2 PARLEE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
�•,{i Massachusetts State Building Code, 780 CMR, 7"edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tmn-Family Dwelling
This Section For Official Use Only
Building Permit Nu er' Date Applied:
Signature: �j ' jj U
JBuildin ommissioner/Inspector of Buildings Date
SECTION I: SITE INFORMATION
I.I ProP"y A dress: (` q 1.2 Assessors Map& Parcel Numbers
svt
1.1a I this an accepted street?yes no Map Number Parcel Number
1.3 Zoning information: 1.4 Property Dimensions:
Zoning It Proposed Use Lot Area(sq R) 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 O On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 ner'of Record:
G 1�ir/' old `3 4-1! �4 r ✓K e t
Name(Print) Addre for Service:
Signature a Teleph�
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constmetion❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Des riptio of Pr ed Works
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire
Su ression $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ (/v� ❑ Paid in Full ❑ Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
/ •y♦,n Q/„ff,UJ�'� �U���- License Number Expiration Date
V N.4 F%r'S>L/Higider List CSL Type(see below)
• Type Descri tion
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 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature 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 the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
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.
ti
" Si nature of Owner Date
SECTION 7b• WN 'OR AUTHORIZED AGENT DECLARATION
1 , as Owner or Authorized Agent hereby declare
at the s to a 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
(Signed under the pains and penalties ofperjury)
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 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 I I O.R6 and I 10.115,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"
�.� Xea�nrr�Q �u�eaCC� ��- �a� acliu�ed
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
' Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 148515
Type: Individual
Expiration: 9/29/2009 Tr# 260417
JEFFREY D. LEBLANC
JEFFREY LEBLANC
19 SHERMAN ST UNIT2
PEABODY, MA 01960
Update Address and return card. Mark reason for change.
Address Renewal Employment Lost Card
FP&r cJ i/ -FN1 -07-PC8450
./�e' �'/:/II IIN:I/IL✓0���. !%. //l.ii!!:'/I//.N!f'<d
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
i 1 Y Registration: 148515
Expiration: 9/29/2009 Tr# 260417
Type: Individual
JEFFREY D. LEBLANC
JEFFREY LEBLANC
18 SHERMAN ST UNIT2
PEABODY, MA 01960 Administrator
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:Ikw:Ri.ry URISC1'I t.
MAYOR 12^�WMHING IONS MELT 4 SALEVI,MASSACI It Sil'I"I N 01970
Tra.:978-745-9595 ♦ P:vs:978-741VM46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
f Q IL 1
Nate(13usilwss/or8ani7atioNlndividuul):
Address: /7 Ste/,/x64,vL g�/
CityiSmtc l.ip 42d& f1/O'hone iI:
Are you all employer'. Check the appropriate box: 'Type of project(required):
4. I am a general contractor and[
I.❑ 1 ❑m a employer with ❑ G. ❑ New construction
employees(full and/or part-time).• have hired the sub-contractors
2A1 Imt a sole proprietor or partner- listed on the attached sheet. ; 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
INo workers' comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their lo.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LE] Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12g. Roof repairs
insurance required.] t amployecs. (N'o workers 13.0 Other
romp. insurance required.]
•Airy applicant drat checks boa bt must alau till out the w:aion Wow showing(heir workus'cumpcn,ution policy infutnmrion.
'I lomcuwta;rs who submit this affidavit indicating they are doing all work and then him outside curumotom must submit a new al'Ld wit indiwring.arch.
4G,nuacwn that check this boa must attached nn additional sh vt showing the name of the subvontrntors and their workers'comp.policy information.
l and an employer that is providing workers'compensation insurance fur my,employees. Below is Ilse policy and job xile
infornlutlOn. � ..,,QQ
Insurance Company Name: — /� o2
Policy k or Self-ins. LiC. *: c //71. Expiration Date
Job Site Address: - c.J _ .Si41 ` � �` - Cily%State/"Lip: ,,_, -
Anuch it copy of file orkers'compensation policy declaration page (showing the policy number and expiration date).
I;ailure to secure coverage as required under Section 25A of`1GL c. 152 can lead to the imposition of criminal penalties of a
fine 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. llc advised that a copy of this siutement may be forwarded to the Office of
I u�'rstigatiuns ul the DIA for insurance coverage vcrificatiun.
l du herrby cerl-y I Id Ilse rains and nu ies perjury that the infurinution provided abov is I e and correct.
SI e:I i I I Date: D
Ph"
Offlciul use only. Do not prite in this area. to be cumpleted by city or town official.
City or Town: _ _ _ Permit/License#_____
Issuing Aufhorify(circle one):
1. Board of health 2. Building Mparttnent 3.Cityffoin Clerk 4. Electrical Inspector 5. Plumbing Inspector
G. Other
Contact Person: _. _ _ ____ Phone#:
Information and Instructions
ptassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplgree is defined as"...every person in the 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
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of:m individual,parmership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than thine 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 he 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, :vIGL chapter 152, .}25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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) namc(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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be 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.
Please be sure to fill in the penniUlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennitllicense 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Oflce of Investigations would like to thank you in advance for your cooperation and should you have:my questions,
please du not hesitate;to give us a call.
The 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-NIASSAFE
Fax# 617-727-7749
Revised 5-26-05
www.mass.govIdle
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
-
I!1 V'4-74;-9�95 ♦ 1'Ax: 978 J4 9846
Construction Debris Disposal Affidavit
(rcquired lirr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNlR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by: q
(name of I uler)
I he debris will be disposed of in
(name of facility)
(address of facility)
si_nat e of I, .. applicant
date