77 PROCTOR ST - BUILDING INSPECTION (5) The Commonwealth of Massachusetts
4 � Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7"edition gui) mg Dept
Building Pen-nit Application To Construct, Repair, Renovate olish a 413-596-2800
One- or Two-Faintly Dwelling Ext 118
This Section For Official U5,10nly
Building Permit Nu ber. DateAppfiykd. -
Signature-
/0
Building Commissioner/Insp or of Buildings Date
SECTION 1: SITE INFORMATION
1.1 PI operty A ress: 1 1.2 Assessors Map& Parcel Numbers
1.1 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 R) Frontage(R)
15 Building Setbacks(ft)
Front Yard Side Yards Rear Yard I
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:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
r SECTION 2: PROPERTY OWNERSHIP'
2. Owner o Re d:
cyG Pu//z. LLC 77 /-�ioc� � /-ca{ �
ame(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building e Owner-Occupied ❑ Repairs(s) Alteration(s) e Addition ❑
Demolition Accessory Bldg. ❑ 1 Number of Units Z Other IRISpecify:?aet tl..r.v btfoa ii
Brief Descriptionn of Proposed Work`: f PA-tir R"F W- i2 iTY-twee /Alle'w B of"es Z
srvr KL.rrro"Alf- ZnPML uw+zT/ /AySacia-rc/ 946 F' P44tfvf2/`
��cc wcw.nn�,�S w/ z E62£Ss wiw.ec:.✓s a.r �G.a2 / .vg r.�
Y7r.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials _
I. Building $ — 1. Building Permit Fee: $ Indicate how fee is determined:
L2. Electrical g ❑Standard City/Town Application Fee
-- 6 °O` ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S t: 500 - _ 2. Other ees: $ _
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire j
Suppression) $ $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 77 o0p— ❑ Paid in Full ❑ Outstanding Balance Due:
7 e'/ al
5-5- So - 76b S
�5 3
s-
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 4q S3�
LARR-Y J License Number Expiration Date
Name of CSL- Holder Iy List CSL Type(see below) "V _
D S r"' - -7r1. "•fR�' Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
�� _RC Residential Roofing Covering _
Telephone WS Residential Window w.d Sidin
SF Residential Solid Fuel Bumin•Appliance irsi:dl_ation
D Residential Demolition
5.2 Registered Home In:Q'�r9�jvem'�en[Coutractor(HIC) / 2 q �
LA�gg Y r. /f'L�rLA k.
HIC Company Name er HIC Re^istrant Name / Registration Number
�7
.4d ress e, -
—_— /0/,7- ! Expiration Date
Sil nature Telephone
III--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 tnc Issuance of the building permit.
Signed Affidavit Attached? Yes .......... Cam :`Jo ........... 13
SECTION 7a: O%VNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTO__R APPLIES FOR BUILDING PERMIT
I C`R �� �4 w� as Owner of the subject property hereby
authorize_ Z. /i" " k- _to act on my behalf, in all matters '
relative to work authorized by this buiiding permit application.
Sii nature of Owner_ _ Date
SECTION 7b: OW Rt OR AUTHORIZED AGENT DECLARATION
1, /{-/tom, as.Owner or Authorized Agent hereby declare
that the statements and information an the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signat re of0 or Authorized Agent Date
(Signed under the 2ains 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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the filC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IG.R6 and 110.R5, respectively.
2. When substantial work is nlanred, prcvide the information below:
Total Floors area(Sq. Ft.) [g$ (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. FL) Habitable room count
Number of fireplaces t9 Number of bedrooms
Number of bathrooms / Number of half/baths
Type of heating system 6srfs 012.4L. F'W W Number of decks/porches
Type of cooling system _ _ Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total*Project Cost"
y
1
CITY OF SALEM
IM,
PUBLIC PROPRERTY
Wel
iaNa
DEPARTMENT
12C WAitIING IONS 1'3LLI' s SAI VM,MAiSACI It iLI-Ii G197,^,
978-7459395 is p.sx. 978-741 984G
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Le ibly
-\ ) )licant Information
TdsK
Name lllueinesv OrgannatinNlndrvuluaq: Z�9r -
Addl-Css: b ,A,s SfL' �(ot�dcl-
/V(d.� 6L�1�{y�S—L�1% Phonei':
City,State,Zip: OI
Are you an employer'! Check the appropriate bell;
type of project (required):
I.❑ I am a employer with a. Lam a general contractor and 1 6. ❑ New construction
have hired the sub-contractors [s�'[Eamodel[ng
-entpluyccs(full anlllur part-time).' _ listed on the attached sheet. 7.
2.❑ 1 ;un a sole proprietor or partner- These sub-contractors have ft: [�1)ernolition -
ship and have no employees workers' comp. insurance- 9. ❑ Building addition
working for Inc in any capacity 5. ❑ we are a corporation and its
IKn workers' comp. insurance 10.�'Electrical repairs or additions
officers have exercised their
required.] I 1. Plumbin g repairs or additions
right of exemption per MC' b P
3.❑ 1 ys a homeowner doing all work c. 152, g 1(4),and we have no 12.E tcuuf repairs
myself. e r workers' comp. employees. iNo workers'
insurance required.] t 13.❑ Other
comp. insurance required.]
•�1ny.,,phcunt Ihut chucks box rtt must also till out the wcoun Inauw showing their wurkus'compcnsaiion policy infurmation.
t I Iomuuwncn who submit this affidavit indicating they are Juing all work and then Ain outside cullou ton must u,mtil a new afrd.vit indiutmg such.
( n a that i 'k this box must Vached 3 'et' A I ch•ct+hawing the panic of the subtiontrxwrs and their wurkera'comp.policy informanun.
I urn an employer that is providing workers'compensnb/on ursurouce for my employees. Below is the p licy und)ob vile
infornrutiun �TL.t-�✓rt� G�(.alL7 •t'
Insurance Companym
Vae: ----
Policy a or Self-ins. Lic. *: WCV CCJ'}. Ex P iration Date:—
Job Site .cadre,,: 7� Pr-caso2 Sp'
- City:Slatc/zlp: ra� MA
Attuch it copy of the workers'compensation policy declaration page (showing the policy number and expiration date).
failure to ,ccure coverage as required under Sodion 25:\of. a 152 can lead to the imposition of criminal penalties of a
in the 1-orrn of a STOP WORK ORDER and a fine
tine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be fum irded to the Office of
Invr,tlgaunns ul the DIA ibr insurance covcrago aefiticauun.
------------
/tlo her,-by certify uncle tl pain+ui d petudties of perjury that the infortnuflon provided above is true and correct.
r-f ])arc:-
OQiciul u.se aidy. Do toot n•rite ire this area, to be c'onrpleted by city or tarvn official-
City or Town: --- ..
Pcrmit/License X._ .. _.
Issuing :\uthurity (circle(like):
I. Board of I Icallll 2- Iuilding 0epartmeut ICityi fora a Cie
4. Electrical luspeetor 5, plumbing; Inspector
6.Other _ ---
Phone q:
Contact Person: __ ---
0.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide.workers' compensation for their employees.
Pursuant to this statute,an errtplgree is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An rnnploy er is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more
„t the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of :ul Individual, panmership,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."
`IGL 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 0r`to'coostruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, b(GL 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-contractors) name(s), address(es)and phone numbers)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 numberon 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.
Phase be Sure to fill in the pennit/license number which will be used as a reference number. In addition, an applicant
that MUSE submit multiple permit license applications in any given year,deed 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 provided to Elie
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.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The I)I)ice ut love.sti"atnons would like to thank you In advance for your cooperation and should)'Oil have any questions,
please do not 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
R,%i,ed 5-26-05 Fax #617-727-7749
www.mass.gov/dia
CITY OF SALEM
j� fJf PUBLIC PROPRERTY
DEPAIZ"I'VIENT
J1K V.
t
Constrtletion Debris Disposal Allidavit
II'Cllllll-Cd IUr all demolition and rcnu\':uiun work)
lit accurdance to ah Ilse sixth edition of the State Building Code, 780 (AIR section I 1 1 ,5
Debris, and the prop isiuns of YIGL e 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by AAGL c
I1I. S 150A.
The debris will be lransported by:
Fit ( s. r— Wc7PCT,+f
I name tit hauler) -
The debris will be disposed of in
l ualnr ul 13e lhty)
Lyv.v j� b Lq
I a:IJrcv. ut luclllty)
♦IL'llalule of pernln applicant
:late
`T. Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Regist lion; 125491 Board of Building Regulations and Standards
Expirationlug One Ashburton Place Rm 1301
RE ;y. lI-/2 0 Tr# 264277 Boston,Ma.02108
G 0 jiypg 160�vidual -
TARRY J.HUDAK Witj Q-
1pt
LARRY HUDAK Lk r
10 SCHOONER RID�F�
MARBLEHEAD,MA 01945 S Administrator t valid without signature
71
osifof�m rag. egu aiand` - --1
Construction:Supetvisor License `
l Lic-tse: CS 49536
`CAE. - //^701'0 Trp 17652
�. LARRY J HUDAF
. 10 SCHOONER Al
MAR BLEHEAD,Av 019
COmm]ssiOnCr p
� i