32 PERKINS ST - BUILDING INSPECTION c '
v\ riie coinntumsr:tlth of %I,1SSaChusettS —
t` Board of Building Regulations and Standards M VIl(I IP \I I I l
l 'y Massachusetts State Building Code. 7S(I CNIR. 7 edition NI
,. Building Permit Application To ('unstrua. Repair. Rrnut ale Or Ih•muli,lt a Itri l.l.nri,n
(bu•- or Tuv-l'tunih Dn rllin,tl 'i vS
_i
This SectifiCial Use Only
[folding j
umber: Dah: Applied:ing C'oinnus,u d In.pcaur of 131 Idn Date
SECTION 'ITE INFORMATION
1.1 PropertydV%A3 =-- 1.2 Assessors Map & Parcel Numbers -- -. - -
15�
I.1a Is this an accepted sweet' yes___ nn_ Map Number P�ro;i Nutnhci
'.� Zoning Information; LJ Property Dimensions:
Zoning District Proposed Use Lot Area lsq to Fiuniuge(it)
LS Building Setbacks (ft)
j Front Yard Side Yards Rear Y aid
i Required Provided Reyuued Provided Rego red Pruv dcd
I
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal sy+trm CI
❑ Private❑ Check if yes[] I
SECTION 2: PROPERTY OWNERSHIP' �!
_. caner'yf Rewrd: p
?p- 0.1 GK 5—ci� "'-/o Cffe l re'f
,arc int) Address for Service:
&1 7 -P 77 gV08'
r_Ne:w:C:,_,-aruL:11,:):n
TelephoneSECTION 3: DESCRIPTION OF PROPOSED WORK"(cheekall hat appl❑ Existing Building❑ Owner-Occupied ❑ Rep:'rs(s) Alterations) ❑ AJdniuo ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ .Specify__
Briet Descript1i'on of Proposed Work": @ _
_�r PL.F_ Mq Sac lNG✓'�....—_... i
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Maierials) _
I. Building S S Q �o
1. Building Permit Fee: $ Indicate how tee a determined:
❑ Standard City/Town Application Fee
2. ElectricalS ❑Total Project Coat' (Item 6) x multiplier — x
1. Plumbing Other Fees: g
J. Mechanical (HVAC) S List: __
5. Mechanical (Fire
Su p preuion) T��tal All Fees: 5
Check No, Check Amount: _ Cash :lnnuupt:
b Total Project Cost: S ❑ Paid in Full ❑ Outstanding Balance Due:
(� got .
SECTION 5: CONSTRUCTION SERVICES
5A Licensed tC�onstructioii Superci`or (CSI.) —__ -- -_ � 1✓/O
7a�'efl✓l (3,%A �h.A_�1r�t.A� nn._F^r_• Licen,c Number I`.NIw.uinn D.1
\�inC o^ S1.- j �h.JL (J _ �/
e.�� `�� ,[ LI. 'I\pe nee below 1 C-,� 31`I 5a�
\JJress Ry'— I c Dwell lion
1. l'nresl rl ClCJ 'Lill(03,04)o(L It
--- RrstnClCJ
]Igl it a \1 %Lasonn Onh
I RC RhIJCnUaI Rolinc cilm`
I elephone \\'S I1.aJrnli.J \\lndu.. .wd ]Idm,-, li
SP RCvJCnu.il SoIIJ I uCl limnlu_ \ j h.wC: lu.l.il Lnn u
D RrslJant Lit DCnwhtnm I
5.2 Registered Home tprov men l Contractor (IIIC•)
-
--
HICCompano . 'amc or HIC Reg l- ant Nv� �� RCg utfat Wn Nu mhCl -
aJdre. CR /ZZ 3w3 Fxplfalwn Dale
Siet a re TClephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pro%]de
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
O
WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of thesubject property hereby
rizr G to act on my behalf. in all matlefs
r .alive t ak auth[ ized byN this building permit application.
1 1y1VL.2J' Z Z �
Si i Lure of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AG NT DECL: RATION
1. , 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.
k1. An
Name '
ature of Owner or authorized Agent Date
ed unJCr 1be alns and penalties of rr'u .)
NOTES:
Owner who obtains a building permit to do his/her own work,or an owner who hires :m unregl,lCrcd contra,u,f�
(not registered in the Hume Improvement Contractor (HIC) Program). will nn( have access to me .uhitf:twn
program or guaranty fund under M.G.L. c. IJ?A. Other important infirmation on the HI(' Progarri and
Construction Supervisor Licensing (CSL) can be timnd in 780 CN1R Regulations 1 10.R6 and 110.R5, fespecti cOk
' When substantial work is planned, pro.lde the information below:
Total floors area(Sq. Ft.) (including garage. finished hasement/amcs. decks nr po(Chi
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of hedroonns -- ___--
Number of h.nhroonts Number of h.ilf/b.uhs __----_.—__---- --
1 vpe of heating +vslem _ _-- Number of decks/ pof�hcs
Type of cnolmg system_
1. Toud Project Square Footage" may be substituted fir "rotal Project
CITY OF SALEM
3 �i PUBLIC PROPRERTY
�'s..•'*�•,`i ,r ilk .
'? DEPARTMENT
LIkW;RI RY:)HISC041.
12C WASHING ION S7REEl' • SA LEM,M.x1SACi It-SE I IS 0197C
rta:978Jt5-9595 to 1':ss: 978- ;Q-984b
Workers' Compensation Insurance Affidavit: Builders/contractors/Electricians/Plumbers
ns Print Leaihty
J11 ylicant Information r
VBftlt; (13usiucsslOrBaniratintdlndrvldual):
J b.:s H CCnA 3Fa1i-0J0
Address: a3 pi oe\tihw—s f&e c
cityst:tto;zin:
Iit�a.�e AA— Phone C 2 2 3�/
Are you an ern ) oyer'i Check the appropriate box: 'Type of project(required):
I.❑ 1 am employer with - 4. ❑ 1 am a general contractor and 1 G. ❑ New construction
)lo ces lull and,'ur urL-tulle).' have hired the sub-contractors 7. Remodeling
1 } ( F listed on the anachcd sheet. : ❑
2. 1 am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
5. ❑ we are a corporation and its 10.❑ Electrical repairs or additions
req workers' comp. insurance officers have exercised their
1 required.] l 1. Plumbing repairs or additions
3.❑ 1 wn a homeowner doing all work right of exemption per MGL ❑ b ,p.
myself. [Ko workers' comp. c. 152, g 1(4),and we have no 12.❑ 119corrSpatirs
insurance rcquired.J t employees. tNo workers' 13. Other s �S
rnmp. insurance required.]
-Ally n,plicaut itw chucks box 01 must:l so IIII out Itic.,knell helow showing Ihoir workers'cumpemalion put icy infurmatiom
' I lumeuwta:a who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new airdavit indiunn8 such.
m i wr Ural check this box must attached an additional sb vt showing Iho name of aw subcontractors and their workers'comp.policy inrormatiun.
/any air employer that is providing warkers'c•ompensatian insurance fur lay employees. BelOw is the policy and job she
information. )_ 'f—��C fr 14 /
Insurance Company Name: f5 J^ —'(—'— - - _. .._..._.__.-...-------- '� ' ,
6/ �-7 — -_- Expiration Date:
Policy:'t or Self-ins. Lie. *:�Ze/Z
Job Sicc :\ttdress: �-V�pIS ._ City;Statip:�2�$
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 east 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. Be advised that a copy of s statement rally be furwarded to the Office of
hlvcmigations of the DIA f'or insurance ca,vcragu vcrificatio
l rho hereby certifjr it, •r t • aims or perjury tha a inforarutimt provided a ove i true and correct.
Darr 2 Z
Sic:lauue: -
pI, (o Q ST Ct'i
Q(liciul use only. Do not write in this urea, to be conhpleted by city or town o ficiul.
Permit/License -____-._. - - - -
City or Town: ----- . _
Issuing Authority (circle one):
1. Board of llcalth 2. 13uildiny Department .3.Cityfrown Clerk 4. Electrical inspector 5, Plumbing Inspector
G. Other . ----
Contact Person: __._ ._-- Phone H:
r-
Information and Instructions
,Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pnr5aant to this statute, an ernpfoyee 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 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 maintenance,construction or repair work on such dwelling house
or on the gromids or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL 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, MGL 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)name(s), address(es)and phonenunber(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
he 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 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 till in the permit/license number which will be.used as a reference number. In addition,an applicant
that must submit multiple permitilicease 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. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Deparunent'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
z,vi. d 5-26-us Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
R PUBLIC PROPRERTY
DEPARTMENT
1)78.74.')544,
Construction Debris Disposal Affidavit
(re(.luired for all demolition and renovation work)
In accordance %t ith the sixth edition of the State Building Code, 780 CNlR section I I I.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit if . is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I I I. S 150A.
The debris will be transported by:
(name ut hauler)
I lie debris will be disposed of in
/klao"Ste
(� �{ (name of facility)
l Y�'ItM O t ' G✓`��'�
TT"_ laddres�ul IhcililV)
ature � Immit applicant
late -