20 RAWLINS ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Cade, 730 CMR, Th edition Revised Jwrnun•
y
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 'I/ON
One.or Ttvo-Family Dwelling
This Section For Official Use Onl
Building Permit Number: Date Applied:
Signature: l
Building um miss nspec o lluildings Date
SECTION 1:SITE INFORAIATION
,A ProQQ��rty A, resat 1.2 Assessors Map At Parcel Numbers
I.I a Is this an accepted street'?yes_ no_ map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use l. Area(sq II) Frontage(tt)
ut
1.5 Building Setbacks(
Front Yard Side Yards Rear Yard
ReyuireJ Provided Required Provided =RequimdProvidcdrovided1.7 Flood Zone Information: em:Zane: _ Outside Flood Zone? l system ❑Public❑ Private❑ Check if es❑SECTION2: PROPERTY OWNERSH
2.1 Owners or Reci rid:, (
e c. %t/t G ✓ t 1
u e(Print) Address for Service:
S6 �5
.• .arum 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKt(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work": / )— 'W+ <5
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
I. Building S !5 �G`i 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List: ffG///lll
5. Mechanical (Fire S Total All Fees: S
r6.
ressionCheck No. Check Amount: Cash Amrnme'Total Project Cost: S ❑ Paid in Full ❑Outstanding Balance Due:
G3k�rChnl�
r .
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
y�J`�,n_ /"L�✓� License Number lispir ion 1)ate
vv + /U List CSL I')pe(see below)
r%PC Description
0l!nrestricleJ a m)5.000 C'u. Ft.
Signature R Restricted 1&2 Family Dwcllin
M Masonry Only
RC Residential Rrwlin C'o%crin
Iblephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
1) Residential Demolition
aegf5.2
ered Home proveme anfracto (HIC)
C Compan Name or t IIC Registr t .one Registration Number
ter, Z,4kM — _ 3-- 7 /z
2 e;ot-- - Expiration 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 to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .........ob— No...........❑
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, � ) t1. - 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
behalfr //?
L
Signature of Owner or Authorized Agent - pate
(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 rro 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 I I0.R6 and 110.115. respectively.
2 When substantial work is planned, provide the information helow:
Total Moors area(Sq, Ft.) (including garage, finished basement/atties,decks or porch)
Gross living area(Sq. Ft.) I labi table room count
Number of fireplaces Number of bedrooms
Number ol'bathrooms Number of half/baths
Typc of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted lift"Total Project Cost"
I�
y
rainln7 Cec :Compf�on
sbcr
genovsf. H 7SUCCCO 45.22
per 40 CFR P
2rt ipsf2IA01c
Lane a:
17110 Ex15 12
A.R p�p1ratbDaso R19967
31
n �icateNum er*R
S-late of New Hampshire
{ Childhood Lead Poisoning Prevention Program
,7 MamherofCONEST
LEAD ABATEMENT CONTRACTOR
BRIAN MOORE
License#: DC-219
n 4
Exp:ratiorn'Date
��• lCabwre� -
Jose�hier on er Dlrectdr
Divisionof P Health NOT
LET A LEGAL FORM OF ID VIIIWII
v�
Commonwealth of Massachusetts z
Division of Occupational Safety
Heather E.Rowe,Acting commissioner
Deleader Supervisor Y�yly
BRIAN J. MOORE.
E Date 08103/1
- Exx p. Data
0810311/
OS000256
Viemberoi C.O.N.E.S.T.HV
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111111111111IIIIIIIiIIIIIIIIIIIIIiIiIIII�NIII�IINII _=
_ N;usirchusetts - Department ul' Public tiafct�
Board of Biiildis Regulations and tihardards 4
Construction Supervisor License
Liyense: CS 54380
BRIAN J MOORE
34 SHIRLEY LANE
SHREWSBURY. MA 01545
olG_ iy�j� ;.Expiration: 7/24/2012
(bnnuisiuncr. Tr#: 30572
CITY OF S.0 E.N1, lLL-1SSACHUSETTS
BU DLNG DEPARTMENT
WASHLNGTON STREET, Y°FLOOR
TFL(978) 745-9595
FAX(978) 740-9846
KI.NBERiEY DRISCOLL
24AYOR THO..%L sST.PiERRB
DIRECTOR OF PLBLIC PROPERN/BCILDNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.5
D.ebris,-and-the provisions-of-MGL-c-40, S 54; -- - - -----
Building Permit Al is issued with the condition that the debris resulting from
Ns work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
&
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
dat
dcbnvlfJe:-
` g� CITY OF SALEM
I„ ,t PUBLIC PROPRERTY
DEPARTMENT
.i+I I::w:1'Y:)KilC, l 1.
vl Xs1 to 1.-WAKM1.\O tUV STa ELT • SA E+,MA11.1CIn it vs0073
7731•1713-9595 • IC+x. 979-74C�nx46
Workers' Compensation insurance Affidavit: Builders/Contracturs/Electricians/Plumbers
Jrlslicant Information Please Print Leeibly
Nain :(1111'nlcss/()r,aniralinrV l ndry iduul): _ —/y—i/e
City,Stacci/.ip: ��l w G`SJU✓�_ Phone il:.27Z tea '2 � 1
Ar�cry�ou an employer!Check the appropriate box: 'Type of project(required):
I.ap-t am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction
culpluyces(full andfur part-time).• have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 am a sale proprietor or partner- listed on the attached sheet. :
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. - workers' comp. insurance. 9, ❑ Building addition
No workers'cum insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
raluircJ.) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per NIGL I LE] Plumbing repairs or additions
myscif. [No workers'cunip, c. 152, §1(4),and we have no 12.❑ Ruofrcpairs
insurance requircd.l r employees. LNo workers 13.❑ Other
rasp. insurance required.]
•nay;,pphcaut that checks box dl must also fill out the secuun Wuw alwwing their wo,kns'cumpen Winn puliry 11i6um:ttiun
' I lummrwrwn who udtmil this affidavit indicming they are doing all. ork and then him outside cauroeton must.uhmil a new al'ridavit indicting wch.
-C'.mtmaura than check this box must aoachod an addifiunal.+hest ahuwing the nolw of the sub<cuuraetors and their wurkers•carp.policy informadun.
/ant an employer that is providing workers'courpensaijan hisurtutce for troy emplopeac. Below is the puliry and job.city
iufanroutiun.
Insurance Company Name: �✓✓`t"'yt^:C _. '�"n•'jv
Policy 4 or Sclf-ins. Lice n: 0St0I24 4 __ .__ Expirullon Date:
lob Site Address:
/o P.,V/t'k5 S Cityistateizip: Soh
Attach it copy of lute workers' compensation policy declaration pale(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ul'}IGL c. 152 can lead to the imposition of criminal penalties of a
tine up u1 S1.500 00 and/or one-year imprisonment,as well as civil penalties in the term of a STOP WORK ORDER and a fine
of up to 5250.00 it day against the violator. He advised that a copy of this stutement may be Itimirded to the Mice of
Inccsngauons of the DIA for io.urarcc coverage wrilicatiun.
/do hereby certify rooter the/rain.'mad pennitje.r u/'perjury that the information provided ab •e is trite rot d correct.
Dal•' 7t
1,11 r •:is
/ic•iul use only. Da not lvrite in tlei.c ureu, to he coutpleted by city ur loivn oJJic•iu/. f
i
ty or'fown• Permit/License 0__
[[js,uinjt Aulhorily(circle onc):
IluarJ of Ilcaldt 2. IluildingMimruncut .3. Cilyi fuwu Clerk 4. L•'Icetrirll luspcctor 5. Pluulbint; lu+pcctor
011ter
Qnnl:act Versus: __ .. Phone #:
Information and Instructions
Massachusetts General Laws chapter I52 requires all employers to provide workers' compensation fix their employees.
Ptirsuartt to this statute, an empluree is defined as"...every person in the service of another under any contract of hire,
cypress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or tither legal entity, or any two or more
„i the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or(he
receiver or trustee of an individual, piumership,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, q'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, a25C(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(.$), address(es)and phone number(s)along with their cerrificatc(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 dale the affidavit. The affidavit should
be rcuarned 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 u 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 is a reference number. In addition,an applicant
that must submit multiple pennitilicotse 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(hat 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. Anew 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 dug license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
I lic office tit Investigations would like to thank you in advance fur your cooperation and should you have:my questions,
plea Nc do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investigations
600 Washington Street
Boston, MA 02111
Tel. M 617-727-4900 ext 406 or I-877-MASSAFE
Fax N 617-727-7749
R< %ised i-26-0
www.mass.gov/din