11 PLANTERS ST - CONSTRUCT NEW SINGLE FAM HOME The Commonwealth of Massachusetts 7Revised,V1ar2011
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OfFci*Use Only ..
lied.Date z
Building Permit Number: pplu _
rTJ
Building Official(Print Name). :- Signature- '_ . . ate
SECTION l:SITE INFORMATION N
1 . r
1.1 Pro erty Address: 1.2 Assessors Map&Parcel Nu%bers
U
/ P!g„T e1ZS J M
Ma Number Parcel Number <
L I a Is This an accepted street?yes_ no P <
1.3 'Looning Information:n t_ r_ p I.4 Property Imensions: co m
i1 "L ,K cJJhF� N
Zoning District Proposed Use Lot Area(sq it) Fromage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
149 1 1 /0 60-; 0 3o I ao
1.6 NV t Supply,(M.G.L c.40,§54) 1.7 Flood Zone Information Municipal 1.8 Sewage D!IW6snl System:
Zone: Outside Flood e7 Von site disposal system ❑
Public Private❑ Check if es
SECT[ONZ: PROPERTY OWNERSHIP!'
2.1 Owner of Record: c px O 30Y zooq
SKbM1UKKG !/ "mil- r.
WW me(Print) City,State,ZIP
004"r) l4A- Sae-`16L
Nu.and Street Telephone Email Address
WDescrCiption
N 3: DESCRIPTION OF PROPOSED'WORKS(check all that apply)
isting Building❑ Owner-Occupied ❑ Repairs(s) Cl Alteration(s) ❑ Addition ❑
cessory Bldg.❑ Number of Units Other ❑ Specify:
sed Work':
OIt b i4mat—, U
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OfRcial Use Only
Item Labor and Materials)
i. Building S . 000 I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S b dpp ❑Standard City/Town Application Fee
1 ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing .S 41 GY76-_ 2*Qther Fees: S
4. Mechanical (HVAC) S l D # ) List:
5.Mcchanical (Fire S 'rutal All Fees:S
Suppression)
� Check No._Check Amount; Cash Amount:
6. Total Project Cost: .S ��_ ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES �
5.1 Construction Supervisor License(CSp (rs•,v�-qF('�`f 3—Ze=—
Jns�� pJjAVYS�( License Number ExpirationUate
Name al'CSL Miller , List CSL'rype(see below)
!D�' YSF✓�-f G�P�
No. ;md Strec{� Type' _ Description
,el�� AAA U Unre
stricted 2 Farm Lip-to elling lO cu. It.
C./ ,"'^ icted I&2F:unit Dwellin
6ty/1'own,State,ZIP Masonry
n Coverinow andSidin Fuel Burning AppliancesSv13—C(6Zj— � tion
Tele hone Enr it address
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dane
HIC Company Name or HIC Registrant Name '
No. and Street Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVITI(M.G.I c.152.g 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 .......... No...........O
SECTION 7a:OWNERAUTHORIZATION.TOBECOMPLETEDWHEN
OWNER'S AGENT OR CONTRACTOR APPLES FOR BUILDING PERMIT`
I,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) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
)OSU 4 's komcw*c r�
Print Owner's or Au prized Agent's Name(Electronic Signature) Date
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 rro have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.massj,ov;oca Information on the Construction Supervisor License can be found at www.mass.aov!Jps _
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) ,(including garage,finished basement/attics,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
1. "folal Project Square Footage"may be substituted for"rural Project Cost"
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Ukrkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FH,ED WITH THE PERbDTTING AUTHORrfY.
Applicant Information Please Print Leath]
Name()3usiness/Organimtion/Individual): SKgsmyySlc�e,
Address: �� l
City/State/Zip: �huUr�..f PhoneM SO Z—� l
Are you an employer?Check the appropriate boa:
Type of ect(required):
LE I a employer with employees(full and/orpan-time).• � 7. construction
2. 1 am a sole proprietor or partnership and have no employees working forme in g, emodeling
any rapacity.[No workers'comp.insurance required.]
3.Q 1 am a homeowner doing all work myself.[No workers'comp.instance required.]t 9. ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will10 Building addition.
ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.n 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-conactors have employees and have workeri comp.insurmamt 13.Q Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. 14.Q Other
152,§1(4)7 and we have no employees.[No workers'comp.instance required.]
*Any applicant that checks box#1 must also fill out the section below showing then 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.
tContracmrs that check this box must attached an additional sheet showing the name of the sub-cofactors and state whether in not those entities have
employees. Ifthesub-conactors have employees,they must provide their workers'-comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jobsite
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: - Expiration Date:
Job Site Address: City/State/Zip: -
Attach a copy of the workers'compensation polity 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 be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby t nder th pat and ies o perjury that the information provided above is true and correct.
Si amre: C Date: 9--�7 J'—Y
Phone#:
official us 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.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
7
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 i \
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-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 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 perrmt/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 dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
t
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. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
36 bl- 239
l 3 P�a-'� �� sl .
CITY OF SALEM
ROUTING SLIP
New Construction by
Certificate of Occ l icy
LOCATION r DATE
ASSESSORS_ DATE
93 Washington St.
CITY CLERK DATE 7 29_f�
93 Washingto t.
f
BLIC SERVICES DATE 01
0 Washington St ATER DATE0 Washington St.ROSS CONNECTIONk�ATEefferson Ave
PLANNING DATE L
120 Washington St.
CONSERVATION
120 Washington St.
ELECTRICAL DATE
48 Lafayette t
FIRE PREVENTIO ' DATE
29 Fort Avenue
HEALTH DATE
120 Washington St.
BUILDING INSPECTOR /—DATE
120 Washington St.
4 ,
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Map 36 Lot 240
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�TREET 8' 15° Sewer Line, f;
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Sewer 12'
Easement
20' Wide ✓, 8^ \ .
N 42, 83