1 RICHARD RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards LC)R
%,t'VI( II'. ITI 'i
MassachUSenS State Building Code, 730('MR, 7"' clition
(ISI I
Quilling Permit Application To Construct, Repair. Reno<ate Or Demolish ❑ RrrisrJ Atnumrt I
One- or Tit o-Family Dn elli1w 1.
This Section For Official Use Only
\ Building Permit Num r. Date Applied: __-
si_nawre: ------
Building C'onumissiuner lnspectur of Buildings Date
SECTION 1: SITE INFORMATION _
Ll Pr�y,PPerly Address: 1.2 Assessors Map & Parcel Numbers
1 KtcKc�� fQoAd -
_. L Cu Is this an accepted street? _yes__ noMap Numher— P:und Nmnher
-1.3 Zoning Information: - 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage iit)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
i
1.6 Water Supply: (M.G.L e. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'?
Public Private❑ Check if yes❑ Municipal ❑ On site disposal .cyAcm ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Mom.
Name(Print) Address for Service:
92ce-7ys y96a _
Signature Telephone
' SECTION 3: DESCRIPTION OF PROPOSED WORKz(check all that apply)
New Construction ❑ Existing Building CV- Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Spccily:
Brief Description of Proposed Work2: .ST
E /5n! {4t (N
/ EOEMt A, l/ / oabdEY—'
---
✓�� a . lv
U *n ( 5 �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ r/ I. Building Permit Fee: $ Indicate how fee is deterd:mine ,
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) .$ List. i
5. Mechanical (Fire $ Total All Fees: $
Su ression)
o� Check No. Check :\mount Cash :\mount:___
b. Total Project Cost $ 7 ���, 0 Paid to Full 0 Outsnmding Bahmce Due:__.___._ 1
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor (CSL)
License Numher Expiration Date r.
Name of CSL- Ilolder
List CSL'fNpc Isco below) _
\JJrcv l e Descri*tion
L Unrestricted (up to 35.(X)0 Cu. Ft.)
R Restricted l&.2 Family Dwelling
Signature M Nlasunry Only
RC Residential Rouhne Cosenne
Telephone \1'S Residential w111JU N' ,utJ 5nlme __
SF Residemial Sohd Fuel 13unune 1 „hanee In U.dlatL-ll
.. D Residential Demolition
5.2 -Registered 11ome Improvement Contractor(HIC)
1AA1A14.e r)y�
HIC Cum` ay Nana or HIC Rcgis>�mn Nat
sps� W taVu r sr 2 _ .y,p 61gGReistraoini Number
gL o
Addrep�A / c17�?-S3/� iJ -, p
f 1 iratiun Date
Signator Telephone J
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 .......... 63� No .._....... ❑
SECTION.7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT J
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
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.,
Print:`lame
Signature of wner or Authon ed mt Date
(Signed under the earns and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut 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(LR6 and 1 10.R5. respectively.
_' When substantial work is planned, provide the information below:
Total flours area (Sq. Ft.) (including garage, finished basement/attics. decks or porcht
I Gross living area tSq. Ft.) Habitable room count _
Number of fireplaces_ Number of bedrooms
Number of bathrooms_ Number of half/b:uhs
rype 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"
(, �
CITY OF SALEM
� PUBLIC PROPRERTY
DEPARTENT
M
orkers' Compensation Insuj_ance Aftidatit: tiuilders/ContractorsiElectricians/Plumbers
1 fllaant Information
Please Print L.eeibly
� Illll �Ifu.in:.. � trg.uur,an�n Indis iJu.dC
art/n1 Q C/7`/ e0X)2'X4C,1VWS
('fly State zip:-t"6/4!/i'3by iNi1 Dlq foo Phone
\re yuu an employer:' Check the appropriate box:
rype of project(required):
I.fI and a cnlplo)cr w ith _ — 4. ❑ full a general contractor and 1 6. ❑ New construction
cinpluyees(full and'or part-time).' have hired the sub-contractors 7. ❑ Remodeling
listed on the attached sheet. •
],❑ 1 In, a sole proprietor partner- I-hese sub-contractors have S. E] Demolition
:hip and harm no emploo yees workers' comp. insurance. y, [J Building addition _ �...
working for me in re a corporation and its any capacity. 5 ❑ We are i -
[No workers' comp, insurance ME Electrical repents or additions
ofticrn have exercised their : w
required.[ 11. Plumbin repairs or additions -�-
3.❑ I am a homeowner doing all work right of exemption per N1CiL ❑ g P +a
C. 152, $1(4), and we have no 1_'.Roof repairs ,J
myself. [No workers'comp. employees. [No workers' _-
insurance required.] 13.[__10 ther
comp. insurance required.)
•:rny.applicant that checks box fol mint also till out the section below showing their wurken'compensation policy information.
* I lomeowners who,uhmit this affidavit indicating they are doing all work and then hire outside contractors most submit anew affidavit indicating such.
:('owracturs that check this hox must attached an additional.sheet showing the name of-the sub-contraclnrs and their wurken'comp, policy information.
train on employer that is providing workerscompensation insurancefor troy employees. Below is the policy and job site
information.
Insurance Company Name:_�& � n7l�TUf}�- //lfSljef�It/L�
n Expiration Data: /
Policy q or Self-ins. Lic. d: D38 h9(e.�
0 City,State/Zip:
Job Site Address: %ICNtfB/J &?to _. . _
.iottach a copy of the workers' compensation policy declaration page (showing the policy number an expirationdate):
Failure (o secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.5110.)11 and'or one-year imprisonment. as well as civil penalties to the titre of a STOP WORK ORDER and a fine
t,l up IU 1250))It day a ttallbt the UUlatur. Ile ad% sed that a copy of illls statement may be forwarded to the Office of
h;l e.nd:uians of the DIA for insurance courage scnficaoon.
/Ja herehy rerti •under the rain. t trd penulrics of perjury that the information prutideJ a� �G c
d corret
Date: S
i nyll_tln re.
--U/Ji,iul rise troll'• no foot,trite in rhi.c area, it)he I omplered by city to toren officio[
Citv for town:
Issuing liuthorily (circle tine):
I. Ituard It Ileallh 2. Building Depar(nn•nt 3. ('icy, fcm n Clerk J. Electrical Inspeclor 5. Plumbing Inspector
h. Ol her .- ------ ----------
Contact Person: .._--- _ -- -- _ Phone ----
Information and Instructions
\Lt,..tc!:u,cn. liiniral l .m,c!cgh0.•rI rcyuirrs .111 enytlo%er, la pro%ide %%orkcrs' compcnsauon for their employees.
('ut.uant to This .t.uute. .In emplu)ee o JetuicJ us ch en person oh he .rr\ice of.i n other under ans contract of lure. "
%I�tc�s or ing.ltcd. oral or %vuten...
emphner is dctitied I, ' .in uh,In;dual. p.utr.cr,hip, ,„omenw I. corporanon or other Ie LaI cnnt%. or mis h%o or more
. t the tote_oing engaged in a loon cmcrpriw. and Including the legal rcpresrntansc, of decca,ed enhphryer. or the
cccn rr or truaee of an InJh%'Jual. p:utnirahtp. .t„ocuuon or other heal enury, employ Ing cmpioyees. I lo%se%er the
of a dwelling house hating not :nore than three .hparnncnts and hs ho resides therein. or the occupant of the
J%%cihng hou,e of mioiher %%h,)rug,lo" pcnhnh, to do mauucnance. conaruction or repair %cork on such dwelling house
a .m the _nnut.ls or hwldtng .ippuitenain thereto .hall not hccause of.uch be deeuhed not be an employee"
M(il. chapter I5_', j25CI(,) also .tate, that 'c%cry state or local licensing agency .shall %%ithhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commons%calth for any
applicant i%ho has not produced acceptable e%idence of compliance ssith the insurance cos-crage required."
\ddnionally. NIOL chapter 152, �25t (-t states 'Neither the conuuonwcilth nor any of us political suhdivimons ;hall
enter into any contract for the performance of public cork until acceptable e%iJence of conipliance with the insurance
requirements of this chapter hove been presented to the contracting authority."
Applicants
Please till oaf 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 certttcate(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 at idavit may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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
,elf-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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please he 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 intixtnation (if necessary) and under"lob Site Address"the applicant should write "all locations in (city or
nr%%n)." A copy of the affidavit that has been officially ,tamped 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. a Jog license or permit to burn leaves etc.) ,aid person is NOT required to complete this affidavit.
I he (Mice of In%estigations %could like nh thank you in advance tor tour cooperation and should you have any questions,
pli.t,e do not he,itatc ro gicc us a call.
I he D) ratnncnt's address, telephone and ISx number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Obese of Investigations
600 Washington Street
Boston, MA 02111
Tel. ti 617-727-4900 ext 106 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I ',...r: I". A.\;nna. INSna.rT * S.0 rpt. M\1i V :6 a 1 1'.ly
I I I V78--4;-9;'); ♦ 1:,\X: 978 74.-4846
Construction Debris Disposal Affidavit
(required lirr 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 # 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.
The debris will be transported by:
Fw , &M/il
-(name of hauler)
I'lie debris will be disposed of in
(name of facility)
(addre . of Iacility)
i
si • talurc of permit applcut
date