7 PALMER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts Slate Building Code, 780 CMR, 7'"edition OF SALEM
t Revised Junowr
Building Permit Application To Construct. Repair, Rc ovate Or Demolish a I. 1rx6r
(� One-or Two-Fumily OwrlliI
`hJ This ec 'on For OfficiO4Jsc Only
Building Permit Num r://// Da Applied: /
Signature: `4"1 /9/l• U
NuilJiny mission nspectar of BY'" Dale
SECT 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map di Parcel Numbers
7 p41MP,r st .
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 La Amo(sq II) Frontage(11)
1.5 Building SetbacW(R)
From 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 es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Or•ner'of Record:
L_,hcaa Goc\ce
Nome(Print) Address for Service:
,
Signature Telephom
SECTION 3: DESCRIPTION OF PROPOSED WORK'(ebeck all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) df I AdditioJ(3
Demolition . ❑ Accessory Bldg. ❑ Number of Units_ I Other O Specify:
Brief Description of Proposed-Work': t�••v o\ wc, e)cot' S� , c! car
Repl4ca .� rEh 1'r C+l rf' C^kry -JCCr
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OlRelal Use Only
Labor and Materials
I. Building S ,SpG,/ 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical S O Total Project Costs(Item 6)x multiplier x
). PlumbMechanical
S 2. Other Fees: S�. Mechanical (FIVAC) S List: !
3. Mechanical (Fire S
' Suppression) Total All Fee::S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
ba
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS 9 S gas 7 3d ac,IG
.Sol'%r� Cci"It*, I.icense Number F%pimliun lyate
Nance of CSI.- I lulder I.ist C'SL Type(see below)
ch. t Uescri ion
:Address 1lnmtrict[d u to)S,1N10 Cu.Ft.
R Restricted IR2 FamilyDwellin
amre M M O,tl
76—J ID-17f714 RC Residential Rouloc Covering
I'eleplrme W. Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolilion
S.2 Rebtered Home Improvement Contractor(MIC) I S^aoq
S C G e^P/�G k C ova V rq C Iv A G Registration NumM
I IIC Company Name or flit:Registrant Name
C�� IC 'r7er"C4 �'1- CRIPrti Z2
Address `7 7j'J'dr--Cf 17y Expiration Due
'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL f 2SC(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 Issuan of the building permit.
Signed Affidavit Attached? Yea .......... 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 ddeclare
authorize to act on my behalf,in
relative to work authorized by this building permit application.
Si ore of Owner Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby that the statements and information on the foregoing application are true and accurate,to the best of my know
behalf._
.�Ghv. has-, ✓t
Prins Ndm
Si o�olshne o� 10-6-aa�o
Agent Date
(Signed 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 a"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 790 CMR Regulations I IO.R6 and I MRS.respectively.
2. When substantial work is planned,provide the information below:
Total tloors area ISq. Ft.) (including garage,finished basement/anics,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
PUBLIC PROPRERTY
DEPARTMENT
.Nm:R:II Y:)KM:01.t.
M\)oa 12:WASHIN61O.N Sr8ELT • SAt h\4,M.xi5AOn s'E:I nGPi7C
978-7I3-9595 • f.sx:1)78-74C-)846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
% ) rlicant Information Please Print Lecibly
�IafTtt: lnusilxzsi OroanintinNlndivulua4: J�
On�r4ra,hC JT��s^ 4v�, r'C
'r Address: r a IOwJPi3« 1
if City'slarci%ip: SQl?y", M4, Okg-*) Phone g- 479— Sgo- ` 17(f
,%rc yI am a employer with ou an employer'.' Check the appropriate box: 'Type of project(required):
I.❑
4. ❑ am 6, 0 I a general contractor and 1 new construction
e luyces(full and/or part-time).' have hired the sub-contractors - ❑ Remodeling
2, ;un a sole proprietor or partner- listed on the attached sheet. : _
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
I No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL 11.[] Plumbing repairs or additions
3.❑ I ant a homeowner doing all work c y152, s 1 4 P and w• have no
myself. (iCo workers' comp. � O 12.❑ Roofnpuirs
insurance required.) t employees. lKo workers' 13.[ Other 4;Jc-k CfQcsr
cornp. insurance required.]
',Any:yphC4,11 dmt checks box#1 must also lilt um the section Wow showing their workuy cumpansmion puliry mliattut6 a
g I lomeuwrwm who submil this affldavit indicating Ihcy are doing all work a,ul then him outside co,ttmeton must.utmsil a new aCfdavil indi"mg sash.
-('omrnton that check this box must attached an additional sheet+hnwmg the unto*of Cho sub ontraclon and their wurkon'comp.policy information.
l our wt employer shut is providing)vorkers'compensation insurance fur oty enuployeer. Below is the policy andlub site
i ifurmatiun.Insurance Company Name: PC --
11olicy 4 or Sclf-ins. Lic. n: _ Expiration Date:
7 Pczl y,— .Sa- Citytstateizip: SglP.tvx �4. 00470
Job Site Address: �—
Attach at copy of lite workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to sccury coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
tiny up to 51.50o.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. Be advised that a copy of this statement may be lurwarded to the Office of
Invcanguuoni ol'thc DIA for insurance covcragu verification.
l du hereby certify under the pains and penultics of perjury that the inforinution provider/above is true and correct.
jDat• o - 6- aa10
Sin;ruure' -
Ogiciul use way. Do not write in this area,to be completed by city or tolvn ojjiciul.
City or Town: Permit/License#__
Issuing Authority(circle ante): -
1. Board of licalth 2. Building Department 3. Cih 1•ona Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. O1tier ._-- - -
Contact 1'crson: _.. _ --- Phone #:
Information and Instructions
..Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplut•ee is defined as"...every person in the service of another under any contract of hirq
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
,v the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of 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 maintenunce, 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 shaU 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, MGL chapter 152, §25C(7)states"Neither the commonwealth not any of its political subdivisions shall
,rarer into any contract for the performance of public work until acceptable evidence of commpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill 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 certi6catc(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 confirmation of insurance coverage. Also be sure to sign and date the of idavit. The affidavit should
be renamed 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
Air the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
111aase be Sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
brat must submit multiple penniUlicense applications in any given year,need only submit one affidavit indicating current
policy information,(ifnecessary)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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lic Otlice of Investigations would like to thank you in advance fur your cooperation and should you hovc ary questions,
please do not hesitate to give us a call
fhe Depwonent'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
R.%iscd 5-20-05 Fax N 617-727-7749
www.mass.gov/dia
THE COMMONWEALTH OF NIASSACHUSE17S
Office of Consumer Affairs and Business Regulation Registration:
IIome Improvement Contractor Registration Program
10 Park Plaza,Suite 5170 Expiration:
Boston,NIA 02116
Received:
APPLICATION FOR RENEWAL OF REGISTRATION
HOME IMPROVEMENT CONTRACTOR OR SUBCONTRACTOR
NIGL Chapter 142A, 780 CNIR R6
(PLEASE READ INSTRUCTIONS CAREF'ULL1')
L Name of Applicant as on Current Registration: _10 fx rx Cn vyxt �' S C t'rn/y tie:t1't�q C hi I'1(3
2. D/B/A used by Applicant(if different from that used with current registration): _ J I C Ff fhIerq Cpl,}dG 2�ti ny J
J. Address of Applicant(if different from address on current registration):
Akeh okr O6
4. No.of Employees: Q
5. If Applicant is a Partnership.Corporation or TrmL slate the name of the individual responsible for Applicant's work:
Fvst
Middle Lasl Social Security No.
-
Telephone No.
ti. Does the Applicant hold any other construction-related state,city or town licenses or registrations': 1/ Yes No
Construction- Expires: 7 , ,(1®� —
Supervisor License: Ic S 8
Motor Vehicle Repair Expires:
Shop:
7. Is the Applicant claiming exemption from the registration fee.(Please see instructions) Yes M No
S. Registration Renewal Fee enclosed:$ iQQ, / Make all certified checks or money orders payable to
••Contmonwealtb of ISlassachusetts."
ONLY CERTIFIED CIIECKS OR MONEY ORDERS WILL BE ACCEPTED
Pursuant to Massachusetts General Laws Chapter 02C 9 49A,I certify under the penalties of perjum that.to the best of my
knowledge and belief,I have filed all state tar returns and paid all state taxes required under law.
�" Wvire OVAPPIleant Title held with applicant �" , P�
A FALSE ANSWER TO ANY QUESTION IN THIS APPLICATION CONSTITUTES
GROUNDS FOR SUSPENSION OR REVOCATION OF THE APPLICANT'S
REGISTRATION.