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11 PRESCOTT ST - BUILDING INSPECTION (2)
fr The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR �.'y� Massachusetts State Building Code. 780 CMR. 7'" edition M1Il Nl( Sf-V.I'll' Building Permit Application To Construct. Repair, Reno%ate Or Demolish a Ro oed hnot.0 r One- or Ttcu-Frunitr Dst elling /. 't r)J This Section For Official Use Only Building Permit r: Date Applied: Signature: 4. 24 ' 016 Budding Cummi sinner/ Inspector of Buildings Dote SECTION 1: SITE INFORMATION 1.1 Prq{�ert �d ress:( /�, 1.2 :tssessors Nla & Parcel Numbers (( t'i2eSls� JT tic-c'�� P i L l 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 fl) Frontage(it) pl.6Wate;rSupply: g Setbacks (R) Front Yard. Side Yards Rear Yard Provided Required Provided Required Provided (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Private❑ Check if yesE3 Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 1( PlLevo 2.1,Owners of Record: / L Name (Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction ❑ Existing Budding ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition Cl Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief scription of Pro sed ork': u '(ws $ z if I a f f 1 r � S( Sa. SEC ION 4: ESTIMATED CONS RUCTION COSTS Item Estimated Costs: Offlclal Use Only (Labor and Materials) 1. Building $ �f7O 1. Building Permit Fee: 5 Indicate how tee is determined: ❑ Standard City/Town Application Fee 2. Electrical 5 ❑Total Project Cost' (Item 6) x multiplier x 3. Plumbing S 2. Other Fees: E 4. Mechanical (HVAC) $ Luc 5. Mechanical (Fire $ Suppression) Total All Fees: 5 Check No. Check Amount: &O Cash amount: Project Cost: 5 6. Total Pr J ��-(� 13 Paid in Full ❑ Outstanding Balance Due. SECTION 5: CONSTRUCTION SERVICES J, 5.1 Licensed Construction Supervisor(CSL) Osli(-FU�- ©� Cl /�. p .] l C � License Number E.a�piyrauou ate Nante of CSL- f1olJer (7(-(Q at CSL Type Isee hcluwl - ln✓ v- Type Descri uun Ad ress U Unrestncted l u i o 35.000 Cu. Fr t R Restricted 1&2 Family Dsselhn Signamrc v4 Mason Only '71r(—ZIpCa Za p t� RC Residential Roofing Covering Telephone %%S Residential Windu,s and Sidon SF Residential Solid Furl Bunune 1 r )tan. hn�.JLw�n D Residential Mniohwm 5. Registered 11 the ImprovgLnent Contractor (IIIC) f 3 "� al � HIC CNatnc ur HIC Regi trans NRe utrauun Number AJ Te a uatiun Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 9 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure it,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 r6A— 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 half. Pro 'Jame Signature of Owner or Authorized Agent Date (Signed under the pains and nalties of r u ) 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. I42A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations 1 10.R6 and 110.R5. respectively. 2. When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) (including garage, finished baserrent/auics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms j Number of bathrooms Number of half/baths j 'Type of heating system 'dumber of decks/ porches � Type of cooling system Enclosed Open I. 3. "Total Project Square Footage" may be substituted for "Total Project Cost" CITY OF SALEM PUBLIC PROPRERTY DEPARTNIENT !'Hill •`i Vl.v:.'It I'.; AC'.t�i lL`a,:,']1141 P I • ti.vI! cl, AL�...�, !tt •I I :. .1'I'=_ T-8.74--'t84t, orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly A t tllcant Information C/' C ' r 4A \ram �D�A �t Il 0w2- TccMPr[,o+. S \:Illlc tliuswns 1i�r_.�niytf�a 1—�uun.InJn:•luell: .1} Address: Zyr 3— � 1 I ('ity,State,'Zip: S" 29,C MA OIgO� Phone Are you an employer:' Check the appropriate box: 7).pe of project (required): I :un a employer with 4. ❑ am a 6. ❑I general contractor and 1 New construction I.❑ employees(full andlor p art-time).` have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling I ip a sole have proprietor mp o partner- and h:n�a nu employees These sub-contractors have 8. El Demolition working for me in any capacity. workers' comp. insurance. 9. ❑.thudding addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their ri>bht of exemption per IvIGL I I.❑ Plumbing repairs or additions 3.❑ 1 am m a homeowner doing all work P myself [No workers' comp. c. 152, $1(4), and we hive no 12.❑ Ro f repairs insurance required.] employees. [No workers 13. Other comp. insurance required.] •:\uy applicant that checks bus It must also till out the section below showing their workers'cum pensatiun policy information. t I Ivnreowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $lnvractors that check this bus must anachcd nn additional sheet showing the name of the.sub-contractors and their workers'comp, policy information. l am art employer that is providing workers•'compensation insurance for my employees. Below is the policy and job site inf'urination. Insurance Company Nanic: Policy #or Self-ills. Lie. #: 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 co.crage as required under Section 25A of-IGL c. 152 can lead it) the imposition of criminal penalties of a tine up to S 1 J00.00 andlor one-vcar imprisonment. as well :Is civil penalties in the toxin of a STOP WORK ORDER and a tine of up to >_250.00 a day against the violator lie advised that a copy of this statement may be forwarded to the Office of I llle"n'—'atiol , uF the DI:\ for insura Ice coverage verification. 71.1,A hereby c viQ' air er joins t ad pea r •rjury that rise information providedabove is true and correct. t Dare rue. rh t 7?. 1- __n SS U/Jicial use only. Do not write in this area, to he curnpleted by city or 6nvn uffiriuL City or -I nwn: _ -. -- Penniul.icense #—_--.------_—_---- lasuini; .\uilwrity (circle one): I. Huard of Health 2. Building Department 3. City l'own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other .-- --- --- Contact Iverson:--_--— -- -- Phone #:___ . 1 Information and Instructions ' y \IasSacltusetts Gencral Law Chapter I I ell utres Alemplo%eIS to pros ide %%orkct;s' Compens;nion Ior their employces. Pill scant io this >cuute, All empluvee is defused as "...at en person in the Service of.mother under ane Contract of(tire. Cy,reSs or implied. oral or n%znwn. ' .\u :ntploier is detincd AS "an indit:du:Il, parnicrship. .ssocfation. corporation or other legal entity. or any two or more ,,(the foregoing e1olaUcd in a joint rntrrpriSe, and includine the Irgal rrpresennnites of a deceased employer, or the r. vt%cr or trustee of an individual. partnership, association or other Ie_al entity, employing employces. Ifowcser the ,.,.o tier of a dwalline house hay ing not none than three apartments and %k ho resides therein, or do occupant of the dot elling 110LI5C oFanother who employs persons to do maintenance. Construction or repair tsork on Such dwelling house or 011 the gnnuds or huilditig appuriCn:urt thereto Shall not because of Such employ ilent be deemed to be an eniploper. , Nit iL chapter I i 2, ?( 16) also States that "every state or local licensing ageney 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." Addirionally, %IGL chapter 152, §]5(171 states "Neither the commonwealth nor any of its political subdivisions Shall enter into any contract for the performance of-public is ork until acceptable et idence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, Supply sub-contractors) nante(s), address(es) and phone nuntber(s) along with their ceniticate(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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom Ill the affidavit for 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 permidlicense number which will be used as a reference number. In addition, an applicant that must submit multiple penmitilicense 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 tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture I is, a dog license or permit to burn leaves c(c.) said person is NOT required to complete this affidavit. Fill: I Mice of Investigations would like to thank you in advance for your cooperation and should you have any questions, pleaaC do not 11CSitate to give LIS a Call. I he I)cpartmmilt's address, telephone and Ia.x nunher: The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston, MA 02111 Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE Itct isrd i-_'0-U5 Fax k 617-727-7749 www.mass.gov/dia CITY OF SALENI < PUBLIC PROPRERTY DEPARTMENT .'FI. Y;$-�l+-)i•)] • t V(. 'i )d iF, Construction Debris Disposal :%ftidaNit (required Cur all demolition and renovation work) in accordwicc with the sixth edition of the State Building Code, 730 CMR section l l l.5 Dcbris, and the provisions ofvtGL c 40. S 54; Building Permit ate_ - _ is issued with the condition that the debris resulting from . ;leis work shall he disposed of in a property licensed waste disposal facility as defined by MGL c 11. S 150A. The debris will be transported by: i uumc of iiaular) I L•c ,4bris will be isposcd of in : l a.,r..r