32 PHILLIPS ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards 7mu.
Massachusetts State Building Code. 780 CMR. 7'" edition hl(Building Permit Application To Construct. Repair. Renovate Or Demolish a Ro
One- or Ttru-Frrntih DN'eUing l tw)y
This Section For Official Use Only
Building Permit No r: Date Applied: ' V
Signature: 4s 2�' 0
Building Commissioner/ Inspector ul Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property :Ph'/Yddress: / 1.2 Assessors Map & Parcel Numbers
32 Li i� S' T s9 ri
I la Is this in accepted street'?yes—A-/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq III) Frontage (it)
[22.1
5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
Water Supply: tM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
blic❑ Private❑ Check if yes❑ P fw" Y
SECTION 2: PROPERTY OWNERSHIP'
Owner of Record:
me tPrint) Address for Service:
nature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building Owner-Occupied Ol Repairsts) Alteration(s) ❑ Addioon ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_— Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
ItemCEdosts: Official Use Only
aterials)
I. Building '/(� I. Building Permit Fee: S Indicate how fee is Jetermmed:❑Standard City/ own Application Fee
2. Electrical ❑Total Project Cost (Item 6) x multiplier x3. Plumbing2. Other Fees:4, Mechanical ( List:
5. Mechanical (Su ression) Total All Fees: S Check No/��CheckAmounl: 2/5 Cash _\mount6. Total Proje4ppaid in Full ❑ Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 20 e 941 /p 2 6 ® 9
`ems 7- ����2 � 5-S v� License Number Espnunun ate
Name of CSL- Holder List CSL Type(see below)
T Desert oon
>ddress I Unrestricted (up to 15.(W Cu. Ft.)
e r.°Ai•ttiG tJr �'Y-/L ' �/i.t/�J R Restricted IA' Famil Ds.ellin
Sig1-1 - _ .M Mason
Oni
.�✓� RC Residential Riwlin Corrnn
Telephone w'S Resldrnual %Vuidui. .md Sidin
�� r9 _ J�� 5F Re.idcnual Solid Furl Buuun¢ \„Icm.: Iu.i.J lawn
C ✓ D Re.idenual Demolition
5.2 Registered home Improvement Contructor (HIC) fO 9.q/ 7
/B 9't�/ 7 do
HIC Company Name or HIC Regiurant Name a Registration Number
G P<�/['fr s c e�/2 G'U y s riP /c T
.address L L y..Yi�Y -ter, Ex i noun Date
2 xZc��� rfs�I ,cr �t3/- s'99-06 s P
Signature Telephone
elep
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 9 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Fat lure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... Id No........... O
SECTION 7r: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , 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.
Signature of Owner Date
/ SECTION 7bb. OWNERt OR AUTHORIZED AGENT DECLARATION
I, �p� �2T �e�.0 //7/� S !' �i/Z , 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.
Print:Name
Signature of Owner or Authorized Agent Dat
(Si lined under the 2ams 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 contrucior
(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 110.116 and 1 IO.RS. respectisely.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemen/attics.decks or porch)
Gmss living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of hathrooms Number of halt/baths j
-Type of heating system - Number of decks/ porches
Type of cooling system Enclosed Open j
3. 'Total Project Square Footage" may be substituted for"total Project Cost"
CITY OF SALEM
3 =�
PUBLIC PROPRERTY
DEPARTMENT
61AIIiP N ItL1"I'isISC,)IL
NLAa OR 120 W\: SIR IT r ♦ S:\1I\1, %I.\J:\CI'I Sp[-IS v1970
Tel.: 978-745-9595 ♦ F.xx: 978-74G9846
Workers' Compensation Insurance Aftidalit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leplibl
Name IE3usincss-Organi[atioNlndividuul): sy"�UGYI OA/
Address:
City/State/Zip: Z �ZNy/ Phone 1#: 2 O s rr 3
:\re ou an employer? Check the appropriate box: Type of project(required):
4. ❑ I am a general contractor and 1 6. New construction
I. I am a employer with ❑
employees(full and/or part-time).* have hired the sub-contractors ? FB/]Remodeling
2.❑ 1 :un a sole proprietor or partner- listed on the attached sheet. 2
ship and have no employees These sub-contractors have - 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers' coin insurance 5. ❑ We are a corporation and its
[ p
required.] of 10.❑ Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work g P
right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. C. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�Cuntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l out an employer that is providing workers'compensation insurance for my entpl ees. Below is the policy and job site
information. // '
Insurance Company Name: eJ �G l/ �'
Policy #or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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 MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 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 this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify under thee paiinnss/and/ppe{nnalties ofperjury that the information provided above is true and correct.
tit n uurz
Phone #
Official use only. Do not write in this area, to be completed by city or town official
Citv or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CityiTown Clerk y. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter I52 requires all employers to provide workers' compensation for their employees._,
Pur>uant to this statute, an einplgree is defined as`'._evcry person in the service of another under any contract of hire,
express or implied, oral or written."
:\n enytlgrer 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."
\IGL 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 commomvealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, bIGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perforniance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till 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 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the penniblicense number which will be 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
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give its a call.
The Department's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
-� CITY OF SALEM
PUBLIC PROPRERTY
�• ' 8 DEPARTMENT
Construction Debris Disposal
kftidatr it
(required fur all demolition and renovation work)
In accordartcc with the iixth edition of the State Building Code, So C`IR section 111.5
Dcbris, and the provisions of 1IGL c 40, S 54;
3uilding Permit a_---- — - — is issued with the condition that the debris resulting from
;his work shall be disposed of in a property licensed wane disposal facility as defined by �1GL c
, 11. 5 150A.
The debris will be transported by:
-
- tnume of neuter)
I Lc cbr.; ill be disposed of in
lulrte �f i::claty)