7 PHELPS ST - BUILDING INSPECTION ; . The Commonwealth of Massachusetts
Department of Public Safety
\hws ichu>cBs State Building C ode 1%80 C:\IR)Seventh Editum
City of Salem
Building Permit Application for any Buildinji other than a 1-or 2-Family Dwellin
(rhis Section For Official U.se Only)
Building Permit Number. Date Applied: Budding Inspector:
SECTION 1: LOCATION (Please indicate Block 0 and Lot 101 for locations for which a street address is not available)
Jx O6 S+ , 'S 2t A s v-^, N\,A
Nu. and Street C iH• /Town Zip Cede Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building W1 Repair Alteration O Addition ❑ Demolition O (Please fill out and submit Appendix 1)
ChangeufUse ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No g—
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ID/
Bri}-f Pie in of Prupo.wd Work: oTZ.t-C l`
tlDescri ( S4- oer 30
t,� b b
Xr ir 6,r s 5_t �l . is
%
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O
Existing Use Group(s): Proposed Use Group(s): t
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Pter Floor(sq.ft.)
Total Area(.sq. ft.)and Total Height(ft.)
SECTION Ss USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 0. Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1.2❑ 1.3❑ 1.4❑ Me Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3ff R4❑
S: Storage 5-1 ❑ 5-2 O U: Utility❑ Special Use❑and please describe F4ruw., (/
Spacial Use:
SECTION 6:CONSTRUCTION TYPE(Check a a licable)
IA ❑ IS ❑ IIA ❑ IIS ❑ IIIA ❑ I11B ❑ IV ❑ VA ❑ VB ❑
SECTION 7: SITE INFORMATION (refer to 780 CMR I11.0 for details on each item)
1Yater Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris ReISw
Pudic❑ C heck duuhede Flrh•.1 Luna•❑ Inalicate munrap,tl ❑ A trench well not be Licenseal Uiatt
I'nvaly❑ ur indurili v Lune: nr an•rte sv.tem ❑ required❑or trvnch or.paa•ift•:
permit e,vncls, e i O
Railroad right-of-way: HJlalds Io Air Navigation: \I \ I h•6•n, t , nnnr..o•n lt.t n t.\,.1 \pphc.ddv O I.:;Iructu«•tc ohmairport aF�F'ru,e chare.0 I.their re%icty C."110vied
.a'l .•n'Un11'. lit,ild vnduvd ❑ )e•❑ ur NnO )"❑ \u Cl
SECTION 8:CONTENT OF CERTIFICA TE OF OCCUPANCY
I .hli,nt,-1 C.0c, LIV(;1 "upl.,: rt pcul C om,trucunn: Occupant Lnad per l l,s•r
I Rq'I Iho buil,lui�;cunl,un doJti).nnAlcr St.Icm` �pvcral�hpoe).tleunv
SECTION 9: PROPERTY OWNER AUTHORIZATION t.
.Name and .\.Idrrac of Pnq+vrtc,Owner ,
Name(Isrinl) .No.and Street lily/rown Lip
Propu•rty 0%%nrr Contact Inlurmation:
iiflr Tvlephune Nu. (busme-s) relephunr No. Icrll) r-mad addntis
If applicable, the prupertY os ner herebv authorizes
.Name Street Addr%c% City/Town Stale Lip
to act on the +ro +rr1Y,sonar's behalf, m all mature relaliYr Its work authorized by this building permit a + +portion.
SECTION 10:CONSTRUCTION CONTROL flilease fill out Appendix 2)
(If buildingis lcs. than 35,WUcu.tt.w cnekivd space and/ur not under Can truction Control then check hen Oand AUP Smioun IU.1)
10.1 Registered Professional Responsible for Construction Control
f o 3 is 3
Name(Rrgj2tranl) Tel shone No e-mail address YL _(pr Registration Number
Z.z RT 9ZV�1 a Wtu� 0�4LS CST- -T. j 7 Z -Za(
Street Address - City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cp✓ am
u}���z���y��Za C�4..v�c�v
J �
1 �� 1 5 3
Name of Person Resprrnsible Is �jlnstruction License No. and Type if Applicable p L
L��`^O+�l�� V
Street Address City/To n Sta t
Sipe •$� GeckT SuB _s`t3. 68I8 y �.�Zc2EX%,& p,,akp Zs_Ca�N
Telephone No.(business) Telephone No. cell e-mail address
SECTION Il:wINSURANCE AFFIDAVII(M.G.L.c. 152 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor A
Item and Materials) Total Construction Cost(from Item 6) =S
1. Building S Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)-S .
3. Plumbing f
Note: Minimum
4. Mechanical (HVA lee.S ntact municipality)
5. Mechanical (Other) S C) f � �'o
Enclow check payable to
6. Total Cast S C(Q- 00 (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
BY cn(rnng my namv L+rl... I herrbv altrsf under the pains and penaltivs of perjury that all of the information contained in this
.tpplicaunn is Irur and accurate to Ihr esf of my knowletigrand understanding.
J�..J �
Ste? SY3 . n�34�' 0'7 27-►
Ilea..-print and sign name rule rouphone.N., I Date
�Ireet W,fre" Cdv/TUK fJf LIp �JU'
%lumcipal Inspector to fill out this section upon application approval: G'v
omr I).rte
CITY OF SALEM
,ai PUBLIC PROPRERTY
' DEPARTMENT
,. N
:.I.UI:.'NI.nY JKl%:L n.L
Wan'a 12C WAS Hi\GION S rxwr• SALE-M,M.%SSaC111 sr.n Sri 1970
-1a:978-745-9595 0 pax:978-740.9S46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
lni licant Information Please Print Leeiblv
Vame lnosiness/Or,�,anizatinrJlndividuall: �Z �� t" 7
Address:
City/StarcZip: d� �� alglS Phonei': Sy& QiK12
:4.re you an cm player?Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with _4. ❑ I am a general contractor and 1 G. ❑ New construction
cot alo ces full and/or art-time).' have hired the sub-contractors
I Y ( p' 7. ❑ Remodeling
2.IN I am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees 'These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
To workers' comp. insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.] officers have exercised their ;
3.El 1 am it homeowner doing all work S exemption P
right of Per MGL I I.❑-Plumbing repairs or additions
Pon '
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Rouf repairs
insurance required.] r employees. LNo workers' 11ES Other
comp. insurance required,]
miry applicant dial checks box it] must also till out the w-cliun bcluw showing their workers'compensation policy infilrmutiuo.
' I lomatwncn who submit this tafidavid indic:uing they are doing all work and then him outside couractors must submit a new afndavit indicating such.
:(,,W Mmrs that check this box most attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/ant an eory)loyer that ie providing workers'compensation inxurnnee far uty employees. Below is the policy and job vile
information.
Insurance Company Name:----
Policy is or Self--ins. Lic.>;: —_._..__.... .. Expiration Date:.
Job Site Address: _ Cilyi$tate/Zip:
.kitsch a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
I-'ailurc to secure coverage as required under Section 25A ul':vIGL c. 152 can 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 die violator. Be advised that a copy of this statement may be forwarded to the Office of
In<'ealigatiuns ul the DIA Cor insurance coverage%c iliealion.
I do herehy certif under a pains and peftahies of perjury that the infonnution provided above is true and correct.
; O Z ^ r7
V� Date'
Ph,tl:c:i: 'Sn�
Ofjic'iui use wily. Do not write in this area, to be completed by city or town official.
Cilv or Town: . .. .. .._ Permit/License
Issuing AW horily (circle note):
I. Board of Ileaith 2. Building Department J. Cityffovi a Clerk 4. Electrical Inspector 5. Plumbing Inspector
(i. Other
Contact fervor: _ Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee 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 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 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 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, bIGL chapter 152, s25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority.". - 1
-'applicants
Please fill 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 nnmber(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 confimtation of insurance coverage. Also be sore to sign and date the affidavit. The affidavit should
be resumed 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 Offleials
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 till in (he permi /license number which will be used as a reference number. In addition,an applicant
that must submit multiple permidlicense 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 of 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 OI lice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offtce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF SALEM
t PUBLIC PRVPRERTY
DEPARTMENT
.Nq \;.:,,N$1'1411 r ♦ NA I'V, I! :J I ;
Construction Debris Disposal Affidavit
(rerluired for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR scclion 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it 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
111, S 150A.
The debris will be transported by:
_.:.... (name of hauled
'I he debris will be disposed of in
(name
ut t'aolity)
(address of facility)
signature of permit applicant
o ? -2 -1 — Ib
date __._--
JOB DESCRIPTION :
Temporarily support existing deck
Remove rotted 4x6 1n fl deck outer support beam
Replace 1"fl deck beam with new PT 4x6
Remove existing railing system
Uninstall 15'fl 4x4 posts, replace with new PT 4x6 posts
Modify railing system to fit and re-install
JOB COST :
Materials $ 240.00 (see job notes)
Labor $750.00
TOTAL : $ 990.00
i
JOB NOTES :
A permit will be pulled due to the structural nature of the job. The building
Inspector will approve and sign off that all work is to code and complete.
The materials receipt will be presented and any savings will be passed on
Every effort will be made to keep the jobsite clean and safe
Debris will be removed and disposed of properly
1 am assuming that the building inspector will not require any additional
Footings because the deck is pre-existing, should a situation arise, an addendum
will be made to accommodate for extra materials and labor
I will use PT 2x6's to temp support the deck and leave them for the fence
As the liscensed const.supervisor, I, David Black II will be on site at all times.
Job will be completed timely and professionally
JOB FOR : NAME : P�1�t�� CDI4Do +SSD&-
ADDRESS :
CITY : sAIcoll IVI A
1 AUTHORIZE DAVID BLACK 11 , AND
KEVIN DUNN
TO DO WORK SPECIFIED IN THE ENCLOSED CONTRACT.
SIGNATURE
TITLE
PHONE (0
1.
Massachusetts- Department of Public Srfctp
1 Board of Building Rcl-ulations and Standards -
Construction:Supervisor License
License: Gs- 103153 _ -
Restrictedto:,00,.,,,.,
DAVID BLACK II 1
22 BELMON7 STREET '
BEVERLY, MA 0191,
Expiration: 7l2l2013
('mmni++iuncr°
Trj: 103.153