23 PLEASANT ST - BUILDING INSPECTION t The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
I Massachusett ate Bu ding Code, 780 CMR, 7" edition Building llm,
ll\ Building Permit A ept
placation To qonstruct, Repair, Renovate Or Demolish a
�\ On -or T fo-Family Dwellinglfll
i ction For Official Use Only _
Building Permit Numb Date Applied:
Signature: L
Buildin Comma loner/In r of Buildings Date
SECTION 1: SITE INFORMATION
I. Property Address: 1.2 Assessors Map& Parcel Numbers
�'' PLti�YY-h)1 !fI
1.I a 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(R)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
1_Arrl. S I R►)d4
Name(Print) Address for Service:
94XTUre Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Uf I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Descrip1Ition of Propo ed Work2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -
I. Building $ .sO p 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project COS': S S d0Q 0 Paid in Full 0 Outstanding Balance Due:
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Numbed Expimuon are
Namc of i L Ider
�N �
-H 1 " List CSL Type(see below)
—� �l_ l Type Description
Addr U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
Cl 7k—T)l S y RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
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........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, ,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 Date
(Signed under the pains 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 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. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1.1 o'A 12C W,sstu.\s:I,rN,S 18 CL r a 5,%t 1 M. MA,%%t.I II if 1 IS O V)7'
Tel. )73-.'13-93'15 • hsx 974-741--/846
Yorkers' Compensation Insurance "•ffida"it: Builders/Contractors/Electricians/Plumbers
_kkr rlicant Information PIeace Print LeHih1V
Name lndrvnlu � '� � �O�al l: 1�
dtlress: Cp2 ZIVp�rn �ru
City,Scnc,zips N �9M 1 �T1n) N`h 01QfSQl'hunc •!: 97� '77 1 — $ �/
.\re you an employer:' Chuck the appropriate box: 'Type or project (required):
I.❑ I :uu a employer with 4. ❑ I afn u general couuactor and 1 6, ❑ now construction
ml,loyrea full unLVur art-time).' have hired the sub-contractors
1 ( p 7. ❑ Remodeling
2 1 sot a sole proprietor or partner- listed on the anachcrl sheet.
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. Insurance 9. ❑ Building addition
S. ❑
I Kn workers' curnp. insurance We are a corporation and its,s(ticers have exercise) their I I.10.❑ Electrical repairs or additions
I required.) g repairs or additions,
3.❑ 1 ant it homeowner doing ail work right of exemption per MOL ❑ Numbing "P'
myself. LKo workers' curnp. c. 152• ¢1(4),and we have no 12.❑ Ruuf repairs
insurance required.] unplcyecs. [No workers' 13.❑ Other
comp. insurance "uired.J
•�m .ygi6uul Am checks boa 111 must:dsu fill wl the wu.on Laluw showing their wurkets'cumpens:aiwi policy inllirtn,aium
'f Iomeuwoera who submit this affidavit indicming they ate doing all swrk aad then him outside cotumcrom must.uhmit a new airdavit indiultny.uch.
d\mvacb+n that check this boa mild..awh d an addaional side.huwiny the"elite of the sub-comrxron and their wur4en'comp.pohry m(urmatiun.
J, ,at tin employer that is providing workers'c•oorpen.artion insurance jar ray emplgpres. Below is the policy and Job sirs
informutiam
Imuramce Cunipauy Name. .
Pulicv a or Sulf-ins. Lic.
Expiration Date:
Job Site Addrees: ___. CltyrSlaterZlp:
Attach If copy of the workers' cmnpensatiun policy declaration page (showing the policy nunibur and expiration date).
1'ailme to secure cos-erdge as required under Section 25A ul'.\IGL c. 152 can lead to die imposition of criminal penalties of a
Tina op to 51.500.00 and/or one-year imprisonment, us well as cis) pcnultics in the funn of a STOP WORK ORDER and a fine
Of up tit S250.00 it day against Ilie violator. lie advi..wd that a copy of this¢cut inctil may be lumarded to the Qlelce ul
Im..m;au�nu of the OIA :or trrularcc c,J,ccrjge icriticallon.
/Ju herrhy canijr tattler the pair wid pentut iy ufperjury thut the in/brinutlon providedy/G eve is true and correct.
Date' 0
rNICY I-)
rh �1 I rr �ffB�I
1)JJiciut use uu!y. no nor writs in this ureu, to be cuutplerrd by city or town official
( itv or (own: _-_ __ I'vrmit/License 0.
Issuing.\ulhurily (circle onc):
I. Board of lleallh Z. Building Department .i. Citi.'Ibnu Clerk J. L•'lectrical luspector 5. Plumbing Inspector
6. Oteter --
Conlael l'cnulll .. _ Phone N:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide.workers' compensation for their employees.
Pursuant to tnis statute, in emp/gree is defined as "._every person in ncc.service of another under any contract of hire,
evprass or implied, oral or written."
An empluycr w defined as-an Individual,partnership,associattou, corporation or other legal entity, or any two or more
.,r the foregoing engaged in alomt enterprise, and including the legal representatives of a deceased employer,or the
receiver or tustee of .ul mdlvldual, partncrship, association or olhcr 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 -
dwclling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or or; the.rounds or building appurtenant thereto shall not because of such employment be deemed to be in employer."
MGL chapter 152. �25C(6) also states that "every state or local licensing agency shalt withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant "Ito has not produced acceptable evidence of compliance with the insurance coverage required.-
Additionally, N161- chapter 152, 4. 25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ol'puhiic work until acceptable evidence ot'compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply toyour situation and, if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of
insuance. 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 cwntimration of insurance coverage. Also be sure to sign and date the affidavit. The aff idavit should
he 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 it 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 fur you to till out in the event the Office of Investigations has to contact you regarding the applicant.
111aase be sure to till in the pcnnitllicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennitJlicense 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
n.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I ha i)iiice of lave%rl.arLUnf \could li'a to thank )'Ou Ill advance fur your cooperation and should you have:my questions,
please du not hesitate to give us a call.
The Deparnnenl'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 p 617-727-7749
www.mass.gov/dia
CITY OF SALEM
A
PUBLIC PRoPRERTY
;
`- DEPART'.10ENT
III '/�5-•�'-" "' I �\ 'i 7.4 '4_ '/i 4.
construction Debris Disposal .affidavit
(reiluired li/r all demolition iuld 1010% uion work)
In accordance %%ill, Ilre sixth edition of the State Building Code, 7S0 CR1R section I 1 1 .5
Debris, and the pro\ isions 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 lacility as defined by MGL c
I1I. S 150A.
The debris will he transported by:
C, .'TwC V4
I name nl hauler)
I he debris will be disposed of in
(name ul iJ rty)
IaJdre.. ul IJCl hlcl ,^/ � /^/
vc❑JIOI I• of 1�I KJIIf
11ky 51
_ gate