1 RICE ST - BUILDING INSPECTION IIThe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
1. !I Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
iii RevisedJurnnrq•
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 20 AY
One-^Two-Family Dwelling
ection For O.fTicial Use p6ly
Building Permit Number: Date Apy*4d: 104:24e!2
X Signature: Z4 1Z
Building Commissioned/lmpecturu oil i f}.tte �—
SEC ION 1:SITE INFORMATION
1.1 Pro rty Address: a 1.2 Assessor Map dr Parcel Numbers
I.I a Is this an acce ted strc yes no Map Number Parcel umbel r
1.3 Zonlost Information:01 1 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) frontage(R)
13 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public Private O Zone: _ Outside Flood Zone? Municipal Of On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
P int) Address for Service:
aura Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': uc •' lc,c = YN '
c =
L��V1 e ��Z C_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCISI Use Only
Labor and Materials
1. Building IS /570 0 1 1. Building Permit Fee:S Indicate how lee is determined:
�. Electrical S 13 Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S3 O(' 2. Other Fees: S
4. Mechanical (tIVAC) S List:
5. Mechanical (Fire S
Su ression Total A11 Fees:S
Check No._Check Amount: Cash Amount:
6. Total Protect Cost: S ?j �D 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed ConstructlonSupervisor(CSL) ZLiccnSCN=bcr
�CP t/. D®� Expintiun Date
Nameo'CSL• I lolder ee below)
Addry LJO� � uicted u to J3000 CutdSign" urc only
& 17+ 4 �, � •® i l�p RC Residential Rooting Covering
felepMme WS I Residential Window and Sidmit
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
r, i
red Home I,rgprovemeat Contlactor(HIC) I to � a
'T`i.h t�J. f 9 f�4i+�) Registration Number
y Name or I�IC Registrant Name w`
e
ice•636 •o I I(� Espintion Date
Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.LL c. 152.1 2SC(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...........O
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Sianature of Owner Date
SECTION 7b: OWNER t OR AUTHORIZED AGENT DECLARATION
,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the bat of my knowledge and
X behalf.
Print Name
Signature UtOWner ocFAIdthdiri Agent Date
(Simned u der the vains and penalties of '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 gq(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 790 CMR Regulations 1 IO.R6 and I WAS,respectively.
2. When substantial work is planned,provide the information below:
Total floors arca(Sq. Ft.) (including garage, finished basement/anics,decks or porch)
Gross living area(Sq. Ft.) i i Cl fi Habitable room count l
Number of fireplaces O Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system A ,•F i3On}c( uS Number of decks/porches •—
Type of cooling system — Enclosed Open
J. "Total Project Square Footage"may be substituted for-Total Project Cost"
L
CITY OF SALEM
Y4-5
PUBLIC PROPRERTY
DEPARTMENT
' aw'.:Nlll'aNIKa�I 1.
\L\1l to
LC\y,Nr11\I:IJN 5.1'g lhl' # 5.\116U,M.tw.vc.i 11 VI'1S G1WIC
1'5-15-; 978-7.15-9595 • F.\x.979-74C-9846
Workers' Compensation insurance :affidavit: Builders/Contracturs/Electrician!i/Plumbers
\ 7 ►licant Infurmalion Please Print Le ihly
�I:I ITlI9usmasslOrganiratinNlndivulual): 1V
Address: � (L) usfcplai
(—) V 1��r=�G $ llPa ►ll �� e'✓`
CityiStale'Zip: H —� 1—�'I 00 t'hune i•: co 1 7
.%re )-4u an employer:' Check the appropriate box: Type of project(required):
I.❑ 1 :un a employer with . 4. Q I ant a general contractor and 1 G. Q new construction
unpluyccs(full and/or part-tinic).• have hired the sub-contractors
2 1 ;uu a sole proprietor or partner- listed on the anachcd sheet. 7. Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity, workers' comp. insurance. g• Q Building addition
No workers'comp. insurance 5. ❑ We are a corporation and its 10.Q Electrical repair or additions
required.] officers]live exercised their
3.❑ 1 ant a homeowner doing all work right of exemption per NIUL I I.❑ Plumbing repairs or additions
myself. (Ko tvarkers' comp. c. 152, §1(4),and we have no 12.0Roof repairs
insurance required.] t amployces. LKo workers'
13.❑ Other
comp. insurance required.)
•spy;,pphcunt that checks box 01 must also fill out the section hcluw showing ihuir wurktml'cumpenuuiun put icy inhurtualiun.
' I IamellWnC"whu submit this affidavit indicating they am doing all work and then him ouoaide cuturactom must.uhmit a mw afrdavil indicating such.
d'.mtmcuN that check this box mnxr ailachcd.m additiunul.4icct+hawing the name critic sub-contraetora and their wurkeos'rump.policy inrurmatiun.
l aur un enydoyer!liar Lt providing Iverkers'evrrtpensatinn incurruree for ary employees. Below is the policy and job.cite
irrformation.
Insurance Company Name: ..
policy is or Self-ins. Lic. N: __. . .. ._ ..._ Expiration Date:
tub Sitc Address: Cityislateizip:
Attach it copy of Ilse workers' cmnpensation policy declaration page(showing the policy nmuber and expiration date).
Failure w secure covcmge as required under Section 25A of`lOL c. 152 can lead to the imposition of criminal penalties of a
Enc tip to 51.500.00 and/or one-year imprisumncnk, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up In )250.00 it Jay against the violator. He, advised that a copy of this slntcinent may be forwarded to the Unice uC
Inv,rsugauuns of Ihu DIA for insurvxc covcra.-c icrilicatiun.
/do her by c • i,V uad !r poitrv'rn/tyd7/p/e�mJricx perjury that the inforti udon provided above is true an`d�s correct.
[6."l
icia/ase only. Do not n•rite in this area, tube corrpleted by city or town official.
ty or'fown: -_ Permit/License x._
uing Aullurrily(circle one):
aard of Ilealth 2. Iluili ing Departtncul 3.Cityi Ilona Clerk 4. Electrical (uspcctor 5, Plumbing; Inspector
I her
liacl Verson:
Information and Instructions
\t:liS.lclla.Setts General Laws chapter 1 J2 requires all employers to provide workers' compensation for their employees.
Pursuant to tilts.statute, an emplured is defined as"...every person in the service of another under any contract of hire,
c tpress or implied,oral or written."
An einpluyer rs defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
d the kxeeoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,piumership,association or other legal entity,employing employees. However the
owner of a dwelling house having not snore 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."
`tGL chapter 152, m+25C(6) also states that"every state or locai licensing agency shall withhold the Issuance or
renewal of u license tar permit to operate u business or to construct buildings in the commonweulth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally, hIGL chapter 152, §25C(7)states"Neither the commonwealth nur,any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the in
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till 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 nuluber(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 docs 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 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 u space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be Sure to till in the pennitllicense number which will be used as a reference number. In addition,an applicant
iliac must submit multiple pennitilicensc 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"Al 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. n dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
I lic 01fIce of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please du nut 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
-rei. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
www.mass.gov/did
{```:- CITY OF SALEM
PUBLIC PROPRERTY
.�i U
,wK
DEPARTMENT
:.I 11 l;. KI�.,}I•I<Ill 1.��.
I li l n' 110 WAM 11\(;I ON S IREET • 5.0 F.M. MASSA( It it rn 01)
11:1:978-743-9M • Ism 978.7.10-9846 -
Construction Debris Disposal Affidavit
(required [or all demolition and renovation work)
sixth edition of the State Building Code 730 CMR section 111.5
I
n accordance with the b >
Debris,.and_the provisions-of.MGL c 40, S 54;_-__
Building Permit It __ 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
111, S 150A.
Thome debris will be transported by:
fa
(name of haul r)
The debris will be disposed of in
/
(nameut'faciity) n 1
10 fTe k asap Ahdov e- T MPt- 0la`t
taddress of tacilily)
sig
nature of permit applicant
date
dchn:�tld,ic