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2 ROOSEVELT STREET - BUILDING INSPECTION
The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPA USELITY Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date A plrAM ed: 1 Building Official(Print Name) Signature _ �re :. SECTION 1: SITE INFORMATION 1.1 Property Ad ress((''� 1.2 Assessors Map&Parcel Numbers 8 FI.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: p IM � a Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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 isposal System: Publio Private❑ Zone: _ Outside Flood Zone? Municipa!-� On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. ppwnerr f mri�1, Record: ,�hn 12� rd: N�ia ie Pnnt) q City,State,ZIP '7 Of A � in�tezA� c� No.and Street Te E it A estldsss SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition AL Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Pr osed Work': U , G r D✓'G V , a SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 'Z (,S b d 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (14VAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 0 Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ,E , License Number toDte Name of CSL Holder List CSL Type(see below) o.and Street Type Description �/� („ O`q -t ,(� Unrestricted Buildin s u to 35,000 cu.ft.) CJfA State, kI ,, 1 V R Restricted 1&2 FamilyDwelling M Masonry RC Roofing Covering WS Window and Siding / ( SF Solid Fuel Burning Appliances (eku;y{�.AACaP 'j e- 1 Insulation Tele hone Email address I t D Demolition 5.2 Registered Home Impr vement Contractor(HIC) h 6 Q Z 0ci 21 � C�—`-L�#' HIC Regis`tration Number � ILxPirlfitioA Date HIC om�a�v Name or IC Registrant e ,, 3n Street� 0670 6 q 0 �Sv Email address i w/Ton, State,ZIP 7Telep�ne 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 .......... 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 er-V) to act on my behalf,in all matters relative to work an rized by 's building permit application. 6 -16 - 6 Print Owner's N e(Electronic Signature) Date SECTION 7b: OWNER'O 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 theist application is true /and accurate to the best of my knowledge and understanding. Jam— lie V� �k 11-' ! Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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(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 can be found at Information on the Construction Supervisor License can be found at 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) 3(-X> (including garage, finished basementlattics, decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths Type of heating system Number of decks/porches f Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealt/t of Massachusetts Department oflndustriaiAccidents I Congress Street,Suite 100 Boston,MA 02114 2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNMING AUTHORITY. Applicant Information Please Print Le bl Name Business/OrgamiwtionQndividual): /-1 Address: IS— F�(M` City/State/Zip: 4� 4A 097 Phone#: Ewipmfim an employer?Check the appropriate box; m a employer with e�loYees(fidl and/or �Pe of project(required): time)' 7. ❑New construction m a sole proprietor or partnership and have m employees working forme in MY capacity.(No wodcera'comp insurance required.) 8. [:]Remodeling a homeewner doing all work myself.[No workers'comp.imurance required.)t 9.,r❑Denlolit10I1 a homeowmr and will he hiring conracton lo conduct all work on my property. I will I OIl"J`-molding addition ra that all contractors either have workers•compensation insurance m are sole 11.Q Eleci l repairs or additions rietor with m employees. 12.L]Plumg repairs or additions am a general conaactw and I have hired the subcoahacmrs listed on the attached sheet. e subcontractors have employees and have workers'comp iasuance.J 13.❑Roofairs re a wrporatim and ib officers have exercised their right of exemption per MGL c. 14.❑Other§1(41 and we have no employees.INo workers'comp.imu•ract•required.] 'Any applicam that checks box#1 must also fill out the section below sho wing then workers'ceconvectim gust s bmit a lion. t Homeowners who submit this affidavit indicating they are doing a9 work and than him outside convectors muse submit a new affidavit indicating such. tCm&acton that check this box must attached an additional sheet showing the mere ofthesuh-cofactors and state whether or not thox entities have employees. Ifthe subcontractors have employees,they must provide thew workers'comp.policy number. I am an employer,that is providing workers'compensation insurance for my employees Below is thepolicy and job site Information /� Insurance Company Name: A 140 C ( �i a, le-- Policy#or Self-ins.Lic.M a O / t) q 0 S v b Expiration Date: ,� / ]ob Site Address:__Z �r�Se LG/f GSty/State/Zip:b-(J,(,L�^ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un r th am aand pennahies ofperjury that the information provided above it tr a and correct Si ature: �c _ ate- 2 Phone M Ofcial use only. Do not write in this areq to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle 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 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 a joint 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 iepair 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 fill 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 certificates)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 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 self-insurance license number on the appropriate line. City or Town Officials 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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill 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 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02 1 14-20 1 7 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 2 Roosevelt Rd Plot and Floor Plan Sapm, MA 23 Ovmen John Nomeman Cnn[nc[ac Jef Gr'varml 5 Sum Area By Label : 0 s' VVV 15 4 B E ' 15 F F L= 1064 f OTC 19? BW= 1064 / 27,%?2 ENT= 24 20 ti o? 30 9 _ W D K= 180 •very ,``} Sv ,or EFL = 183 27 jp8 L V 27� 3 SF - 936 9 SFL 8 , s Se` FFL S {12Q9 A—' f 16 �ojf� _ Owl' FFL �7-f70 11 BMT v jj 2 MO g 's °o slab 2 15 6E13 15 2\ ` �4 !, rs f y 2 Roosevelt Rd Combined Plot and Floor Plan 2�Q, M l O` O Sakm, MA Owner: JOM Gm r n Co nnacror: lef Grmarml 27iOqP8 57. roo 0 Q s� �&Z27 �o I) O 119%70 27;W,0 f 7sQ�fig �S �o© 27� 8 2� �8� Salem,MA 2 Roosevelt Rd Example Contractor: Jef Grvwrml gull L000� 1 Salem, MA Owner: John Nmrrtman ::8: Porch Dimensions ont actor: left uml ao 13" 15t7w a �T - j 0 f 23'8" 7" Lei i a 10" S R065CVM Pd Salem, MA r,` Ovmer: J^hn Nmr�eman Framing Deck ^tm«w: lef Grinarml TFL 3'a8'Ie1� f3]o^":g"pbt bnxa xtammro �s' cnt¢ u'rxbboxd edsnngsl"wan xtxbm to txlw rtf�nd Via bore and nmAt soles rcb pbt h.Wx Fj 1 i - gbll I - _ -- - - z':a"Jnmpht Babb 15113"1o¢a yomvb¢i@40"Dsy w/owhp0ing pmol z v.et pd Salem, Ma Owr�ec Jahn Ni�wman Framing Roof Cent ct�r: JefGrmaml �5 i x poor orcm If: 3 l v8-wm Coatl xtxhel wnn 4'6gsoeuz Inro tM1etlm Jontonthes—"lmr. rxta:.re'on CTtB rt[sM1tl b t I I h,t w hM1NK[ 77 17 8:'ve'xm 222"xVJ1 RxtaS ICI xocs; 9' 2 Aaoee¢e2 M Elevation Overview MA O.r: John Nm..an Contractor: Jef Gn.rml Roof Pitch: 2'% 12or13' 3' -714 0 , 10 S'pOn "9'0 40" 21"� - 23,8„ 2"x10"L Wboard attar EMOSe`Ie� w„„4•Xw�,;tot„,� Framing Elevation 5aem, A to or th...d flmr. Ovmer: JOM1n Ninrleman Contractor: Jef Griwrml Roof Roof or \ 2 tt/12 or or 13° 3%/120r 13' / 2"x 8"RYtm 4".board 2"x 4'frmlrgto rar fzM%" bW board MI, 3"xe"Bmm�z3�.1 r..W Inb Pon Post Trlmm d outto7 x?' 2".1o"t 1p board Po#gaenim attar Wto Wnlogsnl w„b steel 4"I�goh �oare Ill_/ z"Ya•gem cY z1 1—mmm Ino POST 2"z8"Xaip 3"YB"lark[ .rt 6"z6"Post w 2"x4'bbcdngfor: 1:"foots smrtieefp4a oaq / s \ _&/ § � . w . � . \ �