6 RICE ST - BUILDING INSPECTION (� The Contnnn wealth of Massachusetts
V t Board of Building R"uluti0ns and Standards PUR
?IINICII'.\I I'll
-
� Massachusetts State Building Code. 78(1('AIR. 7"' edition
Building Permit Application To ('onsttvct. Repair. Renosate Of. Demolish :t Rrl n,J /
One- or Tit o-!'tin flit, 1)it c lin.t:
r� This Section For Official Use Only cc
a X Bui Wing Permit Numh Date Applied:
` U
Sl�,n:uure: _ — --- -rO ---
Budd of Conunlssiuned Inspraor 1 D:ur
SECTION :
SITE INFORALA'1'ION
Ll Pro erty 'iddress: 1.2 :\ssessors Map & Parcel .Numbers
I.1 a Is this an accepted streets yes no Map Nuolher Pals] Number
1.3 Zoning Information- ' 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Area(sq Ill Frontage (li)
1.5 Building Setbacks (fill
! Front Yard Side Yards Rear Yard '
! Required Provided Required Provided Required Pn"I&d
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Puhli, Private❑ Zone: _ Outside Flood Zone" Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: -
I PrinU Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) •!�7 Akerttion(s) Additi,m ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Wor . <>r �.
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
ILahor and Materials)
1. Building Y �� _ I. Building Permit Fee: $ Indicate hits% tee a JeternnncJ:
❑Standard City/Town Application Fee
2. Electrical `y
❑Total Project Cost' (Item 6) x multiplier x 1
i, Plumbing S �S—rfL ?. Other Fees: S (�i(
4. Mechanical (HVAC) .$ �� List: � /\)
5. Mechanical (Fire
Su) ressiun) Turd :\II Fees: S
• Check No. Check .-\mount: _ ('ash Amount:
0 Total Project Cost ! � /J y�- 0 Paid in Full 13 Outstanding Balance Due:
--- -
SECTION 5: CONSTRL'C'I'IONSERVlCES
5.1 Licensed Construction Supervisor ICSL) Z
� nr.e1 n I d
Nunlhrr I. i I_uul.� I
— I
N stile of lSl. IIuIJer
� Lul CSL T�Ix I,ee
1\ e Ueain �11on
.tare ' le,imltd 11ul❑l111 tNIOCu R 1 _ l
R � Restrli led IR2 F.unll� U��illmc �
Slenaulra St \tasonn 011
Rl. ReslJ.nual
hi lephma — \1S Hc,idClIt Il "IIIJI"' .Ind S1dlII _
SE R..I J:1111al SohJ I-•.ml ]itllnuw \I,hll.un: Im1.11Lun a ^�
D Jentlal DClllul11n41
5.2 Registered Home Improvement Contractor (HIC)
HIC Cunlpauy Name or IIIC Rculsualll Nallie Itegbll'auun :Nw lhir
9 .z, ��� ' S
kldws,
9 7� —boy S4' Ecplrauun Date
' gnn ute - �l:piiois
SECT WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25061)
Workers Compensation Insurance affidavit must be completed and submitted with this apphi atiort. Flllllll"C to pro%Idc
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 OR C TRACTOR APPLIES FOR BUILDING PERMIT
I -- as Owner of the subject property hereby
I authorize to act t.tll illy hchalt. in all matters
re!auve to •vork aut o zed by this bui ing permit application.
I � 1
Sienature of Owner Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
�/Z�y,14 as Owner or Authorized Agent herehy declare
that the statements and information on the fiiregoing application are true and accurate• to the best of my knowledge and
behalf.
udine
-SG- d
Sign lure of Owner or horized Agent Uwc
I Signed under the .ains and enaluesof erju )
NOTES:
1. An Owner who obtains a building permit to do his/her own work. or an owner who hires an unregistered tutor:rcloi
(not registered in the Home Improvement Contractor (HIC) Program). will not have access ill the mhulalion
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program an
Construction Supervisor Licensing (CSL) can be tound in 7SO C'MR Regulations I IO.R6and 1 IORS. iespectivcly.
' When ,ubstanual work is planned, provide the intilrmation below:
Total floors area(Sq. Ft.l _ (including garage. timi hed baeemendautics, decks or porrhl
! Gross livmg area lSq. Ft.) Habitable room count
Number of tueplaces Number tit hedrooms -- ----_._
Number of h:uhml,ms Number of halt/h.uhs
fcpe of heating Sys(em ---- Nurrlher of Jerks/ por.hcs .-- -- —.-_-
I vpe of ioollllg --
3 'Total Project Square Footage" m:ty he Substituted for 'Tolal Piolerl Cosl" ----�
CITY OF SALEM
s PUBLIC PROPRERTY
?` r DEPARTMENT
.I Vr;Rf I N':)Klgh,r l
\I X t,re 12C W ttir a No I O.N S-t:<Elfr 0 S,LLI.U,M.vs.sc:I a it:r I s 0197,^,
Ttr.l.:978.745-9595 • f.sx. 978.7409846
Workers' Cum pe.nsation.insurunce Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Le ibly
%n )licant inrormution
Name lllusincvvOrganiratinNlndlvuluah: u
Address: "O/Z Tom!—!L� e
City,Stare,Zip:
Phone +•.
Are you an employer'.' Check the appropriate box:
Type of project(required):
4. ❑ I :tin a ocncral contractor and 1 6. ❑ New construction
o ces I? ith . have hired the sub-contractors
employucs all a or part-tiux). 7. ❑ Remodeling
?.❑ I out a sole have
o proprietor o partner-
listed on the attached sheet. ,
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity.
workers' comp. Insurance. 9, [3 Building addition
5. a❑ We are corporation and its
�Ko workers' comp. insurance 10.❑ Electrical repairs or additions
I required.] officers have exercised their
right of exemption per MGL 1 I.[] Plumbing repairs or additions
3.❑ I am a homeowner doing all work c 152, §1(4),and we have no 12.0 Roof repairs
myself. IKo workers' comp. anpluyees. iKo workers'
insurance required.] r 13.❑ Other
comp. insurance required.]
-:Njjy:,ppLcanr that checks box ill muss alsu till out the secrton Inauw slwwina their workesi cunspensation policy intlarrratiun.
' I f&'
(' IIWM-n who submit this affidavit indicating they are doing all work and then hire outside"ilraetom niust ,uhmif a new atQdavir indicating such,
r t [hot i rk this box must attwhcd an addaianal sheet h wl se name sg tl of the sub-contractors and their workers'conip.policy inrormarion.
1 am tin employer that is providing workers'c•umpensation in.curunce fa•cry earploprec. Below is the policy unr!/ub aloe
information. 0
Insurance Company Vnme: —_._.. ... _. .
G'1 __ _-_
Policy a ur Self-ire. Lie:is ---- Expiration Date:
Job Site \ddccss:
City:Slatei"Lip:/2_/f
Job Sit n copy of like workers' compensation policy declaration page(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 w S1.500.00 and/or une-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against flit violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invcsugamms of the [AA for iosur;o:ue aweragc Nerilication.
1 do hereb certify hder the pains fill l)l s of perjury that the information provided above is ira sad correct.
I'h re :•
O[Jicial awe wily. Do oar orite in this area, to be completed by city or town ojjicial.
City or'fnwn: -
Permit/License$0 _ _-
Issuing:itulhurily (circle one):
I. Board of Health 2. Iluildin, Dcparunent 3. City71'oss11 Clerk 4. L•'lectrical Inipector 5, Plumbing Inspector
6. Other -
Phone #:
Contact Pcnou: _- --
y
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more
of the toregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,pattriershlp, 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, §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, §25C(7)states"Neither the commonwealth nor an of its political subdivisions y p tons shall
enter into an contract far the erfomlance of ubli-y p p � 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(s), address(es)and phone number(s)along with their certificates)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 confimtation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
Lie 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 apace 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 permit/license 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
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 be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must he filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
f i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he 016ce of Investigations would like to thank you in advance fur your cooperation and should you 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
Ofltce of Invest!s adons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Kreiscd s-26-05 Fax # 617-727-7749
www.mass.gov/dia
.y
CITY OF SALEM
=� •� PUBLIC PROPRERTY
DEPART'�fENT
'.I • 'I; U. ill r • SAII M. Nhl. \t I, I . , _I',
Construction Debris Disposal Affidavit
(rcquired lirr all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CNIR section 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit if 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 MGL c
111, S 150A.
The debris \will be transported by:
Iname of hauler) Ll
The debris will be disposed of in
(namr ut lae�ty) �
(address of lanlity)
agi Iwe u(pennit ap leant
date