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5 RIVERBANK RD - BUILDING INSPECTION (2)
Y The C'omntunwe;dlh of Massachusetts �1 y, '� l Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 C NfR SALLM Building Permit Application To Construct, Repair, Renovate Or Denwlish a One-or Tuvr-Funnl , Dn ellinkr This Section For Official Use only Building Pernlit Number: Date applied: Building 0117cial(Print N;unc) Signature Date SECTION 1:SITE INFORMATION I.I Property ddress: 1.2 Assessors Map& Parcel Numbers F 1.1a is this an accepted street?yes n Map Numher Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: a ) Zoning District Irmtposcd(119 Lot Area(sq It) Frontage(it) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.e.Jn,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check iY us❑ Municipal❑ On site disposal s)stem ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: i i GAVTd/F'IR- �>9/'F 4 , mune(Prim) City,State,ZIP S_ �X'; VJ50-6 4ru/< i�K_ 9P; -AOY-00/e C N�2�1� .Z— (a AaL .C©t,~ Nu.and Street Telephone Entail Address SECTION J! DESCRIPT N OF PROPOSED ORKs(check all that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Specit'y: Brief Description of Proposed Work-: 0z 2�v6 FLCoie, WIZA x 6 fi ry z✓y srsTaL� d K SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: ILabor nd Materials) Official Use Only I. Building S Q 0000� 1. Building Permit Fee: f Indicate how fee is determined: '. Electrical S /O�' ❑Standard Citffosvn Application Fee j �. Plunihing S ❑Total Project Cost'(hem 6)x multiplier pe'o. _'. Other Fees: S ((�� J, \lah:mical il11�.1('1 S List: l6 - ' ?. \Ieehanic;tl IFiro _ ___ _ Suppression) S Total .\II Fees: n. Total Project Cnst: 5 ��pQ©_.� Cheek No. _ _('haek Amount: _ - (',tsh \molars: / ❑Paid in Full 13 Outstanding B:d;mee Due: SECTION 5; C'ONSI'RIICTION SERVICES 5.1 Construction Supervisor License(C'SL) 7 GJ6 License Nunthcr I vpua ion D;oe Na11e tlf C'S1, Holder I is(C'SI. 1')pc(see 110010__--_"--.-- �__� ---- 'I)pu Mscriptiun No, and.Street /C? I I hlreslricmd 1 DuilJin�s ti la 15,000 ul. ILI /�f b " H NmlricicJ IX2 F:unil) Dttcllin Cityil'oa n,.Slate. .IP -- M1i Mason RC R\wlin Covvrin µ'S Windo%v old SiJin SF Solid Fuel Burning Appliances I hlsulation cic hone Fantail address D Denwlilian 5.2 Registered (tome Improvement Contractor(HIC) _ I IIC Registration Ntunher Expiration Dale I IIC C'onlpan) Name or I IIC Registrant None No.and Street I Inail address Ci /Town,State,ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.11 C. IS2.4 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 Is ante of the building permit. Signed Affidavit Attached? Yes .. " ..... ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE C0111PLETED 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 Ownie s Nane(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby att4undcrns nd penalties oCperjury that ail ot'the information contained in this application is true anal as ny knowledge and understanding. Nantc I ltu) Date NOTES: i. .\n Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractur (not registered in the Hume Improvement Contractor(HIC) Program),will 1 have access to the arbitration program or guaranty fund under M.G.L.o. 1 1_'.a.Other intpurtant information on the HIC Program can be titund at \\\\a ni,t,, ,v.t Information on the Construction Supervisor License can be found at p\\,k.ni.1,; fir\ .111'. 2 \\'hen substantial work is planned,provide the information below: Total flour area 1 iq. B.) _ _—____1 including garage. finished bascmenCattics,decks or porch l Gruis lk ing area(54. Il.I _.__ Habitable room count \umhcrof fireplaces .--- Numberol'bedroonls Number ofbathrooms _ . . Number of hall'halhs .. _ . . . I)lie of heating is dent Number of decks, porches I'ncloscd Open i I\pe ol'cnoling iv deal - "' t. "C,dal Project Square Foouage"alas be slibstittned liv"Foul[ Project Coil" CITY OF SAiZlls lVL1SSACHUSETTS BUILDING DEPA&T\LE.\T 120 WASHCJGTON STREET, 3"o FLOOR `�:\• TEL (978) 745-9595 Flix(978) 7 i0-9846 KI.\rBE_RIEY DRISC011. —116YOR THoxsls ST.PIEARS DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMISSIONER Workers' Compensation insurance Affidavit: Builders/Contractorg/Electricians/Plumbers Applicant information Please Print Legibly .VatnC tl)usiness,Urganiraliorolmlividual): �i�a� �T/cQy/ l�-C/1/�Q.A� f_QJ[T�N�N� Address: 19S 2/V74r2i/er)L� City/Statt:/Zip: sk�-pyt Phone N:_22Le oil-0dJ Are u an employer?Check the appropriate box: Type of project(required): I. I am a employer with_-':?_ 4. [] I am a gcnLml contractor and 1 6. cw construction employees(full and/or part-time).• have hired the sub-contractors 2.❑ lam a sole proprietor or partner- listed on the attached sheet. I ?• (Remodeling ,hip and have no employees These sub-contractors have 8. C] Demolition working for me in any capacity. workers'comp.insurance. 9. Building addition (No workers'comp. insurance 5. [] We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MOL I LC]Plumbing repairs or additions myself.[No workers'sump. C. 152, §1(4),and we have no 12.[] Roof repairs insurance required.]t employees.[No workers' I3.❑Other comp. insurance required,) 'Ally applicant dw cheeks box rl mays alw rill oul the aectioo bclewahowing their workers'compsmadon pulley inWrmutton. 'I hwvownen who ruhmil this ilf1davis indicating they am doing all work and then hire outride conlmetors mast suhmit a new aflldavii indicating ruck :Cenuxlurs that check this boa must mach d an additiursd.heel showing the narno of the subtoniticton and their workm'wrap•policy infemtntion. i um an employer that is providing workers'cumpensailon insurance jar s y my earleyeex Below s injoraralaa idu po/Icy andfah site Insurance Company Name: 74P7 "S I'olicy,4 or Sclf-ins. Lic. 0: MA W c9 no Expiration Date: ✓J � /r — ,^^ Job Site Address: 67 V� IV l�!K � Cityistute/Zip: SA L�4'1 Y lr k...'- . Altacb a copy of the workers' compensation pulley declaration page(showing the policy number and expiration date). F3iluru to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Mina up to SI.500.00 and/or one-year imprisonment,as well as civil penalties in the corm of a STOP WORK ORDER and a line Of up to 5250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the OfIicc of Investigwiuns of dtc DIA ror insure I coverage verilicAtin. i do hereby Cerri er d p lid it saides of perjury that the infunnutlo+r provided ubuve is true and correct. Si r,tt u,ltd: 1614ili icialuseuuly. Du not write in this urea, to be compieted by city ur town n/Jirialnr lnsvtt: _.. _. __ Permit/l.icense ft ingAulhurily(circle one):ourd of Ilcalth 2. ❑uildim,2 Dcparmtcnt .I.City%fawn Clerk 4. Electrical hnpectur 5. Plumbing Inspectorther iContact Person: _ . ._ Phanc l Information and Instructions Massachusetts General Laws chapter 152 requires 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 employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,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 any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please rill 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 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 date the affidavit. The affidavit should he 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. Sclf-insured companies should enter their self-insurance license number on the appropriate line. City or Town Ofilcials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to till in the permitilicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicense 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 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for 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 Ofilce of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 2cvi;cd 5-26-05 www.mass.gov/dia CITY OF SALEM, Aus kaiL'SETTS 9LtWL14G 0EP.1871tLVT 120 W.kj.4LYGT0N STRE iT, J'OIZOOII PM (978) 745.9599 KIMBERE Ey DIMOLL FAX(978) 740.9846 MAYOR THo.+W ST.F>FRltlt p DIRE.CTOIt OF PLgUC PROPERTY/gL:mDL,4G CO-%L\IISSIONE)t Construction` Debris Disposal Ah7davit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l I.5 Debris, and the provisions of MCL a 40, S 54, Building Permit M is issued with the condition that the debris resulting from (his work shall be disposed of in a properly licensed waste disposal facility,as defined by NICE c 11 I, S ISOA. The debris will be transported by: (name of haular) The debris will be disposed of in (name or fac+liIY) Oddress of r,,+lay) + dnanrreolperm+tipphc�nt dife �—