60 PROCTOR ST - BUILDING INSPECTION (2) 4 4
I1 QA The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
1U Massachusetts State Building Code, 780 C'MR, 7"edition OF SALEM
Q� RevisedJwrewy
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit N mber: Date Applied:
Signature:
Building Cummiuiane X specs of Buildings Date
SECTION 1:M TE INFORMATION
1 1.1 P A rsss: 1.2 Assessors Map d Pared Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq 11) Frontage(11)
1.5 Building Setbacks(it)
From 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 Sewsga Disposal System:
Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Cheek it aO
SECTION2: PROPERTY OWNERSHIP''
Li.,Pwnert of Record: �Q
n CU{th - TU
Nome(Print) Address for Service:
a& Signature - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS Ohl a8 that apply)
New Construction O Existing Building Owner-Occupied Repairs(s) Alterations) O Addition O
Demolition O Accessory Bldg.O Number of Units— Other O Specify:
Brief Description of Proposed Work': °
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1, Building S O I. Building Permit Fee: s Indicate how tee is determined:
�. Electrical S O Standard City/Town Application Fee
O Total Project Cost'(Item 6)s multiplier a
1. Plumbing s 2. Other Fen: S
C)
4. Mechanical (IIVA s List:
5. Mechanical (Fire s
Su ression Total All Fees:S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S O.a 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed onseruclloo Supervisor(CSL) \
I.icerue Number I:v trati n Date
Name of L'SI.• lulder List CSLType(seebclow) U
c'r r ve I Description
ress U I t Inrestricted(up to 75,000 Cu.Ft.
R Restricted IR2 FamilyDwellin
Signature M M Only
CCI> T�\�—\��?j RC Residential RoutineCovering
relepMsne WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Hanur improvement Contractor(HIC) 1�a\S�
111 .Company Nam or IIIC Registrant Name Registration Number
Address .—� ! v iration Date
P
Signal — 'relephone
A
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I..e. IS2. f 2SC(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
C 0 A✓l as Owner of the subject property hereby
autM^^z�\ - •— ° - Wiz— to act on my behalf,in all matters
relative to work authorized by this building permit application.
� ghobo
Si are of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf. /GLn
� f
Print Name c . ✓j 9/ 3 6 le
Signature of Owner or Authorized dAAgent Date
(SiAned under the pains and penalties ofperjury)
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 sg 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 790 CMR Regulations 110.R6 and t 10.R5, respectively.
2. When substantial work is planned,provide the information below:
Total tloors 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 half baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage'may be substituted for"Tidal Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
14 � DEPART'.10ENT
I ts: 77.4.'4}9S4,,
Construction Debris Disposal Affidavit
(required lirr all demolition and renovation work)
In accordance %�itll the sixth edition of the State Building Code, 780 CNIR section F11.5
Debris, and the provisions 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 it properly licensed waste disposal facility as defined by MGL c
t l 1. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
C E.
(name of facility) e.
(address of lactlity)
s lguaturc of penni[, �plicant
,late
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
UwuN 11C W,viHl\G I ON ST3EhT ♦ SA his,M.\iSACI It it:'Iu0197^ -
11•.1:978.745-9595 • 1'.(x:979-74^•'184b
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers
r ilicant Informadon Please Print Le ibiv
V u nl s NlnJiv luulg '3`(h'C�Z-\Gy\£�
ddress:l-7 ?s ac�
Phone
CitySt:ua%'j
,%rc you an employer! Check the appropriate box: "Type orproject(required):
1.El 1 ;tin a employer with 6, ❑
4. ❑ 1 inn a general contractor and 1new construction
tin agocus full and/or art-time).' have hired the sub-contractors
1 ) ( P listed on the attached sheet. ; �• Remodeling
2. 1 ;tin a sole have
o employees
o partner-
+hip;uul have no mnpluycos Those sub-contractors have tl. ❑ Demolition
working for me in any capacity. workers' comp.insurance- 9. E3 Building addition
I No workers'comp. insurance 5. ❑ We are a corporation and its 10:❑ Electrical repairs or additions
required] officers have csercised their
right of cxem tion per MGL I l.❑ Plumbing repairs or additions
3.❑ I ❑s a homcowrke doing all work c s152, i 14 ,r and w•have no
myself. [No workers' comp. � O 12.Q Roof repairs
insurance required.] t employees. LKo workers' 13.❑ Other
comp. insurance required.]
-.any phcwtl than checks box ill muss also fill out the scoot Wow showing their workuni cumpuns:aiuo pul icy inliartwtiun
' I lumwiwm:n who submit this affidavit indicating thuy are doing all wurk and don him outside comructors must.ubrnia a new alr:davit indiuding such.
-C'ontncmn thou check this box must attached:m additional sh vl showing the name of the sub-conlractom and their workers'corals.policy informariun.
/oar an euglloyer that is providing workers'c•ompensntion fnsur«nce fur lay eurployecs. Below is the policy and/oh site
infor«rution.
Insurance Company Nalne: - ---.._. . __...---------_..__----
Policy is or Self-ins. Lic.Ts:- _...._ Expiration Date:
Job Site Addruss: City/Slate/Zip:
Attach it 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.MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine Of up to S250.0o a Jay against the violator. Inc advised that a copy of this slutcmcnt may be forwarded to the 011icc of
hsvcxnganons of thu DLA for insurance coverayc Krlllcallon.
!do herrhy cot ijy under dr tLi\s raid pen«hics ofperjtrry that the infunnulian provided uboce 's true mid correct.
=�
Saturc' Oat•: �G
Offic•iul use only. Do not n•rite in this area, tube can iplefed by city or town official.
City or Town: _ Permit/License
Issuing Authurity(circle one):
I. Board of I lualth 2. Building Dcpartutuot 3. Cityi row it Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
F'uutacll'crsolc _. . ._. Phone0:
Information and Instructions
.%lassacliu ieus General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an empforee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,parmership,association or other 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
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the.rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.'vIGL chapter 152, §25C(6) also states that "every state or local licensing agency 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."
Additionally, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of conmpliance 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) name(s), address(es)and phone number(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 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 arc 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 for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be.ate to fill in the pennitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 (eity 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
(i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Othce of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du nut hesitate to give us a call
The Department'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
Revi.,d 5-26-05 Fax It 617-727-7749
www.mass.gov/dia