attached? Yes ..........O No...........O 78:OWNER AUTHORIZATION TO BE COMPLETED WHEN ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT SsCjti- � ri�� as Owner of the subject property hereby ze to act on my behalf,in all matters to work authorized by this building permit application. Signature of Owner Date 7behalf. ECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION r)"�'�?� ,as Owner or Authorized Agent hereby declare information on the foregoing application are We and accurate,to the best of my knowledge and Signature o/f(honer or Authorized Agent Da1a/ U (Siwxd under the pains and penalties of '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 M have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IOAS.respectively. 2. When substantial work is planned,provide the intormation below: Total floors area(Sq.Ft.) (including garage, finished basement/actics,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 ). "Total Project Square Footage" maybe substituted for"Total Project Cost" CITY OF SALEM ,, ; , r PUBLIC PROPRERTY ?~'`f DEPARTMENT J 46:NI PY:lMIA:,rl 1. 12-.WASHING ONSYSCL•T • SAL F.M. MASIM:III sr.f Is.�1970 Ila.:778-745.9595 • FAX. 978•7V0�rsaG 'i'lorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers %milicant Information Please Print Leeibi V i11T1� lnlnnkxslt)r�anintinNlnJrvrtluul): /'/�'i 7T'�e� ' "`�x"'t PSd� W''YS�� LYE" '(✓ Address: City,Starci/sip: L yv% W' 6-4 019"40 Phone 1""13s,8 ^ 0 6 7 Are eau an employer? Check the appropriate box: Type of project(required): I. I am a employer with I 4. ❑ I am a gcncral contractor and 1 fi. New construction employees(full and/or part-tinlc).` have It the sub-contractors .❑ 1 ant a sole proprietor or partner- listed on the attached sheet. �• Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working lbr me in any capacity. workers' comp. insurance. - g. ❑ Building addition l No wodecrs'comp. insurance 5. ❑ We area carporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 ant a homcowncr doing all work right of exemption per MGL I LC] Plumbing repairs or additions myself. (No workers' crimp, c. 152, q 1(4),and we have no 12.[ Kitouf repairs insurance required.] r employees. (No workers' 13.0 Other comp. insurance required.] •:eny:npbcaut that checks box nl must also fill out the sectim,bctuw showing Their workus'cumpvnuaiau policy inliurtwliun ' I lumeuwnen whu.uainut this atlidavit indicating they are doing all mark and then him ourside ewurxton mesa.uhrnit a new a1'nda.ic indicting etch. fomcwurp that check this box mthtt mnchal.m addiliutml..,heat.hawing the ,auto of the sub:ontracl,tn and their wurkan'comp.policy infurrnatiun. /rare rat era/duyer ghat!s pruvidinr rvurkers'cumpcnsntinn inrurnnre jar cry eurpfuyeex. Below is the policy and job site iujornrution. _ c Insurance Company Name: &i-5d:�� S'hS • Up CC L ' Vol icy N or Sclf--ins. Lic.it: M A W� 1 Z'vs 1 . . .._ Expiration Dam: I I D Z© ( i Job Site address: t' DT-Ie-�$ P-i,� I C'ityrstat yzip: 8r,1V- % Wlal Attach a copy of the workers' compensation policy declaration page(showing; the policy number and expiration date). Failure to sccurc coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties of a Line up to 31.500.00 and/or one-year imprisoumcnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine of till In 5250.00 it day against the violator. He advised that a copy of this statement may be forwarded to the Office of Invesngauons of the DIA for witirarcc covcrayc s,:rificatiun. l do hereby ccrtigj,V mider the pain.e and penalties ujperjary that the injorinution provider/above is true artil correct. Date: 10 Fh,r e:r `78(-OSB- 0667 Official use only. Do not ,•rite in this area, to be completed by city or farvn official. City or Town: Purmit/License l Issuing.\ullmrity (circle one): I. Iloard of health 2. Iluildin,4 0cpartoreut 3. Cil%.fotsa Clerk 4. L•'lectrical Inspector 5. Plumbing Inspector I (a. Other Contact 1'crsuslt __ Phone tl: ti Information and Instructions \Inssachuselts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Porsu:utt to this statute, an emplurea is defined as"...every person in the service of another under any contract of hire, caprcss or implied,oral or written." An employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more d the turceoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of-in 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 .Iwelling 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." `IGL 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. N IGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfomtance ul'public work until acceptable evidence ofconrpliance 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-contractors) name($), addresses)and phone number(s)along with their certificates)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 be r'Cfnrnetl to the city or town that the application for the permit or license is being requested, not the Department of I ndustrial 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 tire 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 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 fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitiliceatic 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 t i.e. ;n dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he t)tlicc of Investigations would like to thank you in advance fur your cooperation and should you have any questions, please du not hesitate to give us a call. The D.par(mcnt's address, telephone and fax number: The Corrunonwealth 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 Fax #617-727-7749 Ra%iscd 5-26-05 www.mass.gov/dia 'a CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT M \1 qt 120 WASHIM.:i NSI'NLLT • SA FM. MAYNA( IIt tit I'iN JI'):'� 7 r.1: 978.74 9i95 • 1:a\x:978-740-9846 Construction Debris Disposal Af idavit (required fur all demolition and renovation work) In accordance with the sixth edition of the State'Building Code, 780 CIv1R section 111.5 .._ _ Debris,_and.the provisions_of.MGL c 40,,5.54;__ _ Building Permit it _._ is issued with the condition that the debris resultin.- from this work shall he 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 Quune ul'facility) �A0.. (address of facility) i signature of permit applicant 9/io date