7 PIONEER CIR - BUILDING INSPECTION (2) C)21C� - Pb— IS- S52 i t SL? A, 42:7
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish it
One-or Two-Family Dwelling
(� This Section F Official Use Only
Building Permit Number: Date.Applied:
U 1 Building Official(Print Name). Signature• . . Date
-- SECTION I:SITE INFORMATION'
I
1.1 Prop Address: 1.2 Assessors Map3c Parcel Numbers
Address-
r/�
1.1 a is this an accepted street9 yes 110
Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tl) Frontage(If)
1.5 Building Setbacks(it)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
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 Cl On site disposal system ❑
Public❑ Private❑ Check if yes13
SECTIONZ: PROPERTY OWNERSHW
2.1 ¢@ner of Record:I So(l�m Mf} COW
a�zl ESP ��I
17�ine(Print) City,State,ZIP
l6 G(over st 5?8-430-%1( 3
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check at apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) dl Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Drief Description off'roposedWork : &o Over r-ooF C eJS u new
e_ t(dd� aK -J awer, ��6�
v 4 F fi .r.�rr
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S P Pther Fees: S
d. Mechanical (FIVAC) S - List:
5. Mechanical (Fire S Totai All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
�CA)N\S 11_)a1= TO SITS a/I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construct* Supervisory License(CSL) 4!!! 0 3636
SE2a 1v - v /C) Q S,0— License Number Expi tion U e
N:unee of CSL holder List CSL Type(see below)
Type - Description
No. ;old Sueet - --
//�� , A Q�t U Unrestricted Uuildin a to 35,000 w. It.
A y` ' I / t/ �— R Reis icted l&2F:unil Dwellin
City/Town,Slate ZIP tbt isoury
RC noting Covering
WS Window and Sidin
S I Solid Fuel Burning Appliances
I Insulation
'rele hone Email address D Demolition
60
5.2 .Registered Home Improvement Contractor(HIC) 11 d? S o MP In D Ler of SS ��2!!D. HIC Registration Number Expiration Date
I�C�o�p:myJf�arneor_111C Rig' In. tI Name
/ 1'�SI-O J�
No�pnJ$4" m (g'Z 1? "�17 _�(o OD Email udJ
rKs
Ci /rown State ZIP ) / Tele hone
SECTION 6:WORKERS'.COMPENSATION.INSURANCE AFFIDAVIT(M.G,L:c.152.§25C(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 ..........❑ No...........O
SECTION 7a:OWNER AUTHORIZATION.TOBE.COMPLE'li WHEN
OWNER'S AGENT OR CONTRACTOftAPPLIES FOR BUILDING.PERMIT`
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNER'ORAUTHORIZED AGENT DECLARATION
By entering my name bel v, I hereby attest under the pains and penalties of perjury that all of the information
contained in this a s tr a an ccumte to the best of my knowledge and understanding.
7 ./tom '
Print Owner's or Aull riz i gent's Name(Electronic Signature) Date
NOTES:
I. An Owner wh obtains a building permit to Jo his/her own work,or art owner who hires an unregistered contractor
(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. I42A.Other important information on the HIC Program can be found at
www.mass.,,ov.'oca Information on the Construction Supervisor License can be found at wtrw.mass. ov:!Jas .
2. When substantial work is planned,provide the information below:
'fotal floor area(sq. R.) '� .(including garage,finished basementlattics,decks or porch)
Gross living area(sq. It.) 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
3. "1'olai Project Square Footage"may be substituted fur"Total Project Cost"
t
v
CITY OF SALEK MASSAaiUSE7TS
BUILDING DEFARiwm
120 WASHINGTON STREET,YD FLOOR
nL(978)745-9595
KIlv18ERLEYDRISOOLL FAX(978)740-9846
MAYOR THCMAS ST.PIERRE
DIRECTOR OF FUBLICFROFERTy/BUIIDING GOMHSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris;
and the provisions of MGL c40, S 54; Building Permit ii is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
gib,
(name of cility)
(address of facility)
x Si nature-of applicant
Z
Date
v x.
G♦!
Massachusetts-Department of Public:Safety
Board of Building Regulations and Standards
construction supenieor
License: CS 10 r3636r '
SERANf01�RO$7��� ;
167 Stetson Aven am ttMA 8 i
sco
Expirations j
J 11123120TS:'
Commissioner
.•� -✓�c �fnghArwrinMllll O�CJ(l(lJJat�liJt
`��Orfiee of Consumer AR'airs&Business Replanon
-BIOME IMPROVEMENT CONTRACTOR
-- agistration: 144534 Type:, ^I
expiration::7 10/1k016 - DBA - -
S:A R HOME IMPROVEMENT '-
jSERANTONY ROSARIO
167 STETSON AVE.#1
i SWAMPSCOTT,MA 01907 --- •
Undersecretary
i
IL
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, ALL 02114-2017
www.massgov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information I p Please Print Le 'bl
Name(Business/Organiwzation/lndivildual): 0,n Q PCid` P 6agkL6 r.S
Address:
. City/State/Zip: �(-emn /Y7 Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
16,am a employer with ? employees(full and/orpart-tune).• 7. E],�Ictv construction
2.❑1 am a,sole proprietor or partnership and have no employees work%ing for me in $. [XRemodelmg
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.)t 9. ❑Demolition
4.❑I am a homeowner and will be hiving contractors to conduct all work on my property. I will 10❑Building addition
ens
ure that all contractors either have workers'compensation insurance or are sole l l.gMectlical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-cofactors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We we a corporation and its officers have exercised thew right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.)
-Any applicant that checks box Al 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.
=Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their-workers'-comp.policy number.,.
I am an employer that is providing workers'compensation insurance for riry employees. Below is the policy and jobsite
information. '� /" /r 'I
Insurance Company Name: DU t T�-7Cf d 3" �"�5 '
Policy#or Self-ins.Lic.M 00 [ 0 Expiration Date:
Job Site Address: City/State/Zip: gti f N+ n�✓� �� /
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$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$250.00 a
day against the violator.A copy of this statement may he forwarded to the Office of Investigations of the DL4 for insurance
coverage verification.
I do hereby certify under the p ' s an penalties�ofperjury that the information provided above is true and sanest
Signature ry 6_y Date:
Phone �7O �� '� roc t 00
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: 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 writtep."
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,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 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 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 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 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 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 dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number: .
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
$3N�
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY S M
Massachusetts State Building Code,780 CMR
RECEIVE Revised dMar Mar2011
Building Permit Application To Construct,Repair,Renovakl9beWfAla SERVICES
One-or Two-Family Dwelling
This Section For Official Use Only AN 4: 4 .'
Buildmg Permit Number. Date Applied: .*
n Building Official(Print Name) :: , e Signature� ,�r, . , :. ,.ra•�, .� �Da .
_ SECTION 1:SITE'INFORMATION
1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use - Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
`'•' „ , . SECT ION2: PROPERTY OWNERSB3Pr
2.1 err of oto:
crave( talha �lem MA 0/9 -70
Nazi—e(�� - City,State,ZIP
7 Y;oneer� C;rcic J78.N30. d113 e50mg p,veI OD V4I�. comet
No.and Street Telephone TI Emad Addiess
SECTION 3:DESCRIPTION OF PROPOSED WORK'.(check all that
New Construction Cl Existing Building III Owner-Occupied J1 Repairs(s)X Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Descriptio ottfPr posedWo eFo1�n AAd
•/r A• •^
1+i SECTION 4:ESTIMATED CONSTRUCTION
Item Estimated Costs:
,uT Official Use Only''
Labor and Materials) y a
1.Building $ I. Budding Permit Fee $ Indicate how fee is determined:
❑Standard City/TownApplicatronFee n
2.Electrical $ ❑Total Project Cost(Item 6)z ruultipliei z
3.Plumbing $ 2 Other Fees $ -'
4. Mechanical (HVAC) $ Lam• *`r'-`^ `
5.Mechanical (Fire
Suppression) $' Total All Fees $ r 4
Check'No Check Amount Cash Amount. `
6. Total Project Cos $ 00
❑Paid is Full ;, .;' _4113 Outstanding Balance Due:
2'e:S1--TST TO tb '1
—5 l) g1 ��1"�
Ave 1 Gsp,�� 1