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68 PROCTOR ST - BUILDING INSPECTION (2) t The Commonwealth of Ms angp� 'PdNAL SERVICES CITY OF Board of Building Regulatioci Vtu ns and Standar s SALEM CMR Massachusetts State Building Cock' 8AM39 ® lt Revised Mar 2071 Building Permit Application To Construct,Repair, enovatL br PSAnAiA I One-or Two-Family Dwelling This Section For Official Use Only LA Building Permit Number. Date A plied: _ Building Official(Print Name) Signature r` ` Date SECTIONQ:SITE INFORMATION:'. +_ 1 PR,ropVy Addrgss: 1.2 Assessors Map&Parcel Numbers roc nr 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 Lot Area(sq R) Frontage(ft) 1.5 Building Setbacks(ft) Front 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 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 rnwner'ofRecor; S>4-Ic�l A9,A US"i A J ICE Name(Print) / ��^(1/A City,State,ejZIP o.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK',(check all that apply) New Construction❑ 1 Existing Building 91, 1 Owner-Occupied P9, Repairs(s) ❑ 1.Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units ZI Other P Specify: 5raokr D,-k-&Ls Brief Description of Proposed Work: - 1 t SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard. City/Town Application Fee 2.Electrical $ - z �' GD ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ :List: 5.Mechanical (Five $ Total All Fees:$ Su ression Check No: Check Amount: Cash Amount: 6.To al Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: � � II Mtatt,�p -rt� IGo>c SECTION 5: CONSTRUCTION SERVICES 5.1 onstruction Supervisor License(CSL)- I / �l L 3 - 31 t�V (_ ��Olr O F c— License Number Expiration Date Nameof CSLHoIder N (� :i'i-�A I W!4 0,a List CSL Type(see below) Type 'Description No.and Street "' . .. :. > - Ev�y,� t ..�/l , Q —( `r Q U Unrestricted(Buildings toing M.ft. (�_� l' / R Restricted 1&2 Fami1 Dwelling City/Town,State,Z M Masonry RC Roofing Covering WS Window and Siding Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP 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 provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No...........❑ SECTION Tat OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I 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,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate tothe st of my owledge and understanding. Print Owner's or Atrihorized Agent's Name(Electronic Si e) Date NOTES: 1. 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. 142A.Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.govldns �� 2. When substantial work is planned,provide the information below: Total floor 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 3. "Total Project Square Footage"may be substituted for"Total Project Cost' The Commonwealth of Massachuseft Department oflndustrialAccidents -1 Congress Street,Suite 100 Boston,MA 02114 2017 www massgov/dia Porkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licantInformation Please Print 'b lv Name(Business/Orgamzation/Individml):: CyOy (!C t/'r C• id t ,-.��C) Address: City/State/Zip: ©Z� Phone O: �o C 7- %3 23 -c3 o r3c� Are you an employer?Check the appropriate box: FEE3 project(required): I.Q I son a employer with employees(full and/or part-time).• ew construction 2.�.,1 am a sole proprietor or partnership Arid have no employees working forme in any capacity.[No workers'comp insurance required.] modeling 3.01 am a homeowner doing all work myself[No workers'cutup,insurance required.]1 molition 4.0 I am a homeowner and will 6e hiring contractors to conduct al]work on m ilding additionY Property. I willensure that all contractors either have workers'compeasation insurance or are sole ctrical repairs or additionsproprietors with no employees. mbing repairs or additions5.0 I am a general contractor and I have hired the subcont actors l sted on theattachedsheet.These sub-coatracmrs have employees and have workers•wrap insmaace.i f repairs6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. er 152,§l(4),and we have no employees.[No workers•comp,insurance reyuved] -Any applicant that checks box#]must also fill out the section below showing their workers'compensation t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contracrs must submit s new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subconbactors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workets'comp,policy mmnber. I am an employer,that is providing workers'compensation insurance for my employees. Below is the polity and job site information. Insurance Company Name: 94- S`�ry.t!r I`�j �jU�I. /i n,e i� r� Y c (1� •�Policy#or Self-ins.Lic..�#: MAA 6 ` -3() t q 98 --�[�Exxppiiration Date:_-/ — 7 —,�}1 / Job Site Address: &A 'Pr6c"I o r C4 City/State/Zip:S,11[a+l f m , Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required trader MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cent u der the pins a penalties o perjury that the information provided above is true and correct Si re afo ate: Phone M — Official use only. Do not write in this area,to be completed by city or town ofcial City or Town- Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee 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 a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL 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,MGL 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 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)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 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 be 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 sure to fill 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 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 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 etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia OMMONW&A4VrH OF MAS$ItCHU El Ctil C I`AN$ � § 1"ISSUES THE FOLLOWINI; LICENSE SAS �A RFG JOURNEYMAN ELE c� v ! �FRI`'fT � ,,� Mk 02t49"5109` •• r � � „ 14999 B �'01/311. 81113 ,1 � =s s -ON 1 Z v tr?! ®S�M6Vc(�Co D S WCo SHrJ Sv'J �0013 ,pooh -151 Nz jag }s 1 t� C4 I v '7�tsl i o�Q Wooi ,Q OVRnii�y qLIJO o � t L vJ 5'4 + -0 fj'J CY �._ DO 21S: i4K(3 ��1\4 `,k VSA i 'tJ I Ao 3� G I O SG Z Ti.lj O C 10.5E- 'T' y F 14 Sao 01'v't�� NC}S Q 1 57L= 1Nb/� D � (Do i 209 FL . 2 •r - za�l DccarS --`: ,o v\ ZN� I oof m t z+! fig! -ON _ a'tt c� r'g ' t j r — 1 i SY'�6k(�Co i i i i -tsi i Nz i z i � 3 i 4 � i i yrti��� . t cT of bO �L€ t Chi^�R CRb�N&.}5 LA NH}$ o Qpp�N\ I dco L�viNS ca - � � ©co DUc�rS UN �o c �� LCx�oscd� 1 St �,poC ei t� 'L7T J�- rl � n o� 3G� 0 fc � . . 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