3 RIDGEWAY ST - BUILDING PERMITS ,1f
1 .
F� Building
fhe Commonwealth of MassachusettsBoard of Building Regulations and Standards CITY OF
Massachusetts State Buildin g Cod 7 SALEM
e. 80 CMRbRerisrd.tlux'0/l
Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Drelthkq
This Section For Official Use
Building Permit Number: Date App1 ted:
Building 011icial(Print Name) are D•to
SECTION 1:SITEAFO-RAfATION
1.1 �pertyjKj11rels -��� Assessors Map& Parcel Numbers
I.I a Is this an accepte treet?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifycs❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2. wnertof-Record:
Name Print) r-- City,Stat-e,Z I
ZIP
No.and Street el)T ephone' ' '"5 Email Address
SECTION 3: DE CRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
�1 E
SECTION 4: ESTIMATED CONSTRUCTIOR COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S ?, Other Fees: S
4. Mechanical (li\':\C) S List:
5. ,Mechanical (Fire S --
Su session) Total All Fees:S
Lheck No. _Check Amount: Cash:\mount_____
G. Tutal Project Cost: ❑Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Const uction Supervisor License�C L)
r =I I l
License Number livpiratiou Date
Name of('St. 11(c( {
/�/ 1 '/ List CtiL I"ape(sec below)
NS eet \l\ Type Description
v� U Unrestricted(Buildings up 0 35,000 cu. 11.)
R Restricted 1&2 Family Dwellin
City(fown,State,ZIIP(� M Masonry
UGI V 0 RC Rooling C'overin
- W'S Window and Siding
f (�j �) I Solid Insulation
Burning Appliances
(/J1. (rf`7 6 I I Insulation
'I'ele hone Email address D Demolition
5.2e-Registered e ed 11 tide Improvement Contractor(HIC) Jirj ]�
�f J� I CtI o I IIC Registration Number lispin tion Date
I IIC 'ompan) N n y1 I Registrant n
N un •et Y/ O1 CJ 0 Email address
Ci /Town,State,ZIP
1 Y'relc hone I
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 .......... ❑ No........... ❑
SECTION 7a: 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do hislher own work,or an owner who hires an unregistered contractor
(not registered in the Hone Improvement Cuntractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 1 q2A.Other important information on the HIC Program can be found at
ygw,nnp .goc_oc:i Information on (he Construction Supervisor License can be found at yob_dph
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement'attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of lireplaces" _ Number of bedrooms
Number of bathrooms Number of half baths
1)pcof heating sy stern __----__-- Number of decks, pore ies - -----"-_
1)PCofCoolings)stem_ inclosed
i. 'Total Project Square Footage-may be substituted for-focal Project Cost"
CITY OF S. -&Nf, NLASSACHL'SETTS
8lAW= DEPARTtLNT
110 W ks"NGTON STRM, 31O Rocit
rM (978) 745-9595
RVt(978) 740.9846
K1J®F.Ri.EY DRLSCOLL
.MAYOR THoua StPtxns
DIRECTOR OP PLBL c PROPERTY/BLIIDLYG COJLV(SSIONER
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I l 1.5
Debris, and the provisions of MOL 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:
(name of hsular)
The debris will be disposed of in :
(name of facflfty)
5w5M�
(address of facility)
aiynamre of permit a licant
1A
ddfe
AhnudJ w
' CITY OF SALEM
* ,J' PUBLIC PROPRERTY
DEPARTMENT
.�bP..M'IYJMM I'll
11 11.+1
11:1Vn HUA1;Ill, SIstL•1' • 3.111 N. \1.h1.k.l 11 V I nJPr7�
.713-9593 If 1:if wN.?4vi,144
Workers' Cumpenaation insuru niI imiavih 1#Ilders/CuntracturslEle trlcians/Plumban
't l llicant In urmuNo
PI Print Le 'hi
�I;IITC I Ilualle�yl)rgsnv.11inrvin/Jrv`�Juul1:
'iddress:��
Cily,.5rarci%ip SGI� Q/V� l " Vr, I'huneii: - I 125 ��s I S(�l
I .\re y is It an enee Oyer'!Cheek the approprlaI@ bas:
I.❑ I am a umpluyur wish 4. C] 1 alto 4 guncral conuaetor and I 1 SPe I't project(reyulrrd):
tpluyccs(full and/ur part•lime).' have hind the soh-uuntracwrs /I ❑New cunstruetiue
I•un 4 solo prnpricnlr or punster• listed on the anachod sheet : y ❑ RelnoJslin`
ship and have no umpitil These sub•contrsctars have
Corkin! tilt m ity.g in any capac workers'comp. Insurance. 13
d' Demolition
Ka workers sump. iltsurince 3. ❑ We are a calporstion and its 9' ❑ouiWind additiun
).❑
squired.) )tylccrs 114vc 9119mis6d their 10•❑Electrical«pain or additional 1 a111 4 hmncuwncr Juind Al work fight(No orusemptiun per htGL I L[]Plumbing npuirs ur 4JJitiofu
myself. waken'cutup, c. I Sl,41(4).anJ we hnva no
psurunca rcyuired.j r cmpluyeur. (No workers' 12[]Ruul'npui
annpinsunncanyuinrl.) 1),(]Uther ° 1
•1n1.,;gdlcuY Ihal cWeYa halo AI mlyl:Jw lill uW IMr Wolutl belulr awann I'I lumwtrnara why 1lYlallf this altlJavil inalylin I e Avir y'Wk1ra•cunlyyYyyiuy Iwllvy wliylllWiyl►
•C•,nlrsse' I IYM cIN'ck th-00� is boa mull plavhwl•la WJIh""I"All dl work and ItK%him Im1114a vYYlnilpa Mimi.
lk�l a1nlYille Ihv n,tnM a''he lak•eyryrirlyre dYd Itlfe yyrkalalw Ilnitav;f injimsl vKh.
/ll/p y//Crrllll0)'If r/lyr if/rfYl•/dInge Ivafftrrs.coin elevation llLfYf/lper a//N t/p Y, �P'f"'IRy tYnMealilla
itl/ur/rrulGpa �(1� �/ n ((l / y p/1 roe Brlafv&rAr pu/ley unl//ul.rig
ImuraneeCtlmpaoyNmne
Villicy 4 ur Sclr-ins. Lie.M; 0 (/�
I EApirauun Date:
y b $ita AJJresv: i� U
\ttacA n cagy of Ila workan'emnpcnsafloa pull y Jydarutlun plrge(showlnll the policynumber and¢spl►atlua e
ti there lu l,5fl culeruge as required unJcr Sccliun:J1%ul'SIGL c. 132 eau lead to the imposition orcriminal Penalties Ora
line up oI S LSnO,IM anJ/ur uue•year iulpri.Yulnncnr, of well aY civil pcnulhu in the I'unn oleo JT!)p 1VURK ORDER and s Tina
.)(till nl "lls ul 4 Jay.tg:6r the Vi.gIPce nr. Ile 4Jvi.r•J that a copy of IhiY.dmcmcnt may bu Iurw4rJcJ w the Ullicu ut'
let
,ahy4ul nls of;ltu (1L1 :or nnucu'cc a��crayu I crilicalum.
/Ju/nn•by certify apder /�r prlipr aed ptnuhie ujprr/nry r the ip/unnyNop yrvvrded ubuw i rrua r rd correct.
Il y//&iuI tilt wily. I'd i'at mitt ill//#/.I urea, to Ar rump/etrd by airy of to ilia o//lriuL
I �I ily of l•Olrn:
—.—�_ Pennir/Llecnfr Y
lk.uing .\ulhurity (circle nnc);
I. 111�4rJ of Ileulth I. Ihuldin;L. 0111ar Ihp.vhuclll 1, "1.1- r41111 Clerk 4, l•7cUrical fnytc0ur i, plumping lolpcetor
i
I l'• nl.tcl 1't nun:
c
information and Instructions
1n tor
their
`IttPluyeer.
v crwn m the service of another under any cuntnct of hire,
�i,hs;achu:cus Ucneral Laws chapter I i2 ,cquues all enysloyer+o provide workers wmpensa t
Pur.u.utt to ties inure, an rmplurra is Joined as _e cry p'
c%press or or lied, aril or written." oration or other legal entity, of any two or inure
c
Nn ,npluper is JclincJ as'•an individual,partnership,asloeianoo.Cory
t the I;,requml{engaged m a loyer.of the
ame enrerpnse. and including he legal represenrativas u m evmvlo)Cos.IHowevcr the
of herein.of the Occupant of the
i ecmver or dwells of•0 individual.having not more than"SOCIalicia
apartments and who i n usijes r repair work on such dwelling{house
,wrier of a dwelling{house tt
urtenant thereto shall not be of such employment be deemed to be an employer."
,Iwelhng house of another who employs persons to do muinununce,sun
struor on the.,rounds or building app
-,tGL chapter 152, 023C(6) also states that"every state or local ileensing flags i shall witlrhold eM lhfo any
o►
lesvidsoco Of Ihect with the Insurance coverage required:
renewal of o license or parntlt to operate t business or to construct bull' In the wmm subdivisions shall
applicant who has not produsd 1SC 01 abates"Neither he commonwealth nor any of its political
\dJiliurally, mUL chuptsr 1 s_, i- l
%alint into any contract far the etbeen Presented bo nhe contracting gt authartityv'Janca ufomVliafrce with the insurance
requirements of his chupner
Applicants the boxes that apply to your situation mho if
checking{
aJ es)and Phone numbers)along{with their certifiClij of
plcaae rill out the workers' compensation atndavgt completely. Y with no employees other than the
necessary,supply nub-contruclors)nama(s),' this(
worker' compensation insurance. if an LLC or LLP does have
inset ance, Limited Liability Companies(LLC)or Limited Liability PaMenhipt(LLP)
_ members or PuMan. are not required to carry be submitred o the Department of industrial
ld
employsea,a policy is required Bt advised that this affidavit he s may oa vie s of
Accidents for confirmation of in coverage- Apso be sun to slop and Jutt the ul'lldevlt. Tlu affidavit shoo
he rortmsd to the city or town that the application for the ponnit or license is being requested,not the it w
1 ndustriul,\ccidanu. Should you hava any goestiona regarding the law or if you an required to obtain a workers'
indust sal,lore policy.Please call the Depufansnl+t the number listed below. scif•insured companies should enter their
iii,lipe-golf.insurance license number on till appropriate line.
(,Ity or'taws Offlclals
the applicant.
Plcase he sure that the affidavit is complete tmd printed legibly. The Department rat provided u space at he bottom
Ile tite affidavit for you to fill out in the event the Office of Investigations has to contact you regarding PP
Pl:use be sure to fill in the pennitllicense number which will be used as a refer cricc nuinber. In addition,in is applicant u r or
that morn submit multiple pannitlicatsse applications in any given year,need only suborn one afii bet indicating
w the
policy informa io he a colisa�h+has bean attic ally stamped or marrkedss"the upplil; hbys tile city oratown Ina
ytiobee in each
Y
tusvnl•••,\copYof
applicant as proof that a valid aifidavit is on rile for futon permitso or licenses. t now afo any fidavit of 4Mus be lilted out sac
I e`1r.1'I hoes en�n r owner
permit Ill burn citizen
leavesisobtaining
e.)`td pets riot P fC4Ulfed o relatednnit not complete h l affidav tmmercial venture
I he of lovestigations would lee to diurk you in adrutec for your cooperation and should you hasa:my yuesuans,
t li lice
please du not hesitate to give us a call.
the Ucparuncnt's address, telephone and rax mumbeer
Commonwealth^wealt)1 of htassaehUsetU
Deparanent of Industrial Accidents
Oit&e of Invesdgations
600 washington Street
Boston, MA 02111
'ref. p 617.727F� 6l7.72 o77a9".MASSAFE
d .4 n.us www.mus.gov/dia