6-8 POPE ST - BUILDING INSPECTION t -
1
I"he ComtltUnwealth of iN9ussachusettS Ft)It
Board of Budding Reguhuions and SLandaids Nil'Nll"II' VI.II l
Massachusetts State Building Code. 780 ('MR. 7"' edition tit:
I
Building Permit Application To Const,uct. Repair. Reno%ate Or Dcnx)lish a R, riwd Loawu,
Oise- or Tcu-Fumill Dot'lling 1. 00S
OThis Section For Ot'ficial Use Only
Building Permit Numb• . Dade Applied
Building C )III ill nsumod Inspector ul 13uildmgs Uute
SECTION I: SITE. INF'ORNIA'HON _
1.1 Proqy Address:q& 11.2 Assessors %lap & Parcel Numbers
I,I Is this an accepted Street" ves r no MuP Number Poreel Nwnhcr
—
1.3 Zoning Information: 1.4 Property Dimensions:
R.3 0%10laY —
Zuning District Proposcd Use Lot Area(sy Ip Fnnuaee (li)
1.5 Building Setbacks (ft)
j Front Yard Side Yards Rear Y:od
Required Provided Required
Required Pivaidcd
1.6 Wat Supply: IM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood�one'
�bt
Puhlic Private ❑ Check if yes umeipai n O sue disposal nyatcin ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: q r ASS I] AN
L.Le�n Doo�lnss w+«+ T7�7[r
Name (Print) Address for Service:
,111ti. itz- 33Y c -- -
Sienatur Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction Existing Building ❑ Owner-Occupied ❑ Repairsfs) ❑ AlteI I onus) ❑ Addition ❑
Demolition ❑ Accessory Bid,. ❑ Number of Units I Other ❑ Speciljc .
Brief Description of Proposed Wurk2: f-��u+ 0 ' --
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
L Building I. Building Permit Fcc: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical S ❑ Total Project Costa (Item 6) x multiplier x _
I
3. Plumbing "' 2. Other Fees: S
J. tNlechanical (HVAC) 5 List:
5. Mechanical (Fire s - --
Suppression) 'Tutu) All Pees: 5
Cheek No. CIICA .-Amount (:a>h Amount
j o. Total Project Cost: D Q ❑ Paid In Full ❑ Outstanding Balance Une:- -- --
Jq ?
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) �' (
Oy
paA-,,�Ck N A ssf LICC Se Number [Apinuon Daw
.Name of C'SI_- I IolJer
List CS I_'I\lie sec hdow-1 _
\JJrr,s fv e Drsrri nun
L L''nres(rlrtcd Iu nt 3?.INTO C'u. fit.( -
R Resu i.ted l&2 F:umh Dddelhne
Signature ..\I \I:uonn Unk
Ql$ " Sol --)1 4 RL' Rc>IJrntlul ���line(\r�enn¢
Telephone R'S Rro-idrmiol AA'uidudd .wd S1,1111„
SP Kea Jentr l Solid Fuel Burniin_ \ppli.mer h(.Lilldln ai�
D Rcnidenuul Deuwluwn
5.2 Registered Home Improvement Contractor (HIC•)
HIC Company Name or HIC Registrant Name Ree(stration 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 pnwide
this affidavit will result in the denial of the Issuance of the building permit.
Signed .Affidavit Attached? Yes .......... ❑ No ........... 0
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 in my behalf. in all matters
relative to work authorized by this building permit application.
Signatue of Owner Date
SECTION 7b: OWNEW 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(he 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 (1-110 Program), will nu[ have access to the arbitration
program or guaranty fund under M.Q.L. c. 142A. Other important infi n nation on the HIC Program and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I IO.R6 and 1 MAO, respectively.
When substantial work is planned, provide the information below:
Vaal floors area (Sq. Fl.) (including garage, finished basement/at ics. Jerks Or porch) I
Gross living area (Sq. Ft.) Habitable morn count
Number of fireplaces (Number of bedrooms ---
Number of huthrooms Number Of half/bath, _
l \'pe of healing system Number of decks/ porches
Type of cooling system Enclosed ( )pen
FT-7 foial Project Square Footage" may he Substituted for ""Fond Project Cost'
-` CITY OF SALEM
PUBLIC PROPRERTY
•......�` DEPARTMENT
... ,':
%�9 u]i�:J��:zcET 0 S.,;. fit. SIA,i.\( t„ .i:,'.> _.')':
')7d-74:A46
Construction Debris Disposal Affidavit
(reyuircd for all demolition and renovation work)
In accordance w ith the sixth edition of the State Building Code, 730 Cb1R section 111.5
Dcbris, and the provisions of)iGL c 40, S 54;
Building Permit p - _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by 'NIGL c
IL1. S150A.
The debris will be transported by:
O�JG 2 tplSo.f��
— -._ U,amc of haularl
I I:e ,!�:bris will be disposed of in
CITY OF SALEM
3
PUBLIC PROPRERTY
DEPARTMENT
\L1` 'H I�� \t.\�i li`:'�r"S l l!ti P r • ti.\I f\I, \L\��.\' III �i�I :. :1'7-.
Workers' Compensation Insurance :V'ti(Jasit: 13uilders/Contractors/Electricians/Plumbers
t tlicant Information please Print Le>;ibly
N;imc tm,dwa>s Indn,.ludlC LLO±,10
\ddICSS: lat L ne•• G"),%)A.
City'StatuZip:
YSeaerl.l., wt w phone : �17 &- g 2 2 3 3 '! S"
.\re von an employer:' Check the appropriate box: 'Type of project (required): -
I.❑ I am a employer with d. ❑ 1 am a general contractor and 1 6 New construction
employees (full andlor part-time)." have hired the sub-contractors T ❑ Remodeling
listed un the attached sheet.
_'.❑ I :un a sole proprietor or partner-n e g_ ❑ Demolition
v
ship and have nu employees These sub-contractors have
working tile i any capacity. workers' comp. insurance. q, ❑ Building addition
[No workers' rump. it 5. ❑ We are ❑ corporation and its 10.0 Electrical repairs or additions
required.) ofticrrs have exercised their
right of exem Lion per IviGL 11.0 Plumbing repairs or additions
}.❑ 1 am a homeowner doing all work S 2 P and e have no
myself. [No workers' comp. c. I S_, 31(3), l2.❑ Roof repairs
insurance required.] } employees. [No workers' I3.❑ Other
comp. insurance reyuired.l
• aca boa h I must also till out the section below showing their workers'
:\uy pplicint that cheeks indicating they are doing all workan en compensation policy information.
' n who checks this affidavit
d then hire outside contractors must submit a new affidavit indicating such.
I Iomeow
:('.nvractnrs that check this hot nmet attached an additional.sheet showing the name of the sub-contractors and their workers'comp.policy information.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
inprntation.
Insurance Company Name:
Policy k or Self-ins. Lic. N: 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 L%1GL c. 152 can lead to the imposition of criminal penalties of
tine up to S I,5oom0 and/or one-year imprisonment, as well as civil penalties in the tbnn of a STOP WORK ORDER and a tine
„f op to S2O 5 .()O a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
I II\cstic:uions tit the MA tar iuxiranrc eo\ertge ver tic:uion.
/do herrby t'erriji' under the pains and penalties uj perjary that the iojnrmation prnrviJed above is true and correct,
Phonc rob .
1i%It,nure: i
t)ljiriol use only. no not write in this area, to be completed by city or town official.
('itv or I oan:
b,suing .\uthorily (circle onc):
I. Board of Ilealth 2. Building Department 3. Cit)d'fuwn Clerk a. Electrical Inspector 5. Plumbing Inspector
h. Other -----
Contact Person:_ __--_-_ --—__ Phone a:__
Information and Instructions
\las>:ichusdtts General Laws chapter I i' resµtires all cny,losers hr pro%ide workers' coinpensmion for their entplo}ees.
I'll rsu.uu to this statute. ,tit r•rnpluree is Joined as "_.cN crN person in the scn ice of another under any coutrtct of(tire,
r y,rrss or implied. oral or written.'.
An anrplo t'er is dctined as 'an it divd tie I. p.nnr.ers hi p, issoci:u too, eorpor:uion or other IcgaI entity w st. or mo, to or ore
of the (orc_oing engaged in ajoint enterprise. and including the legal represcluatikes ofa deceased employer. or the
rccci%cr or trustee of ill individual, painiership. association or other legal entity, em loving ent,Ilovces. Iw-loe\er the
P _
,m tier ofa dwelling house having not more than three ap:tttnrnts and who resides therein, or the occupant of the
JtSelling house of another who emplovS persons to do ntauttcn:une, construction or repair work on such dwelling house
or on the grounds or building ;tppurtcn:mt therctg,hall not because of sudt em tlo)mcnt be deemed to be an cru lover...
\I(;L chapter 152. ss2�06) also states that "every state or local licensing-agency SSshall withhold the issuance or
renewal of a license or permit to operate a business or to construct bG laidb3`tn the M&IuRu`rA4� ,itf(Ur any
applicant t ho;It•y'§ jhtt'prt).11u(adau.ccptable evidence of cornpliance with the insuryn_c�• coverage required.-
Additionally, MOL Chapter I �_.0 I.i) states-Neither the eonunonw'calth•nor;m}P"tY dFS uhtti at subdivisions shall
enter into any contract fir the perl'ormance of public work until acceptable c�idence of connpliance with the insurance
I equirements of this chapter have been presented to the contracting authority."
v
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 nuniber(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 he 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 he 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.
Please he sure to till 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 tiny given year, need only submit one affidavit indicating current
policy information (if necessary) and tinder "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
O.C. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
Tine Otfice of fnvestigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give Its a call.
I he I)cparttncnt's address, telephone and tax number:
i The
Department f Industrial Accidents)
OMce of Investigations :: `e-
I y
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
12e•.iseJ -�6-u5 Fax # 617-727-7749
www.mass.gov/dia