9 PICKMAN RD - BUILDING INSPECTION (4) J
26 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR, 74,edition OF SALEM
'w Revised Junuarr
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. _(Nlv
One-or Two-Family Dwelling
is Sec ' n For O se Only
fFmntYard
Permit um r: Date Applied:
:
Buildi Cummissioncr/ or of Buildings Date
SECTION 1:SITE INFORMATION
rfy�ddli ar: Q 1.2 Assessors Map& Parcel Numbers
1 0
s on accepted street?yes no Map Number Parcel Number
g Information: 1.4 Property Dimensions:
trict Proposed Use La Am(sq 11) Frontage(11)
ing Setbacks(0)
Fmnt Yard I Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40.§54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
4/- 2.1 Owderr of Record:
Name Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ AdditioJC3
Demolition ❑ 1 Accessory Bldg.O 1 Number of Units_ Other Q Specify: `
Brief Description of Proposed Work': /
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OHlclal Use Only
Labor and Materials
1. Building S `—('j I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
O Total Project Costs(Item 6)x multiplier x
1. Plumbing S 2. Other Fees: S
4. Mechanical (i1VAC) S List:_
5. Mechanical (Fire i, , —
Su ression S Total All Fees:S_ �_�
Check No. Check Amount: Cal Amount:
6. Total Project Cost: I S S C) 1 Jrl Paid in Full O Outstanding Balance Due:
sew 1—w 43 f ic'"YM
SECTIONS: CONSTRUCTION SERVICES
5.1�Licensed Construction Supervisor(CSL)
l a —7 /D I.iccnx Number b7er �� I:apinI n U tc
Nurnt ooll CSL-I Iuldcr 1 Gp List C'SL(�fype/ 1 below)0_
h r I Description
WJress Q �/f(' "1 1 U IIlnrestricied(up to 35,000 Co.Ft.
R I Restricted Ih2 Family Uwellin
Signature M I Masonry Only
t RC I Residential Roofing Covering
1"elephone V WS 1 Residential Window and Siding
��— (� — / 3 SF Residential Solid Fucl Isurnirut Appliance Installaliun
t D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 `� U
f IIC Company Name or tIIC Re, trant Na e d Registration Number hh
AJJreu l l �� /� a/U
1— P��e
Signature Telephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.! 2SC(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes .......... 0 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r' 1pp
r ( ( l as Owner of the subject property hereby
authorize s°� !i`t iA S to act on my behalf,in all matters
relative to work authorized by this building permit application.
Seariature orowner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Sinned under the pains andpemilics of •u
NOTES:
1. 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.W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:.I�n:7 RLLY UNIA:1 q.L
41�S'<ta 12C WA]HIN(.WN S'IREL'T • SyLEM,MASSACI II:SE I'IS Gl=7
'1'Ll.:978-745-9595 • FAX: 978.740-7846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information ,�yt Please Print Le ibly
Cq
NaMe (Busilwssi()r.anizatioNindivi(luul):
AddreSs:_ LL kQ to c
✓ / l e r 1 � r S Re G y�vi / i 4
Cityi'Statc;%ip: P (/hone N: d ^ r�) /U ^ -3 -5-/ 3
Are you an employer'.'Check the appropriate box: Type of project(required):
4. ❑ I am a general contractor and I
I.❑ 1 • no a employer with 6. ❑ New construction
and nt to ces full and/or art-time).` have hired the sub-contractors
P Y ( P 7. ❑ Remodeling
2 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have S. ❑ Demolition
Working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'cum insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am it homeowner doing all work right of exemption per NiGL I LE] Plumbing repairs or additions
myself. [No workers' comp. c. 152,g 1(4),and we have no 12.0 Roof repairs
insurance required.j t employees. [No workers' 13.0 Other
comp. insurance required.]
-Ally applicant that checks box 01 must also till out dtc sucliun W.ow showing their workers compensation pulicy information.
r I lumen ssurs who submit this affidavit indicating Ihcy,arc doing all work and non hire outside cuntmctors must oahmit a new,afadavil indicating such.
:Contrwton that check this box must attxhed an additional sheet showing raw nano of the sub•contractom and their wurkers'comp.policy information.
/am can employer that is providing workers'compensation insurance jar my employees. Belov is the policy and job site
infuraortiom
Insurance Company Name:---.. ..._ -. ..............._.._-.__..___---_Policy it or Self-ins. Lie. n: . .-__.___ Expiration Date:
Job Site .Address: CilyiStateizip:
Attach it 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.`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 it day aguinst the violator. De advised that a copy of this statement may be forwarded to the Oflicc of
Invcsti-gations ul'the DIA for insurance coverage vcriticaliun.
l do hereby certify undo min end petmlt' . brjur shut the infunnulion provided above is irpe and correct.
Sirnalnrc: Date:
�--q' - ;2 0 /0
Phone:7:
Ofjic•ial use only. Do not write it:this area, to be cunipleled by city or town 01jiviul.
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Ilcalth 2. 1ltlilding Department 3. Cityffosyn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other -----
Contact Verson:. _..-.- .. - _ -_--- Phone 0:.
Information and Instructions
Alassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empfgyee 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 toregoing 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, Q25C(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, §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 fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)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 continnation 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 Offlelals
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 till out in the event the Office of Investigations 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 pennidlicense 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 bur leaves etc.)said person is NOT required to complete this affidavit.
The Office 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
Office 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/tiia
CITY OF SALEM
S. 5^
'r r PUBLIC PROPRERTY
` J DEPARTMENT
h I
\I '..."I` 111: \\,\il ll.\I,:(�\}[ala r # 1.\II \I,
4-'4iAj95 • f:\Y: 'i78.74D 9841,
Construction Debris Disposal Affidavit
(re(Iuired li)r all demolition and renovation work)
In accordance wvith the sixth edition of the State Building Code, 780 CNlR section I 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
(name of hauler)
I'lie debris will be disposed of in
(name ul facility)
(ad(fress ol'I'acility)
signature of permit applicant
g _ q _ ad
date