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58 PERKINS ST - BUILDING INSPECTION (4) The Cornmotmealth of Massachusetts H)R i r Board of Building Regulations and Stand: ids %It'NI 'll' \I.I'll t. j dt Massachusetts State Building Code, 7SO C'MR. 7 edition I SI'. " Kcri,rcJ htnwrrc Building permit Application To Construct Repair. Renoeatr Or Denntlish a One- or Ttru-Funnily DtreNing This Section For Official Use Only \ Building Permit Num r: Date Applied: • 2 ` O v— Siamtlure: 0 ---- Build ng of unissiona/ Inspector of Buildings Date SECTION I: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map & Parcel Numbers s� s s� _ I.la Is this an accepted street? yes_ no Nlap Number PaICel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning—District----- Proposed Use__— I of Area tsq 1)) _-- Frontage(li1 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Pio, ded 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❑ ,yluniciP al ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record j J� / P2({")Ins Sr 5(q)Pil'1 Name(Print) Address for Service: 00 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) �kl Alteration(s) ❑ Addition ❑ Demolition K1 Accessory Bldg. ❑ Number of Units-A— Other ❑ Specify:_ Brief Description of Proposed Wurk , , SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only — (Labor and Materials) J I. Building $' _ 1. Building Permit Fee: $ Indicate hors fee is determined: �Slandard City/Town Application Fee 2. Electrical $ ❑Total Project Cost (Item 6) x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List` $. Mechanical (Fire $ — Total All Fees: $ Suppression) _ : Check No. I Check Amount: _ Cash :\mount: _ o. Total Project Cost: $ 500 Vaid to Full 0 Outstanding Balance Due:__.___ SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSI.) 96-i p-1 ��D — ZQ/O &� P� / ra Licrnse Number F:vpu:wun Dale Nantc of CSL- llol er List CSL Type tscc hcluwl Type Descri own kddress r p ( Unrestricted Mp to 35.(N)Q Cll. I'i.l R Restricted M�2 Famih, Dskelling SignatuyJr M Masunn Only ~ ��O '" RC Residential Ruofine Co�crine Telephone \1'S Residential Wmdw� and Sid:,- SF Roidemial Solid htiWfi ..... c.\ >>h:mc: In>t.iil.u. n —D Residential Demolition 5.2 Registered Home Improvement Contractor (HIC) HIC Company Name or HIC Registrant Name Rcgistratiun Numher Address Expiration Date Signature Telephone SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(o)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pomde this affidavit will result in the denial of the Issuance of the building permit. Siizned SECTION 7a:OWNER AUTHORIZATION TO BE .0 ❑�— COMPLETED WHEN I OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject properly hereby authorize AJ(Cn© to act on my behalf, in all matters I reiative to work authorized by this buildin;; permit application. 7 c7 �nature of Owua ��✓✓ _ Date SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION ��; �yjQ __,_ as Owner or Authorized Agent hereby declare that the statements and information on the foregontg application are true and accurate, to the best of my knowledge and behalf. r ( Print Name Signature of Owner or Aut rued Agent Date (Signed under the pains 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 contractor (not registered in the Home Improvement Contractor(HIC) Program), will not have access to the ;ubitr tiun program or guaranty fund under M.G.L. c. 142A. Other important information on ti,e HIC Program and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. , When substantial work is planned, provide the information below: Total flours area(Sq. Ft.) / (including garage, finished basemenUattt�s, decks or purch) Gross living area tSq. Ft.) .,j'lJ/J Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms / Number of half/baths I'vpe of heating system t9 ✓�/r.S Number tit decks/ porches _ ' Type of cooling system -- Enclosed Open 3. "Toad Project Square Footage" may be substituted for "Total Project Cost" r CITY OF SALEM 04) PUBLIC PROPRERTY DEPARTMENT - 'Ilorkers' Compensation Insurance :%.ftidacit: Builders/Contractors/Electricians/Plumbers Please Print Le ittly t )ltiant Infornietiiin // IrC.uu/.,ti,m Inhl dud11: (//U ddl-CSS: �St Fer-- y i 0 SS City States Zip: 62/UO Pbone 4: `7 ('. 'Ire you an employer:' Check the appropriate box: Type of project(required): I ❑ 4. Q 1 :tin a general contractor and I 6 I :ml a employer with ❑ \ew construction have hired the ached sheet. ®'Remodeling employees (full and'ur part-slim h' listed on the attached sheet. 7. 2.❑ 1 .,in a sole proprietor or partner- I here 5ub-conlractors have 8. �Demolition ship and have no employees workers' sump. insurance. y. ❑ 13uilding addition working for me in 5, e a a wry capacity. ❑ We corporation and its [No workers' cutup. insurance 10.❑ Electrical repairs or additions Icyuired.I uthcers have exercised their ri ,ht of exem tion er MGL 11.0 Plumbing repairs or additions 3. I a homeowner doing all work c S152, $1(4) and we have no 1_'.❑ Roof repairs myself. [No workers' comp. employees. [No workers' insurance required.] 13.❑ Other comp. insurance rcyuired.l •,\oy applicant that checks box 91 must also fill out the section below..lowing their workers'compensation policy information. ' I iomaowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aftiJav it indicating such. :(\nrtra,mrs,hut:heck this box must attached:m additional sheet showing the name of the sub-euntraetors and their workers'comp. policy information. /am tin employer that is providing workers'compensation inssurunce for my employees. Below is the policy and job site informaliun. Insurance Company Name:—_ ----'- Policy X or Self-ins. Lic. ft: Expiration Date: City,State/Zip: Job tine Address: .\tt•ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). f:,ilurc w secure co%'erage as required wider Section I5 t, of\IGL c. 152 can lead to the imposition of criminal,penalties of-a _ WORK ORDER"and a fine line up to S I,ioLLUU and'or one-year imprisonment, as ,%ell as civil penalties in the Rim of a STOP nl till to S250.0h0;t daY aVallist the l Iolatur. Be ad%ised that a c,)py of ill,] statement may be R)rwarded to the Office of In,c.n_ati,ms of the DI:\ for insurnce coxerage scnticauon. /Ju hereby rerrift under th pains ,"Id lienafiev(,J perjury that the infornwtinn pro,ided above is true all sorrel- Dare ' !/ yn,uure. III one --U/Jicrid u,e tin/r. no not w rite in this area, to he cuinplered by City or town (Y]h iaL ..— (-ill or tow it: Issuing itil ity (circle one): I. Board tit Ilcalth 2. Building Depart t. ('ityt-town Clerk 4. Electrical Inspector 1;. Plumbing Inspector 6. other --- ------ - -- ---__ Contact Person: . -- Information and Instructions \I.1>,.IC!.u.nls l encral I .its, chaplcr I rcquoe, .ill cinplo,cr, h, pros ide corkers compensulon for their cnlplosees. I'ul,uant to this ,(.little. all r•rrtploree i, delisted AN ' ct ery pcnon ul file ,cn ice of .m,nhcr under.ulv Contract of hire. :,I,i c,s or itn pl led, oral or tsntle It %:I 'wtldoler 1, &1111cd .0 .ol indl t;du.l1. p,1111!r,hip. .i,.ocu non, corporation or o,Ihcr legal cnuty-. or .lily too or more , t 111c rot:-oily ell caved in a joint cntcrpn,e. and Including the legal rcpresentant eo of a dceca,cd cnlploy er. or flte :C,.L%cr or uu,tce or in mdlt idual. p;utner,hlp. .l„oaanon or other legal cnnty, employ ine employees. llouever the ,-.s ncr of a duvIhng h0Use• has ing not snore than three apartnncnts and oho rc,tde, tterrut, or the occupant of the du ihil , hou,c o � 1 %%� v f .un tiler ho cnq h " prison, to do nl.untulance, con.arucnon or repair a ork on ouch duelling house „r ,m the -rounds or building applutcn.lnt tllcrcat ,hall not hec.ulsc of,uch cngtlos nlcnl he deemed lit he an employee" \Il d. ehaplcr I i2, �2(i ,) also ,late, that 'c%cry state or local licensing agency shall ss ithhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant oho has not produced acceptable cs idence of compliance with the insurance coverage required." Additionally, .NIGL chapter 152, j 2i('(-) states "Neither the commonwealth not any of Its political subdivislons ,hall cuts into any contract for the performance of public cork until acceptable et idence of colllpltallce with the Insurance requirements of this chapter have been presented to file 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-contractors) nauhc(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 nlennbers or partners, are not required to carry workers' compensation insurance. If an LLC or LLP dues 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 In%estigations has to contact you regarding the applicant. Please be sure to fill in the permit,license number which will be used as a reference number. In addition,an applicant that must submit multiple permiulicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under"lob Site Address"the applicant should write "all locations in (city or low%W.- 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. W here a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.c. a dog license or permit to burn leaves etc.),aid person is NOT required ro complete this affidavit. I he (mice of Invcsligations would like n) thank you in advance tor your cooperaliun and should you ha%e any questions, plate do not he,Iate to Bice us a Call. the 1)cpaltntcnt', address. telephone .and t:tx numher: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021 1 1 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE u:t i,cd s-'0-0 Fax N 617-727-7749 www.mass.gov/dia CI TY OF SALEM Sri PUBLIC PROPRERTY DEPARTMENT MkWi HIAT 'KNI.01 1, M SAI F.M. NIASSAG It 5I I iSOPU- 'I[.I.: 978-74i-9595 * FAX:978-74-3-9846 Construction Debris Disposal Affidavit (requited for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5 Debris, and the provisions ofMGL c 40, S 54; Building Permit # - - is issued with the condition that the debris resulting from this work shall bedisposed—of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: Te7, (name of hatifer) I'lic debris will be disposed of in (name of facility) (A 51— Qusk"- Mq (address ot'fMlitv) —40it'i't'leof permit applicant C? (late ddhkaff'!"c