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22 PURITAN RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM / U ' RevisedJunnury ( Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008 One-or Two-Family Dwelling This SccjidqorOtTicia] Use_Qnly Building Permit Number: Date ted: �'.ZG6• Y� Signature: q.vo •I Building Commissions In eetor of XiAngs Date SEC ON 1: SITE INFORMATION 1.1 Property AdM: vJ 0 l 1.2 Assessors Map& Parcel Numbers I.1a Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Ike Lot Area(sq ft) Frontage(It) 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 y?,l/ Private ❑ Zone: _ Outside Flood Zone'? Check if yes0 Municipal fa On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 O nee of Recgr�l � n � 'e' Gj('�A n T 2 2 ('u r r 7/3 t� LC sl Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work--: m ,e. - T n i Zx w- 7Gl� fan sTr� [T ,OPa/ / 7 x/rti decic fc; 5,4 e- /a c a"Tio SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ '�ego, V-� 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost 3(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: $ 4. Mechanical (FIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees: 3 Check No. Check Amount: Cash Amount:_ 6.Total Project Cost: S '2 ©p,0� ❑Paid in Full ❑Outstanding Balance Due: N d, �- M SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) /' Z I ? 14 ZQ , �ey r'� �, �\�lil pS License Number 1 Expiration Date Ngm�of CS�,-,�olel�P �^ ^d V� List CSL fvpe Isee below) y 6 t" V fi Type Description AdZa�ct�ss.f�� /1 e//} Z p� U Unrestricted u to 35.000 Cu. Ft. — —� V7 i It Restricted 1&2 Family Dwelling Signatur M Niasonry Only RC Residential RoofinE Covering elephon WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 'i 5.2 Registered Home Improvement Contractor(HIC) L)/ / O 3 1 me-1IC Company Na r'FI1,C Registrant Name Registration Number Address �— // // Expiration Date Signature '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...........Cl 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: OWNEW OR AUTHORIZED AGENT DECLARATION 1 C,/y ff/s S ,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 behalf. Pf vo Print Name Signatur Own uthorized Agent Date under th pains and enalties of er'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. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I O.R6 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors 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" i CITY OF SALEM PUBLIC 13ROPRERTY a DEPARTMENT .ism:n:rr aal,ss a 1 \Islixh 12:WAstf1.\6l U\irxELT * SAIL•M, IYt.1Yh.\6111 -a I Is,) V11-,763i9i'13 a P.sx. 97x•71C.73/6 Workers' Compensation Insurance .%flldsvit: Builders/Cuntracturs/Electricians/Plumbers \unficant Information Please Print Leeihly V:IIT1C IBuuitess/QrganintinNlndtviduall: �or'�C- (y �j////Qf or-) f1/7/(— Adtfress: 60 L1S�P Fri — Cily,Starc;%ip!r�i1'e-At, IV," l ei Z f Phone it: ;FjS- IVS .kre)uu an employer?Check the appropriate box: 'Type of Project(required): - 1.0 I :ml a empfoycr with 4. ❑ 1 am a gcncral contractor and 1 colpluyvcs(lull and/or purl-time).• - have hired the sub-cuntracturs ls' New construction 2.611 anti sole proprietor or partner- listed on the anachcd sheet : 7• ❑Remodeling ship and have no canpluycus These sub-contractors have S. 0 Demolition working forme in any capacity, workers'comp. insurance. _q,_0-OuilJing-uJJitiun ----- - -tknwtylitcrs'cuing. insurance-- 5.--0 Werrc a caporatian;md its ---- ------ required.) orYcers have exercised their 10.0 Electrical repairs or additions 3.0 f ant a homeowner doing all work right of exemption per lvf i 1 I.❑ Plumbing repairs or additions myself. (Ko workers'comp, c. 132,§1(4),and we If ve no 12.0 Ruut'rcpairs insurance required.)t elnpluyecs.(Ko workers' comp. insurance requinxl.) 13.0 Other •tiny.�pp6caia ihW chocks boa Of must also fill out the seclwn twlaw dwwins Chair w•wkmi cuntpenuai,wt policy othermatiun, 'I Wmvawnen who v armif this aftldavit indiuiins they ate Joins all work and then him outside ewnrneton mwt.uhmil a new arndavit indieatins vwk.-(,mtm fors that shack this box intalh anached an additional shoef.huwins the nano of the adfy -I nlractors and their wurkan'rang.ptaicy inftttmarion. /am mr employer that is providing workers'rumpenration iararnnct/br illy ensplgiwer, Br/mv is thr pu&y uqd/ub.rifts ia`aririuliant. Insuratice C'unipany Vmne: policy 4 or Sulf-ins. Lic.0: Expiration Diue: Job Site Address: Cityistate/Zip: Attach At copy of I he workers'cumpensatlon policy declaraglun page(showing the policy number and expiration date). ' Failure to secure coveruge as required under Section?SA ul'.%IGL c. 132 can lead to flit 4111po3ition of criminal penalties of a line up es S I.500.00 anJJur une-year imprisonment,as Wulf as civil penalties in the form of a STOP WORK ORDER ands fine of up to i230.00 a Jay against flit violator. Ile advised lhut a copy of this slulcmcnt may be Awwarded to the Oilicc of Inresngauons of thu DIA for insurance coverage scriticatuin. /1/0 hereby terrify iitt poi id penaltiex uitperjury that the in/bnnuflon provided above is Mae and correct. ;I •:C flit•' L IS- FOfflciui use may. Od oat mitt in this urea,to he ruatp/rted by wiry ur taivth a/J&ial'Pion: I'vrmioLicenic0.\ulhorily(circle tine): of Ilvaldl 2. Iholi ing Dcp:trtoheol .1. r:ilyiI'uwn Clerk 4. Electrical Inspector 3• f lumbing luspeefor I 1'ersun: _ .. I'honc•-1• Information and Instructions ,,\lassacllusetls loencral Laws chapter I�2 1'l'gUl[eY all CIIIplO`C on in the Yrs to crvice of anulherc ui lelrinny eJmrzi of hire for their s Pursuant to this slatule,an emplored is defined as"...every p' apress or implied,oral nr written." \n emploper" defined as"an individual,partnership,association,corporation ti ether legal eased or any two r t more .d the IJreSJIng engaged n a Joint enterprise.and including the legal rCpfeYClllatlVCa JI]deceased employer,Jr the CCCCIV er or tfaslCe Jf.n Illdl Vldtlal, partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments who resides therein,or she occupant of the Dwelling house of another who employs Persons shall uotto do ninbecause constrtion or repair such k on employment be deg wored tocbe an employer."dwelling �e or )it the grounds or building appurtenant state or local licensing agency shag withhold the issuance or \IGL chapter 152. Q25C(6)also states that"every renewal of n license or permit to operate a business or to construct buildings in the commoaweulth for any ;tpplicant wile has not produced acceptable evidence of compliance with the insurance coverage required." Additionally' bIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political wth then ns shall enter into any contract for the perfomwnce of public work until acceptable evidence of conlpliatice with the insurance requirements of this chapter have been presented to the contracting authority." Applicsnts -- — -Please fill-oat-the workers' compensation alfidavit completely,by checking the boxes that upply to emtcuiresituation (1�l of nand if necessary,supply sub-contractors)name(s),rildress(ee}and phone number(a)along — --- insurance. Limited Liability Companies(LLC)or LimitedcompensationLiability abPartnerships umnce(Lam)with or no employ does s other than the membersmembersur partners, or,are not required to carry employees,a policy is required Be advised that this affidavit re t be sign and to the Department'Ill* Industrial -Necidents for confirmation of insurance coverage. Also be sure to Ylen a is Jute the ufst being ed.n The affidavit should the permit or lic he resumed to file city or town that the application oas regarding the law or if you are required to obtaot Department workers of Industriul Accidents. Should you have any y compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriutc line. City or Town Oftlelsls ffiduvit is complete and printed legibly. The Department has provided u space at the bottom Please he sure that the a till out in the event the Office of Investigations has to contact you regarding the applicant of the affiduvit for you f PI.aYe be sure to till in the pernit/license nwnber which will be used as a reference number. In addition,an applicant that must submit multiple pennitllicense applications in any given year,need only submit one of idavit indicating curtent policy information(if necessary) and under"Job Site Address"the applicant should write"all lucutions in (city or town)"A copy of the uftidavit that has been officially stamped or marked by rite city or town Inay be provided to the affiduvit is on file for future permits or licenses. A new affidavit must be tilled out each applicant as Proof that a valid year, where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture 1 i.e. et dug licence nr permit to bum leaves etc.)said persell is NOT required to complete this affidavit. I het)tl ice tit Investigations would hke to thank you in advance fur your cooperation and should you have any yuesuons, pleurae do nut hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents OQIee of InvesdIIadens 600 Washington Street Boston, MA 02111 'Pei. p 617-7274900 ext 406 or 1-877-MASSAFE Fax M 617-727-7749 www.mass.gov/dia CITY OF SM.&M. NLkSSACHUSETTS • BVIiDLYG DEPARTMENT 130 W.+sHLYGTON STREET, 3iO FLOOR T EL (978)74S-959S FAX(978) 740-9846 KI.N(BFRr FY DRISCOLL T ,�UYOR �toaus ST.PtEAAB DIRECTOR OF Pt LIC PROPEATY/8L'BDNG CONNISMONER Construction Debris Disposal Affidavit S (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit Al is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c l 11,S 150A. The debris will be transported by: &0 Fi cue Tip f (name of hauler) The debris will be disposed of in I ^ T (name of facility) C (address of facility) 00�4— of permit applicant date dcbnutf.bw