7 RAVENNA AVE - BUILDING INSPECTION 4t The Commonwealth of Massachusetts
FOR
Board of Building Regulations and Standards IP
Massachusetts State Building Code. 780 CMR, 7'h edition MUNICIPALITY
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Antum
One- or Two-Family Dwelling 1. 2(x)3
This Section For Official Use Only
Building Permit Nu ber:: Date Applied:
Signature: L y�Z9/U�
ui i Commissioner/ pector of Buildings Dat�
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
—r Ma Number Parcel Number
1.Ia Is this an accepted street?yes- —no_ p
1.3 Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq ft) 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:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p po y
SECTION 2: PROPERTY OWNERSHIP'
2.1&wner'ofR�gord: 7 2s)/td�
t C S"AQ Q f�Gt/ -&'ok ' —
Nam;:Alrino 0� Address for Service:
Signature Telephone—
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ S city:
Brief Descript' n of Proposed Work2: c
C i2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
(Labor Labor and Materials)
I. Building 3 1. Building Permit Fee:$ 2 'Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $ Z ��
Suppression)
Check No.76 Z Check Amount: Cash Amount:
6. Total Project Cost: $ APaid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervi (CSL) o 6 f/ 7"Y-6
0 O
sS �'4 License Number Ex Iran m Dale I.
Name of CSL- H der 1� List CSL T U
a l Q(n ��• _Q IPA n1,9• ��q�d ype(see below)
4JJre % Type Description
U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted 1&2 Family Dwellin
Si nature I//( / M Mason Only
7576 - RC Residential Roofiny.Covering
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5; Re aster Hums Impr ven Contractor(HIC)
eve 'aY�
asompany ame or IC Rggystrant N mQ d /�,w Registration Number
Address •J"'�
4/-r 'Expipfition Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure ht provide
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 ORCONTRACTOR APPLIES FORBUILDING PERMIT
L_ l o7e, CC J kal o // , as Owner of the subject property hereby
authorize "/"i >P to act on my behalf. in all matters
relative t work a thorized by thi building permit dwication.
Signature of Owner Date
SECTION 7b: OWNER' 2R AUTHORIZED AGENT DECLARATION
[, S 41P ' ,as Owner or Authorized Agent hereby declare
that the statements and informati n on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature olf n r or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 1 IO.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics.decks or porch)
Grass 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/parches
Type of cooling system Enclosed Open
3. 'Total Project Square Footage"may be substituted for'"Potal Project Cost"
` CITY OF SALEM
a
T PUBLIC PROPRERTY
DEPARTMENT
I?d-i:i rl l+N li+ +I .
S I!(I I 1 • S V1 P
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers
li, t Ili\ant Information Please Print Legibly
V ally IHu:mc, � treenttunon.Inds:Joel l:
��Ght"�Y QanSuc2✓�
\ddresS: a� r60j
city, sLite.Zip: 'ttewt pr 41, C)/ 4'7(} Phone
.\re yj an employer'. Check the appropriate box: Type of project (required):
I.101 :un a employer with 4 m 4. ❑ 1 a a general contractor and 1 6. cw construction
- "�
employees(full and'or part-time).* have hired the sub-contractors 7. ❑ Remodeling
_.❑ I listed un the attached sheet.
:uu a sole proprietor or partner-
,hip and have employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity workers' comp. insurance. 9. ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their
rcquircdl l 1. repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per NAGL ❑ Plumbing P
C. 152, $1(4), and we have no I'_.❑ Roof repairs
myself. [No workers vm p
insurance required.] ' employees. [No workers' 13.❑ Other
comp. insurance required.)
•:\nv.+pplicant thin checks box y I nmst also till out the section below showing their workers'compensation policy in fumtation.
' I new affidavit indicating such.
Iomeowncr.s who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a
$'+nuu<mn that cheek this bus must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l aat an employer that is providing workers'contpens'ation ins ranee f/or my employees. Below is the policy and job .site .
infiirnmtion. /1 / h� / .�
Insurance Comp;my Name:_TLLJ t� U�^,Y 1vJ`
n 70 r-� ^ ��
Policy x or Self-ins. Lie h:�)�1(Do D 6o Z /VOC Expiration Date:
Job Site Address: 7 J p� Es City/State/Zip: Sr'\
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Ftilure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1.50o.00:md/or one-year imprisonment. as well as civil penalties inthe firm of a STOP WORK ORDER and a tine
of up to S 250-110 a day against the violator. lie advised that a copy of this statement may be tonvarded to the Office of
Inse,ti¢alions of the D1,4 for insurance :oocrace ceritication.
l du herehy c'0*h- under to u l penalties ofperjury that the is trl lid correct.
;ien.nttrc: —Tr
Pl,+ t Ci 7,r 2ys �/tr7
- -ollPctoll use oil.I'. Do not n'rite in this area, m he completed by city or rant a%fic'iaL
its or fawn: - _.. PermitiLicense #.__-- -
Issuing Authoril* (circle one):
elty'1 fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector
I. Board of Ilealth 2. Building Department 3.
6. Other ----- ------
Contact Ile rso _ --_.-.__—.—_ ------ Phone N:__—_
Information and Instructions
\la»ac l:a Sc tIS (kneral Laws chapter I requires all cnhp lo�a, to pros ide workers' conhpc nsat ion Ior their cmplcagees.
I'unu.uu to this >tatwe. an rngrhtree Is dcri ncd aS '. cN cr} person in the sets ice of another under any contract of hire.
c'\111 e'S or implicd, oral or ht I incn."
.\n empht t'er is defined a, "an inJit;d ua1. pa rmersh ip. associ:u ion. curporai ion or other I La entity. or an,, III to or Inure
,,I the flucguing cne:t red in a joint entei prise. and including the legal representam es of a LIrre:ued employer, or tale
rccci%cr or trustoe of an individual. partnership, :t.Ssociation or other IcgaI entity, eulplo�ing employees. Ifoweser the
U•.I net of a ,laelline house ha%ing nut more than three apattmcnts and who resides therein. or the Occupant of the
II%%riling house of:InOther wlto enIpinvs persons to do maintenance, construction Or repair work Ofl Srlch dwelling house
- „I of the gnnunls or building appurtenain I lie reto Shull not because of Such cmplo%nhent be deemed to be an employer..
%IUL ch:Iprer I i?, §2ic(6) also rates 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 cununonsyealth for anv
applicant who has not produced acceptable evidence of compliance with the insurance coverage required "
A IIIIJionally. MOL chapter l i?, 2 07) states "Neither the comnwmvcalth nor any of its p6litical subdiv ieiorts shall
enter into any contract for the performance of public work until acceptable c,,idcnce of compliance with the insurance
rcquircncnts 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) nune(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 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 Sure to fill in the penniulicense 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
It olicy infimmation (if necessary) and under"Job Site Address" the applicant should write "all locations in (city or
IOWIl):" 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
yrar. Where a hone 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 \'oT required to complete this affidavit.
The ()lf icc of Investigations would like tO thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a ::all.
I he Dcparnnent's address, telephone and tax number
The Commonwealth of Massachusetts
Department of industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Ite\iSed �-'6-0]
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALELI
• PUBLIC PROPRERTY
DEPART�IEtiT
t:li f
Construction Debris Disposal Aftida-t it
(required Cur All demolition aad renovation work)
In accordwice with the sixth edition of the State Building Code "SO CMR section 111 5
Debris, And the provisions Of NIGL c 40, S 54;
is issued with the condttwn that the debris resulting nom
a — as defined by
v1GL c
Building Permit 1 facility
;his work shall he di;poscd of in a properly Licensed waste disposal Y
: 11. 5150A.
Tile debris will he transported by:
name of uautarl
I I.a bri; will be disposed of in