52 OSGOOD ST - BUILDING INSPECTION 7 ,9 �
� 3�3
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
t '.I Massachusetts State Building Code, 780 CMR, Vh edition OF SALEM
Revived January
I Building Permit Application To Construct, Rep ir, Renovate Or Demolish a 1. 1008
One-or vo-Family Dvv !ling
Th s Se tion For Offici I Use Only
Building Permit Nu be/r:: Date pplied:
Signature: - a'PvY' Z
-tP� L�
Building Commission /Inspector of it in Date
SECT ON : SITE INFORMATION
1.1 Propped Address 1.2 Assessors Map& Parcel Numbers
L 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 R) Frontage(0)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.11 Qwner of Record•
C�h�1-4b�
Name(Print) Address for S
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 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
I. Building S pp ec: I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (tIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 13 Paid in Full ❑Outstanding Balance Due:
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constru tl0a Supervisor(CSL)
2u Jr ` License Number Expilatiollt Date
Name of�Sl-II,lolder ,ram\ List C'SL Type we below)
1� L YJV 1-6
021, w
f. Description
.4 ss U tlnrestricteJ u to 35,000 Cu.Ft.
_ 4 JNDo R Restricted l&2 Family Dwelling
SignaturA M Masonry Only
c
�('�l �'��j j RC Residential Rooting Covering
lclephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2�$egistered Home Improvement Contractor(HIC) x_ Jmtion N�a umb�, )
LC�rY l 7 er!
HIC Cum y Name or!It(, Regist t Name Regtst
A 1J2ess `?-th � E pimC n Date
Signature feleph n ne
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...........O -
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.
Si+ ature of Owner Date
,f SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
/- that the stafL n nts and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the ains and nalties of r'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 vol 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"
i
CITY OF SALEM
} PUBLIC PROPRERTY
yv -
DEPARTMENT
::LV ;KI EY UaIR:o 1t./.
\I�n,n 12C WasHING J ON S ruEL't'* Snu_.a.Mnssc:I I:,r:I is 01970
Tta:978-145-9595 is 1'nx:978-740-9S46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
l \pnliutnt Information / Please Print Leeibl_v
Nain (13u<ilxx5 Orvaniz:uioNln lividuul): 5A ORA ' r—e—)�
Address:
City/srateizip: r215- _ Phone r'':
Are sou an employer?Check the appropriate box: 'Type or project(required):
I.ff 1 am a employer with t<- — 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).' have hired the soh-contractors 7 remodeling
2.❑ 1 ant a sole proprietor'or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in,any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers' cum insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
I❑ I am a homeowner doing all work g exemption
right of per MGL 1 L❑ Plumbing repairs or additions
P P'
myself. LNo workers' ctmip. c. 152, §1(4),and we have.no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any.j,plicant That checks box hl must also fill out the scclioll hcfuw$flowing their w•orkua compen cation policy information.
' I lemeuwra:n who submit this ar7davir indicating they are doing ull work and then him outside conrraclors must submit a new al'rdavit indicating such.
�Contnwturs thal check this box most attached can additional sheet showing the name of the sub<ontmetors and their workers•comp.policy information.
l aat rat employer flat is providing workers'c•oinpensation im.sarance far my employees. Below is the policy and jab site
itrfarmation.
insurance Company Name: Elrl°
Policy a or Self ins. Lic.t:: ___........_. .._..___—_ Expiration Date:
Job Site Address: CityStateiZip:
Attach a copy of the workers' cotnpensation policy declaration page (showing the policy number and expiration date).
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 a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. iic advised that a copy of this statement may be tbrwarded to the Office of
lavcstigations ollhe DIA for insurance covcrage%eritication.
l da hereby certify wader the pains and penalties afperjury that the information provided above is trite and correct.
Siernmtre: . Datc-
Pltul:c:+:
Official use wily. Do tat n•rite in this area, to be completed by city or town affic•iat.
Permit/License x__-_.--.-.- _- .--- ---_ -. - -
Issuing Authority(circle one): `
1. Board of lle:dth 2. Building Department 3. Cily/Ibtcn Clerk 4. Electrical inspector 5. Plumbing; Inspector
6. Other
Contact Person: - - - _---- Phone it:
r
Information and Instructions
;Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an etnpluti•ee is defined as"...every person in the service of another under any cownct of hire,
express or implied, oral or written.".
\n employer is defined as"an individual, partnership,association, corporation or other legal entity,or any two or more
Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee ul an 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
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 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 perfomlance of public work until acceptable evidence of compliance 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 number(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 contimtation of insurance coverage. Also be sure to sign and Bute the affidavit. The affidavit should
be returned to the city or town that the application for the pennit 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.
Please be sure to fill in the permit/license number which will be used as it reference number. in addition,an applicant
that must submit multiple permiUlicelse 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 tilled 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.
The Off ice of hivestigatlons would like to thank you in adVallCe fur your cooperation and should you have:sly 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
OMce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.govIdle