16 RIVER ST - BUILDING INSPECTION (3) �+ a The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
Massacuse htts State Building Code, 730 CMR, Th edition OF SALEM
Revised Aunurtq-
Y �+ Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 1008
•- One-or ilv Dwell'
1 is Section F r Official U my
y
Building Permit Number: D pplied: o
'< r
Signature:
Building Commis' er/Inspecturu ildings Date
SECTION 1: SITE INFORMATION
1.1 roperty Address: 1.2 Assessors Map& Parcel Numbers
tl� i2i f P tr 4hca&
I.1a 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 fl) Frontage(R)
1.5 Building Setbacks(it)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ P p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record:
,, e7e l f f gd,, a l f a In l y t<n ��n fLt`t�^.tr S iree�
Name(P' Address for Service:
(at-4-
SignaiMmi Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition A14KAccessory Bldg.❑ Number of Units_ Other ]�,Specify: �2
Brief Description of Proposed Work':
_ $ ' nK Xg�
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S (61 0(10 Cl Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES +
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Name of C.SI.- I lolder
List CSL 1'Ype(see below)
F'a
Description
AddressI I Unrestricted itip to 35,000 Cu.P1.
It Restricted 1&2 Family Dwelling
Signature I N1 Masonry Only
RC Residential Roofin Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
1) Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature rclephone
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 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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:OWNER'OR AUTHORIZED AGENT DECLARATION
1, 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 Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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(IIIC) Program),will'trot have access to the arbitration
program or guaranty fund under M.G.L.c. Ig2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I l0.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type 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 SM-E.NI, AXSSACHUSETTS
B BDLNG DEPARTNWNT
120 WAS14LNGTON STREET, ]"FLOOR
TM (978) 745-9594
Etx(9 7 8) 740-9846
Kf\tBERLEY DRISCOLL THONUSST.PtFRR8
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BI:BD[VG COSLL\IISSIUNER
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianvPfumben
4imllcant Information Please Print Legibly
VRmCIBusiiaSrOrg,niratioalndiviJuall: �� f" ���� ' `
Address: Q'
City/state/Zip: Phone +qa • q I `fib
Are you ao employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
elo to ees full and/or part-time)." have hired the subcontractors
2. I ass a sole proprietor or partner-
P y ( P listed on the attached shcct.t ?• El Remodeling
❑
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9• [] Building addition -
I No workers'comp.insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions
required.) officers have exercised their
3 am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions
n
Xmyself.(No workers' comp. c. 152,(i 1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. [No workers' 13.0 Other"h1ZV i
e (Ap..Uf W vtA _ +U) E'F C4 V 0 f:W' comp.insurance rcquimd.l
-Any upplicum dtar du+:ks boa et must alto rill uut the a tim blow ahowing thaif rorkui compenariun polity mtia mation.
't r,..as mr,who sulmit this affidavit indicating they an doing ail work and then him oWrido contractors most submit a new 21T.davit indicating such.
:Commcton that chat this box man aaxhod an additional sheet showing the name of the subeontncton and their wurken'comp.policy information.
l am tin employer rhat!s providing iverkers a canpensarlan iasurance for my employees. Below Is rite policy and jab.sire
injorrnurlon.
Insurance Company Name:
Policy 4 or Self-inn.Lie.fl: Expiration Date'
Job Site Address: City/State/Zip:
,kitsch s copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. De advised that a copy of this statement may be forwarded to the Ofliea of
Invesliguliong of the DIA for insurance coverage verification.
f de hereby certlj t r sfr the gins aoJ peaalr/es of perjury that the beformarlon provided above is true mod co"'e'L
s ,,
P t �' t '`�L - t . l 0
OJjic ial use only. Do not write in this area,be be completed by city ur town ejjlrlaL
City orTuwn: ___
Issuing Authorily(circle one):
I. Board of Health 2.Building Department 3.Cilylrusvn Clerk 4. Electrical luspector 5. Plumbing Inspector
6.Other
i
Contact Parson:__ ._.. . . Phone 4:
i
Information and Instructions
lassachu,ems Gencral Laws chapter 152 requires all employers to provide workers' cumpensauun tor their employces.
Pursuatif to tius sutute, an rmplgrtre is defined as "...every person in the service of another under any cuntnct of hire,
xpress or implied, oral or written."
An empleyer is defined as"an individual,partnership,association,corporanun or tither legal entity,or any two or more
a the toreguing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
recmver or trustee ul'.ur individual,paamcrship,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 tin 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 this"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 u(cumpt ante with the Insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ufpublic work until acceptable evidence ofconiplianne with the insurance
requirements of this chapter have been presented to the contracting authority."
-applicants
Please till out the workers' compensation affidavit completely,by checking ilia boxes that apply to your situation and if
necessary, supply sub-contractors) namc(s), address(es)and phone nuatibar(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 does 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
scif-insurance license number on the appropriate line.
City or"rown Officials
Please he sure that the affidavit is compietc:nd printed legibly. The Department has provided u space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pl.asc be sun:to fill in the pernitilicense number which will be used as a reference number. in addition,an applicant
that mart subunit multiple penniti'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 uffidavit that has been officially stamped or marked by ilia city or town may be provided to the
applicant as proof that 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.c. it dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he t)I lice'tit Itive.irlgations would lake to diank you in advance last your cooperation and should you have any questions,
plca,e du nut hesitate to give us a call
f he Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Iovesttigaidons
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax H 617-727-7749
www.mass.gov/dia
Jr r
`6 CITY OF S.UY.M, 1LL-kss icHUSETI'S
BUIXILYG DEPARTMENT
120 WASHNGTON STREET, 3""FLOOR
` TPL (978) 74S-9595
FAX(978) 740-9846
KlatBEAL.EY DRISCOLL
MAYOR Tm usST.PmRast
DIRECTOR OF PLBL C PROPERTY/BUTEXI IG COMMMIONER
Construction- Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition.of the State Building Code, 780 CMR section l l 1.5
Debris,_and-the-provisions-of MGL-e-40�S 54;— --- -----
Building Permit k 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
l 11, S 150A.
The debris will be transported by:
l W tWV60V
(name of hauler)
The debris will be disposed of in
r^
f a6LK2 �
(name of facility)
(address of facility)
Zia
gnature of permit applicant
33t l�
hate
CITY OF S.ULE.�I
PUBLIC PROPERTY
DEPARTMENT
lu,u.aaar oeurrn�
v..rae i so vss�o�c.�anaar•swan w+uoa,ms of•-o
tti rs.ris•ss�s• r•..a.+��r+o.sw
HOMEOWNER LICENSE EXEMPTION
Pfeess filet �
Due
Job Loeados l �i vtrt 51
Home Owner Addrese KQ 1? ,rr.,—styr-e
Home Owner Telephone u t 4 a
Pneeaot Mnifng Addiae ttp 12, ur�r St Heed
no current exemption of"Homeowners"was extended to inchtde owneroccupied
dwellings of two Units or leas and to allow such homeowners to engage on individual for
him who.does not possess a lic nz%provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Pasco(s) who owns a pared of land on which he/she resides or intends to reside,on
which there is, or is intended to bq, a one or two family dwelling; athched or detached.
structures accessory to such uss and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Omciak on a foam acceptable to the Building
Official, thu he/she be responsible for all such work performed under the Building
Permit
The undersigned"homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATLMI[, ,
APPROVAL OF BUILDING INSPECTOR
See other side for state code