36 PROCTOR ST - BUILDING INSPECTION The Commormealth of MassachLISCUS —
V t Board of Building Regulations and Standards t
VI( NI( I'Al III
Massachusetts State Building ('ode. 7ti11 ('v1R. 7"'edition
Building Peirnit Application T nlsu uCt. Repair. Reno%ate Or Dcnioli,h a K irrr J.h un, u
(hl • ry Trru- iu))ily OtrcllinR
'Phis coo For Official Use Only
Building Permit Number: Date Applied: (/U
Signalure: T.
Budding Cui u rr i„ione >pertur ul a mgs U:uc �� U
SEC-PION 1: SITE INFORAIATION
�1.1 Prop• tY c--kAddr2.s• Th /A 1.2 :Yssessurs 11ap & Parcel Numbers --------- -
36 ��c�/� Si .]rr �"/
I.la Is this:m accepted ,tree):' v-es_ nu Map Nunther Parcel .N'unihrr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area tsy It) Frontage iIt)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rcar Yard
Reyuin•J Provided Reyuoed Provided Requited Prnudrd
I
r.6Water Supply: (M.G,L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone.,
uhlic ❑ Private❑ Check if yes❑ Municipal Cl On site disposal system ❑
,w' J2 SECTION 2: PROPERTY OWNERSHIP' /�11 V zO kfIaecord:,4G�n k,, � pT`IpJ.y� /2�C- -o<� S/
Nam• Print) I"� I ` er ice
,
Signature_ Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(cheek all that apply)
New ConstrEO
❑ Existing Building ❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ r\JJitinn ❑
Demolition Accessory Bldg. ❑ Number of Units I Other ❑ Spceily: _
i Brief Description of Proposed Work'': w to a
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
� Item Official Use Only
(Labor and.Malerials)
I. Building 5
I. Building Permit Fee: $ Indicate how fee a JctcrmntcJ:
Standard City/Town Application Fee
2, Electrical 5 ❑ otal Project Cost (Item 6) x multiplier .x
3. Plumbing S ?. Other Fees: S
4. ,Mechanical MVAC) S List:
i. Mechunieal (Fire ---
Su ) ressionl Turd :\II Fees: $
0 (' ck No. Check :\mount: _ Cj.,h .\mOnutc
0 Total Project Cost: 5 J��• aid In Full ❑ Outanutdmg Balance Due:-_--- —
/yIa'�L C t7 Cd�T�G(/-3G�7YL
SECTION 5. CONSTRUCTION SERVICES —
.1 Licensed C'unslructiun Supervisor ICSIJ 996 g— 1-O S
Ilinc Number )aic
(�
Nanw• nl C L IIuIJcr h
1*� 4,5-Z Lul CSI_ T pe),ec hclou l ___ ._ foe
De?ill 111U11 _
ddl ee>
I 1'llre,lrleled it (o !`.1No it F1
R HL.,lnctrd ISc_' F.unih
Sign:lulle S/ / \f \I:uonrs Unls
_HC— Rcsldrnual Ru):h ...
r.•Irphunr \1S Nc,iJ.nu.d \\in.lur•. ,:nJ Sidu�a _
SF Rc,iJcn U.d SuILJ I .Icl Iiw nu)c \hl�h.0 r.. In....l
D Rc,ldcundl Deinnhuon
5.2 is red I Dine In o tent Contractor IIIICI
FIIC C'y)I�tr:mv al or fll Rc a nl N'an,e � l i` ,�TR,"g.,,,Liuon .Nwuher
�' � 77N
cadre„ ------ 9/35& r
I Signature hcicphonc
I I
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (NI.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and ,uhmined with this ipplicltion. Failure ❑) pro,idc
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
as Owner of the suhlec( property hereby
authorize _ --_—.- it) act tin my behalf. in .III Inatlers
re!ative to work authorized by this building permit application. �
i
Signature tit Ossncr Date
SECTION 7h: OWNER( OR AUTHORIZED AGENT DECLARATION
— I
1. , as Owner or Authorized Agent herehy Jeclare
that the statements and information on the foregoing application are true and accurate, to the best of my kno.viccli and
behalf.
Pant .Name
Signature of Owner or Authorized Agent Date
(Sign d under the pairs and 2enalties o perjury)
NOTES:
I. An Owner who obtains a building permit m do his/her own Mork, or :mow ner who hires an unregi,lcied eontrlctor
(not registered in the Home Improvement Contractor (HIC) Program). will not have access (o the arhur:own
program or guaranty fund under M.G.L. c. IJ'_A. Other important information on the FIIC Pro,ur: in :in
Consauction Supervisor Licensing (CSL) can be tilund in ',SOCNIR Regulations I M R6 and 1 I0.R5, iespecusely.
s When ,ubmantial work is planned, provide the information below:
Total floors area iSy. Ft.l (including garage, finished basement/utics. decks or porch)
Gross living area ISy. Fee) Habitable room count
Number of tireplaces Number of hedroom,
Number of hathrooms Number of halt/hxh, — ---- -_
f\pe of healing sy,tem -_ —__ Number of deck,/ poi,hcN _
I ype tit cooling sls(em
Z 1UI:11 PrI,J CcI Square Footage" nlaN he substituted for '`Folal Pioject Co,t
J
CITY OF SALEM
PUBLIC ['KOPKERTY
DEPARTMENT
NNorkers' Compensation Ilisurance :\ftida>it: Builders/Contractors/Electricians/Plumb r
. _ . Please Pri
nt Legibly
� 1 Iltcan[ Inform.+Uon ,p
/cobi cGc
`,llllc tliu,inr„ t ll'/t7-_-`❑nt.tu,in IndniJu.tl l: {//r
Clry Statc.Zip:
oVk MP 0190d-, Phone 4-
Are you an employer.' Check the appropriate box:
Type of project(required):
I.❑ I all, a enlplupar\x A4. ❑ 1 :un a general contractor and 1 6 ❑ New construction
employees (full and'ur pa listed
have hired the sub-contractors listed on the attached sheet. 7. FiRemudeling
2.❑ I ant a sale proprietor or partner-
,hip and have no cln Pluyees I hose sub-contractors have 8. ❑ Demolition a. _
\vorking for me in any capaei[y.
workers' cunip insurance. y. ❑ Building addition
[No workers' comp. insurance 5. We are it corporation and its 10.❑ Electrical repairs or additions `
otticers have exercised their
reyuia homeowner
i I I. Plumbin re airs or additions
J.❑ I am a homeowner doing all work right of exemption per MGL ❑ g p�
re c. 152, $1(4),and we have no 1_2.❑ Roof repairs
myself. i workers' sump. employees. [No workers'
insurance required IJ.❑ Other
sump. insurance rcyuired] ,
•:\ny appli,,ant that checks box NI mn>t also till out the section below showing their workers'compensation contractors
policy s information. '
[ I lomeuwners who submit this affidavit indicating They are doing all work and then hire outside conlmcturs must submit a new affidavit indicating such.
udors that check this hox must attached an additional sheet showing the name of the sub-contracture and their workers'comp.policy information.
I um an employer that is providing workers'compensation insurance for tiny employees. Below is the policy and job site '
Insurance (bmpuny Name: V� �3 �e2
Policy X or self-ins. Lic. As: :741 �w 3 Expiration Date:
City state/Zip:
Job Site Address:
.\n•ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coserage as required under section 25A of biGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.ioo.00 arid'of one-year imprisonment. as well as civil penalties in the lorm of a STOP WORK ORDER and a tine
nl till IJ 1�50I)o,,i day ❑galtl,t the violator. Be ad\'I,ed that a copy ofthis stIstenlent utay be forwarded to the Office of -
In\can_:uions of the DIA for insul-.lnce co\erage \cnticauon.
hereby rem 1'oriel the pants and penalties tr/perjury that the infirrnation provided above is true and correct.
j.
D;uc46
g DOc OO
iiyn_Itur Q g
ollh ial u,e onlr. Do oar mite in this area. ut he a wnpleted by city or town officiuL
Cits or town: .. . --.-... . . —. -
Permiul.icensc $$ _ -
Issuing isuthority (circle me):
I. Board of health 2. Building Department J. ('ih/fawn Clerk J. Electrical Inspector 5. Plumbing Inspector
6. other
-- -------- -----------
Contact Person: _-- __ Phone 4:_--
i
Information and Instructions
r.'
\la„ac!:u,ens l icncrtl I .ns, chapter 1 ; requires .ell cnyilodcis u, prod ide dd orkers' congtcnsmion for their entplodees,
I'ut.u.uu to this ,twutc, .tit rutplot ee I, dciitcd .is " rd er\ pct,on if, the ,cn icc of .mother under .in% contracl of hue.
yv c,s or tin I,I c& oral or ds Inon." .
croph)I'er is defined .is *.tit :nd,k dual, raitncr,l u p, a„octanon, corporation or other IcedI cntity. or am rdso or more
d the cn_aUed in a joint aucrpn,e. .tnd including the legal wpreecntarnes ul a decca,cd employer. or tttt
:rc vdcr or nu,tee of lit mdntdual, p;otncr,hip. a„oct.tion orother legal entry, enytlo�mg cntployce., Iluwever ate
,••.drier of a Jwcllutg house h;tding not more than three iparunentS and ddho resides therein. or the occupant of the
d dd ci!utg hou,e of another who eniplod, persons to do ntaurtcnance. construction or repair work on ,uch dwelling house
,.r on the ---rounds or building .rppuricn,un theta to 'hall nol,hecatise 6f,rich cmplm mcnt be deemed to he in employer."
\I(il. chapicr I>'. s i(.(n) also ,tales lhal`"c. 'Cry state or local licensing agenc).shall ss,ilhhuld the issuance or
rencss al of a license or permit.to operate a business or to construct buildings in the eitmmonwcalth'for in
applicant who has'not p}uducid.ucceptable es idence of contplfahce with the u he insrance cLvi.rjge required."
Additionally, .\IOL chapter 152, �25('1-I ,fates 'Neither the cxnnnwm 'illy
vealth nor of its political suhdi%istons shall
ewer into any contract for the perfotmanee of public ddork until acceptable ed idence 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) nante(s), address(es) and phone number(s)along with their certiticate(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
u lf-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 (he affidavit for you to till 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 pemtivlicense applications in any given year, need only,su6r lit ixie`utfidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
sown)." 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 the 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 burn leaves ctc.)said person is NOT required to complete this affidavit.
Ilse (Mice of Indestigations would like to thank you in advance for your cooperation and should you hade;my questions,
ple.t,e do not hc,ltate to Give its a call.
Ilie I)crai rowin'a address. telephone and fix nuuther r
jhe Commonwealth of Massachusetts `\
Department of Industrial Accidents ,
OlTice of Investigations f
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
cad ,edl ;-_n-u5 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
' y PUBLIC PROPRERTY
DEPART!'vIENT
IIV..,'\
Construction Debris Disposal Affidavit
(rc(Iuired li)r all demolition and renovation work)
In accordance ith the sixth edition of the Slate Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal Facility as defined by MGL c
111, S 150A.
The debris will be transported by:
PO.hi CGo JP C-
I name(iC hauler)
I lie debris will be disposed of in
LA )LA
(mmne ut Iaalny)
(address of('acuity)
slgnaturc Ut penult .Ihpllcant
0-I 0 O�
oat