18 PORTER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CI' Y OF
CIh19 'x 'i, Massachusetts State Building Code, 780 C NIR SALEM
'L•'•• Revised I/ur_If)l/
Building Permit Applic: ' n Construct, Repair. Renovate Or Demolijai
Unr-a 7uvi-Furf)i!c Dlrrllins
T is Section For Official Us
Building Per it Number. D pplied: _
Building Official(Print, tune Signature / 1 DJ1e
SECTION 1:SITE INFORMATION
I.1 Property Ad ess: 1.2 Assessors Map& Parcel Numbers
I,la Is this an accepted street?yes no Map Numhcr Parcel Numher
LJ Zanhtg Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal ❑ On site disposal system ❑
nert of Re ,/ �JSECTIO�N2: PROPERTY OWNERSHIP'
�r]Cd✓�Xrd
N;mte Print) City.State,ZIP
l /�a � �yJ�3 o
No. and Street Telephone hnmil Addmss
SECTION J: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Pr ed Works:
<
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
I Labor and .\laterialsi Official Use Only
I. Building S I. Building Permit Fee: S. Indicate how ree is determined:
2. Electrical S ❑Standard City?ovvn Application Fee
O Total Project Cost"(Item 6)s multiplier _ _ x
i. Phunhi°g S ?. Other Fees: S
1. 1,lech:mical ill%*.\(') S LisC
I s. \lechanical Wire
Su>>ression) S Toted .\ll Fees: S_ --__ --- ------
Check No. Check Amount: C ash \mount.n. Total Project Cost: 4� �S�d�dd --- ._
❑ Pnid in Full ❑Outstanding Balance
Bul:mcr Due:
3 1.
SECTION 5: C'ONST'RUCTION SERVICES
5.1 Construction Supervisor License(C'SL) J0��
-.����—^�- �/ja,(� IZJL License Nunthcr Ispirmian Dntc
Nauu of l'SI. I lulder
—
__.1 `— ------ ----�---- 'I')pe Description
No. and Sirect
�/f ��--,,pp ^7� (I I4lreslncted I IIuilJin s ti to 15,IIU0 cu. Il.l
R RcsuicleJ IR''_P:unil Docllin
Ci1)i oll n,Slule.LIP � M1 M1lason
R ' Roof n Covcrin
A'S Window;Ind Siding
SF Solid Fuel I3urning Appliances
9 (/ I Insulation
l'ek hone 1(nlail address D Demolition
5.2 a isteKed Ito Improvement Contractor(HIC) 6,12
l/G �t' Gi✓ IC Registration Number ispirn 'un Uatc
I IIC pan) N;u>'�e or U�E' Registrant le to
No. :1pdAcc ( ,!)n U../� ,�' 7�� L•'mail address
CCC�own,State,ZIP / ✓ I / Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 4 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 TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
stained in t applica a 1s true and accurate to the best of my knowledge and understanding.
Print Other's o Authorized Agent's Name IFlcctnmic.Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Cuntractor(HIC) Program),will tw have access to the arbitration
program or guartity fund under M.G.L.c. 1 42A.Other important information on the HIC Program can be found at
tttttt I Information on the Construction Supervisor License can be found at
2. When substantial \%ork is planned, provide the information below:
Total flour area(sy. R.) _ I including garage, finished basement attics,decks or porch)
Groislking:realsy. 11.l —_,- _ - llubitable room count
_ .- -
Numberoffireplaces___ Number of bedrooms
Numher of bathrooms -- -- - -- Number of half'baths
_- .. ... . - - - Number of decks porches
I\pe of heating iy item
1-le of c001i"g s. iletil _. _ - _ 1'ncloied _. _ _ --Opelt
t. "1'olal Project Square FoolagC" may be iubstiluled liq''fU1;11 Project Cost"
+ CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.,ur.nl l Y:,nM ul1
�linw
11: lttAafN.\GIU.\jleCL•1 j,1{I•N, M.\1h.\t.IIIvl'IIS 1,)?3
I'i•.t. 77L?tivini • P,x v7M•?lC•nsM
Workers' Cumpensation Insurunc r \lllduvit: Uullders/Cuntracturs/Ele riciuns/Plumbers
% i illcant In urm•Jllon
�lIIIM(thr.I-Wssil)r;Ianv+tinrvindsv,duull:
lildrrsr:
I'hunn
\re I Iu its employer:'Cheek the apprnprla4 burr:
I I :utl a empluyer with 4. .1.)Iw oI Trot ect(rwlulred);I � ❑ I sort a general cauutttor and 1
'•❑ enlpluyccs(full andlur part-time).a buve hired the.ruh•coniracwrs 5. ❑ New construction
I am a Sala prnprienlr Air partner• listed on the attached.sheet : y ❑ Remodeling
ship ant hove no empluycun These subcontractors have
working tier me in any capacity, workers' comp, insurance.
g' 0 Demolition
I Kn workers'cutup. infurance S. ❑ We aro a col 9, ❑ OuildinR addition
rcyuireJ.J pontinn ant its
orMcen have a tereiseJ their I o.0 Electrical repairs or additions
3.0 1 and a homouvner Juing all wark right of eaenlption per h1Ot 11.0 Plunibinr repairs ur addition
nysclf. (Ko workers'cutup• c. I52,§1(4),and we hove no
infumnca rcyuired.J I cmplayevs. (No workers' 12.C] Ruul•repaire
crnnp, in.surati reyuireJ.J 13.0 Utlner
•q,q.0114a4 rh,e'Plea has rt must:dw fill uw the aroumr L%ww'l l.,nwrrwrwn whe rulrrnif this Gaidavit iwiurin r Jwwrne rheit wwtN1'vunryenyatun Alley rnlinnYuirrt.
a M or June all•wra a W short A4e uwfsM euturneron mwl.ulvnir a nsw+aRJsvil inJiur:ne wwh•
r,•nrnwnwv rhsl ahcfh Ihra Ep corral+rtahre„n aJdiriuryl aheM ahuw:ne IAr nanN of 1M lu►erreraddfe and thew%whrts'comp.Intlrey rntbrrnsriue,
/um all eutplayrr that 11pruRd, X lvorArrt'rumprnrotlon htrunrticr or to rm
Br/
istlurmudot6 / /• y p/opre.R situ fir thrpuWty an✓/u1 sift
Insurancu C•onnpany .Valne:
Policy our Svlf--ins. Lic.to: —
EApiratwn Dart •
tub jlte -\rlllreff: / a, �� -
-� Cltyr$late/Zip:Attach a cuyY of the workers'conpcnfutlun policy duelarullun page (showing the policy nwnbur and explraHua dare).
Pallurc w xcure cu.eraye as required under urent, ?JA u -VU c. 152 eau lead to Ill#imposition of criminal penalties of a
(ti uT nl S0.00,4xi y IdaitYur be thin i. B11111' mmcnr, as well,s civil(wilallics in the turn ofa STUp WORK URGER and fine
ai up ro i'SA.q(i a Jay iguiust IM vLll,lrnr. lie advrecd that a CITY urthu.,taLL'ment may be IurwarJed iu the Ullice uC
III1'i TII�JI41111 ei Jiv UTA Iqr ulanr:u'cC a,vcr+gc icrilicanun.
/Ju/h•rrhy t crli j nn•1 trrinr un✓ aro/tier u�yrr/try that the in unnrNon/• yrvri✓r✓u0uw is true nrt✓corru c4
It)!/trio/rnr ou/y, /)d,rot write in this urea, to be cuutpletr✓ily city of sown u/JAW
(7rr ur Pawn:
-- Permit/Llecme�
I,auing Aulhurity (circto noe);
I. Ih,.trd of lleehh 1. Ihuhfin� liyl.lruncut 1. l:iti,'fltin C'Icrk 1. L•'IcclriCal lot tcc/ur i,
G. Ofhvr
i I Plumbing In,yccrar
Y: �
information and Instructions
1+on in the service of another killer .illy :unlrlcl of hire.
�Lus.lchu:etts licneral Lows chaytef 152 reywrcs all eulpluyars to provide wurkers' cumpensauon nx their eo1P oYees.
1•ursu.alt to Iili,,latule, an rmPferre is defined as"._every pc'.
;.press or unPfied, oral of written." or illytwo or more
�n empluprr 1+dctined as"an individual. PuMership, ,ssociaooa.corporatwn ur other legal cnhry,
ed In a)omt enierprisa,and including the legal(CprCntity %:m `�,^ employees.INaw�crhhe
•,1 the IJ(C5011ig engaged
asmNshlp.assoclallea or other legal entity,Cmp y a ' P
L eceiver or uusleo of.ui iudiv IJual. p
awns to Jo muintenunce, construction or repair work on such dwelling{ heir
owners a dwelling{house having not Inure than three apartments and who resides therein,or oho occupant of
,Iwelling house of another who employ'pe
u( on the grounds or building appurtenant thereto Ing shall not because of such employmum be deemed w be in employer.'
�IGL chapter 152. �:SC(6) also states that"every scats or local"Carol buildings
I shall withhold the Iswaan or
avldsaso f t construct witb the Insurance coverage required.'
renewal of r Ilccnso or permit to operate•business or to construct buildings la the commoeweultb or as
Applicant who has not produced acceptable of its Political subdivisions shall
AJJitiorally, %IGL chupter I S]. S-'5C171 slates"Neither the eommenwble a not any
enter into any contract for the performan aventPJbo the contract g atil uthority."
of cunlyli ulce with the insurance
requirements of this clmpler have been p'
Applicants checkins the boxes that apply to your situation and.if
compensation affidavit cotl'palYhene number(s)along with their certiffcatc(s)of
Plca.+e rill gilt the worker,' comps adilressl ). p with no employees other than the
necessary,supply;tub-contructot(s)name($),
insurance. Limited Liability Companies(LLC)or Limited Liability PaMenhips(LLP), P
nelnbars or partners, are nut required to carry workers' compensation iubmittcd. If as LLC of LLP Boas have
employees,a policy is required 90 advixd th�'�ts affidavit'nay Also be sun to%Ilan and date the al'tida to the vill. ltolaffidavit ishould
licaagedOl1 for the permit or license is being requested, not the UOPortmant of
\ccidents for confirmation of insurance coverage.
he resumed to the city or town that the app questions regarding the low or it'you are required to obtain a workers'
Industrial,liceidenta. Should you have any y
eotnpensation policy,plasma call the Depa merit at the number listed below. Self-insured companies should enter their
mber on the appropriate line.
.elf.insurance license nu
city or' own Omelsl,
oil to till out in the avant the Office of Investigations has to contact you regarding the applicant
Please he sure that the affidavit is cumpiete and printed legibly. The Department has Provided u sputa h the bottom
of the affidavit fat'y
applications in an given year.need only submit one affidavit indicating current
,'Ease be sure ro fill in the p1 out i the
nmibo:r which will be used as a reference Y e number. In addition,an applicant
Iliat must submit multiple Penniulicmise licant should write"all lucatiuns in (' Y
Ld or marked by the city or town Inay be provided to the
Policy information(if nccesaary) and tinder"lob Site Adthcsi'the gar "
town I ,,%copy of the uffdevit that has been officially stamp'
tow icant is
proof that a valid affdavit is on file for future permits of licenses. Anew atTlduvit nwst he tilled out each
y cur. W here a hums owner or citizen is obtaining a license or pennit not related to any business or commercial venture
I i.e. •1 dug lieen.+e or permit to burn leaves Cie.)said Pcrson is NOT required to complete this affidavit. ucsu ale,
1 I1C i)I1j"ill Ilrve+ngatluns ivuuld like to dlank y'uu In JJvallce rut your couperatlon alld Should you Nava:rnY y
111case Ju not Ilesit2tc to give us o call.
fhe U,Parnncns's aJdre+s, telephone JThe Commonwealth of Massachusetts
Department of Industrial Accidents
018ee of Investigations
600 Washington Street
croon, MA 02111
'fel. 4 617-727-4900 ext 406 or 1.977-MASSAFE
Fax M 617.727.7749
J ;.If, www.mau.gov/dig
CITY OF S,VLEM, NL1SSACHUSET7S
BULWLVG DEP-A)MONT
120 WASHLYGTON STREET, 3'FtOOR
TLL (978) 743-9595
KIMSE LEY DRMOLL FAX(978) 740-9M
,MAYOR Tlio.mu ST.PIBntu;
DfAF�TOR Op Pl'BLJC PROPERTY/8"MLYG GONOUSSIONER
Construction Debris Disposal Affldavit
(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 a 40, S 54;
Building Permit Al is issued with the condition that the debris resulting from
11 work shall be disposed of in a p
l 11, S I SOA. roperly licemed waste disposal facility as defined by MGL c
The debris will be transported by:
(n.une at'houler)
The debris
�will be
disposed of in
(name of facdiiy)
(Jddrels ot'rjcihiy)
tlnan+re ofpermrt applicant
,L to