31 PERKINS ST - BPA-08-1047 The ConununwCalth of Massachusetts
t rIt
Ro;ud of Building RCeulu[iuns ;utd Standards Mt .Nil IPAI I 'i
\,Jassachuscus State Budding ('ode. 780 CN1R. 7" edition
Building Permit ,Application To Construct. Repait. RCnos ate Or DC In011Sit a R rn Jlr�,reu�
One or7'uv-humilt prrrpin,¢ _nu,'
rh s Section For Official Use Only
Building Permit Nwn r: _ Dare Applied:
Sianamrc:
Buddi F Conlon. ion../ linpertur of It .. ties Date ___—
SECTION I: SITE INFORMATION
I. 'raper Tress: 1.2 Assessors Map & Parcel Numbers
_ l dL lLt(Ai C —svv c �i — ---- -
I.lu la this ;m accepted sttYet' vex l� tin_ Map Numher P,ucel .N'unihcr
1.3 Zoning Information: 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Area(sy tt) Frontage (11)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rcar Yard
Required Provided Required Provided Reyu I cd Pru.iJCJ
1.6 Water Supply: (M G L c. 40. §54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zone: _ Outside Rood Zone:' Mrinieipul On site disposal syaCm ❑
Public' Private ❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: l� � ��n c.Sk<L I/16 l�(3C�
r
Namc 1 Print - Address for Scrvice:
—6►- 8L(C4 -a(1, l -
SenaRo Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ R,pnirsl s) Alteration(s) ❑ AJditi.m ❑
Demolition Cl Accessory Bldg. ❑ Number of Units 1 Other ❑ Speedy:
Brief Description of Proposed Work-: f44 a yLkTr—K.VU c-,"t xv« io, ) Co
SECTION 3: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Ilem (Labor and Mamrialsl
L Building ( VS6U I. Building Permit Fee: S Indira,, ho.e f„ is Jcternu nrJ:
❑ Standard City/Town Application Fee
2. Electrical S 130G "i ❑ "final Project Cost' (Item 6) x multiplier x
I
3. Plumbing S irOU 'CO 7. Other Fees: .S
1. Nkrhanird IH\':ACT S
List:
5. Mechanical IFue
fo(al :AII Fees:
Su p tression)
Check No. Check Amount: ( ash :Anawnt
o, Total Project Cost: $ 'LLG GO � Paid in Full ❑ Oulsl:mJing Balance Due:
I
SI?CTION 5: CONSTRUCTION SERVICES
4;.l L.icensed Construction Supervisor (CSI.)
�ttM�C w IEl (�'10� C I-icrnse Nwnhcr I:ytir;uwn Date
,N:une of('S L- IIoIJrr
pu L.ut CSL 'I'ypc tsrc hrlowl U _
Vd rr + CSl 0 I've Descri nun
( ('nresiocicd (u t to 35.000 Cu. 1:1.1
R Restricted 1'2 F:unth D'o Cdlte
Sign t te Only
'qA RC Rrsidrnual Ruuting Cowan_
I Iephone _ AA'S RC>I&Ii ml A1'111dwo and .Sidine _
SP I2c Ideatl Lll Soh.l Purl I ll I I ll_ A tl+ I III IIhIJIJ I I
D Kdadeuual Urntolwon
5.2 Registered Home Improvement Contractor (11110
111C Company Name or IIIC Registrant Name Registration :Numher
Address
Pspuatiun Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submined with this application. F ilure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Anached'? Yes ..... No ......._.. ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S
_.AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I• w��7t-�i.S'l l./UL'�"i l�'V�'���+— as Owner of the subject property hereby
authorize 'Z:tiX - g (t111h2T'H'ICJ�— to act on my behalf, in all matters
relative to work at 4x�rized by this building permit application.
Sian roof Owner Date
SECTION 7b: OWNER( OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
e6rgnpk�ndet
me�''�
e o �Kv`r or Authorized .Agent Date
the parts and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work. or an owner who hires an unregistered contraaur
(mot registered in the Home Improvement Contractor (HIC) Program). will not have access oo the arbitration
program or guaramy fund under M.Q.L. c. 142A. Other important infoin—ation on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 C•MR Regulations 110'R6 and 110.R5, respectively.
l 2. When substantial work is planned, provide the Infoormation below:
Total flours area(Sq. Ft.) (including garage, finished basement/attics, decks or porchi
Gloss living area tSq. Ft.) Habitable roam event
Number of fireplaces Number of bedrooms
Number of bathrooms - Number of halfihmh> _--
l\pe of healin_ system Number of decks/ pore hcs --------
Type of coaling systern Elidosed _Vpen
"Tool Project Square Foalagt may be >ubstituted tin font Project Cash
J
=� CITY OF SALEM
` PUBLIC PROPRERTY
' '�- ���•! DEPARTMENT
%`�iI
rFl.'I78-74i0;45 • 1 ,x: )7J-74;-A46
Construction Debris Disposal Affidavit
(required Cur all demolition and renovation work)
in accordance w ith the sixth edition of the State Building Code, 730 CMR section I I1.5
Dcbris, and the provisions of NIGL c 40, S 54;
13uildiny Permit f! _ is issued with the condition that the debris resulting from
;his work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
-- (name of hauler)
I'he debris will be disposed of in
W(� —_
j�In�rr.,l faa�rty)
. CITY OF SALEM
PUBLIC PROPRERTY
3 1�1r
t;G DEPARTMENT
,,dI11ll:I l.1 llRhd •,l l
,I.tl, ,R I': AC.\.IIIN, S ilk I I • SA II lt.
i-vSy; to F\s: •1'S ?J -'78�n
NN'orkers' Compensation Insurance :V7ida%it: liuilders/Contractors/Electricians/Plumbers
> )Ii ant Information {mot {�P�hcas L
�e /Print _/eei/blY
N.Illlt I nu;inra(p)[gall m tatuindid lJualis WbA
Address: Q GILO S—ft1t L
City,Statr.'Zip:
kre sun an employer:' C heck the appropriate box: Type of project(required):
i,Eff�'l a111 a employer o,i(h4. ❑
❑ 1 ant a general contractor and 1 6. New construction
_�d_
employees (full and/or part-time).` hate hired the sub-contractors E Remodeling
'.❑ I :uu a sole proprietor or partner- listed on the attached sheet.
,hip and have proprietor
etor or par These sub-contractors have 8. ❑ Demolition
working tax file in any capacity. workers' comp. Insurance. y, ❑ Building addition
INo workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercise) their
tight of exemption per NA
11.0 Plumbing repairs or additions
3.❑ I ant homeowner doing all workand we have no
myself [No workers' comp. C. IS_, I(3), 12.❑ Roof repairs
insurance required.] employees. [No workers' 13 ❑ Other
comp. insurance required.]
':Noy JpphCallt that Checks bVY hI most also till ,of the section below showing their workers'compensation policy information.
t llonleowners who Submit this affidavit Indicating they are doing all work and then hire outside Contractors must submit a new affidavit Indicating such.
K\mtractors that:heck this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp. policy information.
l utn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
llLillranCC Company Nante:_
Policy #or Self-ins. Lic. N:
Vi G aQ n- sod O Expiration Date:
.lob Site %dd a
ress: ) ( f"`Zd��"`� �l SftLqAA City/State/Zip3'1A 40 L l 1 y
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure ni secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1.�;011.00 andor one-year imprisonment. as well as civil penalties in the toxin of a STOP WORK ORDER and a tine
lit up to S'50.00 a day against the violator. Be advised that a copy of this statement may be tor-%arded to the Office of
I m.cstivanons of the DIA tor insurulCe eoter:lge %Clitieatioll
l Ja hereby cerift' unrkr i id penalties ofperjurr thn�i�rnation provided above is true and correct
<icn,tur•/ Date:
I'linnd: �'V '
--illficiot use only. Do not write in this area, to be completed by city or town official.
0tvor fosse: _---------_.— --- -- Permit/License #--_-----_---------
Issuing Aulhority (circle one):
I. Huard of Health 2. Building Department J. Cih/fuw'n Clerk 1. Electrical Inspector 5. Plumbing Inspector
6. Other --
Contact Person:_------------ — Phone 4:_
Information and Instructions
\I;tsacl:useus Ocncial L:nvs chapter I requires all enyrloscrs to prox ide workers' compensation 1'nr their employees.
I'•,usu.uu tD this statute, ,ut einploi ee is dclilled is .....e%ery Pelson in the sea ice of miolher under aiiv contract of[tire.
c\pic,s or implied, oral or written."
\n einph,ter is dclined as ";m individual. pailnership. .I socialion. corporation or other Iveal entity. or:uty two or more
Athe loteeoing engaged in ajoint enterprise. and including the legal rcprrsrntatis es of a deceased employer. or the
recci%er or trustee of an individual, partnership, association or outer legal entity, entplo)in_ employees. llo%s'ever the
opt ner of a dwelling house haying not more than nn
three ap;uents and is ho resides therein, or the occupant of the
dtt clling house of another motto cuiploys persons to do nwintcnance, construction or repair work on such dwelling house
or on the _rounds or building appurtenant thereto;hall not bcc:utse of such entplo)anent be deemed to be an employer."
\L(iL. chapter 152, s-SC(6) alto states chat -eN cry state or local licensing agency shall w i(hhold the issuance or
ew
renal 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, %IGL chapter 152, 32507)stares "Neither the coil momvea I(h nor any of its political subdivisions shall
enter into any contract fir file pertimnance of public work until uccep(ablectidence of compliance with the insurance
requirements of this chapter have been presented to the contric(ing authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) mmne(s), address(es) and phone numbers) 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(he affidavit for you to till out in (Ile event the Office of Investigations has to contact you regarding the applicant.
Please he sure to till in the permit/license number which will he used as a reference number. In addition, an applicant
that must Submit multiple permit/license 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
1 i.c, a dog license or permit to burn leaves etc.) said person is NOT required to complete (his affidavit.
The r)ftice uF Investigations would like to thank you in advance for your cooperation and should you have any questions,
plc;ue do not hesitate to give us a call.
I he D) p:u'tmcnt•s address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations '
600 Washington Street
Boston, MA 021 l 1
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia