15 RIVER ST - BUILDING INSPECTION (2) G •
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The Commonwealth ofMassachusetts + � IEIVEfI
� ��sP�cri r�n��.�.���
` ' Boazd of Building Regulations and Standazds �'M
� � Massachusetts State Building Code,780 CMR �, evised Mar20ll
N Building Permit Application To Construct,Repa'u,Renovate Or Demol�is�PR�'' � p, �� 3�
�'' One-or Two-Family Dwelling '`_ " -
� This.Section For 0€ficial Use Quly . . ;';„,
� Bu'ildiagPermitIFumber: Date�rSpplied:'' � ��4,�'`'k ;� `�d�'
�. s } ,3 � �
� � �� � � f �Lt9�sdyy
� smldingofficiat(r.vrtt�aine) �.S;gnanae� ..� e
� ,! ! `['SEGTIO�T1:SITE INFORMATION ' ' ` . "
11 Property Address: � 11 Assessors Map&Parcel Numbers
/S R i vo_r Sf� �
11 a Is this an accepted street?yes no Map Number Parcel Number
- 1.3 Zoning Information: 1.4 Property Dimensions:
. Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(fr)
Front Yard Side Yards Reaz Yard
Required Provided Required Rovided Requ'ved Provided
1.6 Water Suppty:(M.G.L c.40,§54) 1.7 Flood Zoue Information: 1.8 Sewage Disposal System: -
Public❑ Private❑� Zone: _ Outside Flood Zone? Municipal� On site disposal system ❑
Check if yes0
SECTION 2l PROPERTY ON7YERSHIB1 " .. ' .
2.1 Owner'of Record: �
La-riS� �c�eag ��em �n
Name(Print) City,State,ZIP
�5 R�`v�y sfree�-'
- No.and Sveet Telephone Emai]Address
SECTION 3:DESCRIPTION OF PROPOSED WORK3(eheck all that apply) ` '
New Construction❑ Existing Building❑ Owner-Occupied ❑ `Repairs(s) ❑ Alteration(s) ❑ Addition ❑
� Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: �
BriefDescripf nofProposedWorl�: u/ 7'tC
�-/ �E.��p ra /e/o �'11 S .e tl 4�»
/
� � � '" SECTION 4:ESTIMATED CONSTRUCTION COSTS ` �;"� � � � �
-., _
Item Estimated Costs: Official Use Only ; '`
Labor and Materials �
1.Bailding $ 1. Bnilding Pernrit�ea:$ `- �ndicate hbiv fee is dete�mined:
2.Electrical $ �Standard CiryA'own.Appl�cation Fee , -
O Total Project Cost�(Item�6)x multiplier x � : � �
3.Plumbing $ 2. OtfiexPees: $ '
4.Mechanical (HVAC) $ :List: . . ' . . .
5.Mechanical (Fire $ .:Totat All Eees:$ � �
� Su ression � �
o a Check No: Check Amou�t: �. Cash Amount: .�
6.Total Project Cost: $ y��� p pa�d in Full O,Outs;anding Ba9ance Due•
�'�,� � C�s.�-a ���--
MA��� S ( io
SECTION 5: CONSTRUCTION SERVICES
5.1 s onstiuction�Supervisor Licen (CSL) ___�.3�� 08 2 �7 ?
�d�� v � �j,Q. ry��Q �t/Q�� License umber Exp� lion
Narn�;CS � oltlei +'=-" ' �ti
�" �� � t // /' List CSL Type(see below)
.3� • �arM/ �rtlrlOYi/'i,S � �
No.and Street TY��� Description, .
G�9 2� Unrestricted uildin u to 35 000 cu.ft.
G�oue.eg�.e�- �a �v R Restricted 1&2Famil Dwellin
�ty/1'own,State,ZIP M Maso
RC RooSn Coverin
WS Window aud Sidin
�. SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
. Registered Home Improv ment Contractor(AIC) py /� �
���Q f./ �� V 0
��� / ( � HIC Registra6on Number xp ation Date
HI m �q, Qame rHI e tN e n ,�
�a,�,� �`�"Na Ln /�_v.� 7�
No. Street Email address
� ce � o ��9°3 9�?�ZS�{ ra� `2��2'�'I C`�S
/Town State,ZIP Tele hone (1 '�'R�P��•C 0� li
SEC7TON 6:WORKERS'COMPENSATION INSiJRANCE AFFIDAVIT(M.G.L.c;152.§ 25C(�)
Workers Compensation Insurance�davit 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. i
Signed Affidavit Attached? Yes .......... ❑ No........... ❑ �
SECTTOAT 7a:QWNER AUTHORIZATION TO BE COiVIYLETEA WFIEN
OWNER'S AG�NT OR�ONTRACTOR APPLIES FOR$pILpING PFI�MPI`
1,as Owner of the subject proper[y,hereby authorize �
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Narne(ElecVonic Signature) Da[e
� � � SECTION�76E OWNER� ORAUTHORIZED AGENT DECLARATION � .
By entering my name below,I hereby attest under[he pains and penallies of perjury that all of the information II,
n[ained in this pplication is true and acwrnte to the best of my kriowledge and uuderstanding.
o � m � 8 /
Print Owner's r Au orized Agent's Name Electronic Signature) � ate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered con4actor
(not 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 Progam can be found at
.t�vw.mass.gov,'oca Information on the Construction Supervisor License can be foand at www.mass.:tov/dos
� . 2. When substantial work is planned,provide the information below:
Total floor azea(sq.ft.) (including gazage,finished basemenUattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of baUvooms Number of halflbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Projec[Square Footage"may be substituted for"Total Project CosY'
� The Commonwealth ofMassachusetts
�� Department oflndustrialAccidents
t , 1 Congress Street,Suite I00
Boston,MA 02114-2017
� www mass.gov/dia
�F'orkers'Compensation Insurance�davit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE pERM1TTING AVfAORITY. �
Aoolicant Information p /J P�ease Print Leeiblv
Name(Busiuess/Organization/Individval): /{D�1` �r � — 0�{a
Address: 3 S' i' � .�,/� 0 n �o� •
City/State/Zip: �o c Q /` 0 hone#:_ 9' �<Q 2 8� 2S�Cf.
Are you au employer? heck the appropria4 box:
Type of project(required):
1.❑1 azn a employer witA employees(full and/or part-time).• 7. ❑New construction
2.�I am a sole proprietor or par6�ership and have no employees working for me in $, RemOdelin
any capaciry.(No workers'�comp.inswe�ce required] ❑ g
3. I am a homeowner doin all work m selt 9. ❑DemOlition
❑ 8 y [No workers'comp.inswance required.]1
4.❑I am a homeowner and will be hiring wntractors m conduct all work on m perty. 1 w•��� 10❑Building edditiOn
y pro
eruure that all contractors cithu have warkers'wmpenaation insurance or aze sole 1 I.❑EleCtriCel 7epairS oi additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.❑I am a general co�mactor and I have hired the subcontrecron lisred on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.i 13.Q Roof repairs
6.�We are a coryoration and its officcrs have exercised the'v nght of exemptlon per MGL c. �4'��� � .(�
152,§](4),and we have no emp]oyees.[No workers'comp.insivance requued.] U cr i � y/i�
uc
"Any apy]icant that checks box#1 must also fill out the section below showing the'n workers'compensauon policy information.
� t Homeowners who submit this affidavit indiwting ihey are domg ali work and thrn hire ourside contractors must submit a new a�davit indicating such.
IConeacmrs that check this box must anached an additiona]shcet showing the name of ihe sub-wntactors and stare whether or not Mose entlries have
employees. Ifthe sub-contractors have emplayces,Ney must provide the'u workers'comp.policy manber.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
injormatron.
Insurance Company Name:
Policy q or Self-ins.Lic.#: E�cpiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showiag the policy number and eapiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$I,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ceKi under the pains and penakies ajperjury lhat the information provided above is true and correct.
Sig�a[ure: ` � Date �/ 2 � � l�'
Phone#: 7j �
O�cia[use on[y. Do not wrue in this area,to be completed by city or town a�ciaL
City or Town: Permit/License#
Issuing Authority(cirde one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions ,
Massachusetts General Laws chapter 152 reqaires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An emp[nyer is defined as"an individual,partnership,association,coiporation or other legal enrity,or any lwo or more
of the foregoing engaged in a joint entecprise,and inc]uding the lega]representatives of a deceased employer,or the
receiver or irustee of an individual,partriership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apaztrnents and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, conshvction or repair work on such dwelling house
or on the gounds 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 with6old the issuauce or
renewal ot a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who Las not produced acceptable evidence of compliance with the insuranre coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of i[s political subdivisions shall
enter into any contract for the performance of public work unti]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 checldng 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 certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partrierships(LLP)with no employees other than the
members or parhiers,are not required to carry workers' compensation insurance. If an LLC or LLP does have
em lo ees a olic is re uired. Be advised that this affidavit may be submitted[o the Department of Industrial
P Y , P Y 9
uld
Accidents for�confirmarion of insurance coverage. Also be sure to sign and da[e the afl5davit. The affidavit sho
be retumed to the city or town that the application for the permit or license is being requested,not the Depaztrnent of
Indus[rial Accidents. Should you have any questions regazding the law or if you aze required to obtain a workers'
- compensation policy,please call the Department at the number listed below. Self-insured wmpanies should enter their
� self-insurance]icense number on the appropriate]ine.
City or Town Officials
Please be sure that the afSdavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fil]out in the event the Office of Investigations has to contact you regazding the applicant.
Please be sure to fill in the pemriUlicense number which will be used as a reference number. In addirion,an applican[
that must submit multiple perrniUlicense applications in any given year,need only submit one affidavit indicating current
- policy information(if necessazy)and under`7ob Site Address"[he applicant should write"all locarions in (city or
town)."A copy of the affidavit that has been officially stamped or mazked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future pemvts 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and faac number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 � . www.mass.gov/dia
` �TYOFSALEN� MASSA(�it�ETI'S
a� , Bcffi.nnacvsra�xr
120 WA9D/JGIIDNS7REET,3IDFLODR
7Y+a.(978)745-9595 �
RiMRRRiF]'D��jj,
FAx(�78)740-9846
MRYOR 7�NAS ST.P�RRF
DIRECIY�R�+FUBIICPR�ER7Y/BLDIDIIaG�ON6R
�'
Construction Debris Disposa/A�davit
(required for ail demolition and,.renovation work)�
In accordance with the sixth editfon of the State Building Code, 780 CMR, Sectfon 111.5 Debris;
and ihe provisions of MGL c40,S 54; Building Permit# is issued with the
condition that ihe debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as de�ned by MGL c 111, S 150A.
The debris will be transported 6y:
(name of hauler) �
The debris will be disposed of in: .
� � pav�o /``2 ll O �eor���0 ��
(name of facility)
(address of facility)
( • .
Si ature of applicant
Date �
,;
. .
\'�
\
V. `� � ,>.
,i x �� �
�'��
Salem Histo�ical Commission �
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 �
�s�s�sis-ssas FAX(978)740-0404
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction 0 Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other work
as described below will be appropriate to the preservation of said Historic District, as per the requirements set
forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance.
District: McIntire
Address of Property: 15 River Street
Name of Record Owner: Larissa Lucas
Description of Work Proposed:
Construct enclosed addition on corner of building matching footprint of existing shed per drawings prepared by
R-JFramke Construction dated 3/I S/I S with an alternative to put in clapboards instead of a second
cornerboard at juncture with main house.
Addition to be painted to match existing house.
Dated: March 17, 2016 SALEM HI CAL C MMIS ON
BY. �/ �;Gy'�/' / �
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals)prior to commencing work.
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