2 1-2 ROPES ST - BUILDING INSPECTION (3) The C'onunonwealth of Massachusetts
Board of Building Regulations and Standards C1 FY OF
Massachusetts State Building Code. 780 C•MR SALEM
Building Permit Application TO Construct, Repair. Renovate Or Demolish a
One- or Ttvu-Famd.V Dnrelling
This Section For Official Use Only
Building Permit Number: _ Date Applied: _
"wl.t�u, LvTTz-Vrkvc� 1 A
Building 011icial(Print Mania) Signature Dale
SECTION I:SITE INFORAIATIO
1.1 Property dress: 1.2 Assessors.Nap& Parcel Numbers
6 13 S T
I.la is this an accepted street?yes no Map Number Parcel Nunnher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Imposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage�Disposal System:
Public t� Private❑ Zone: _ Outside Flood"Zone? Municipal E 0n site disposal a stu
Check if ycs❑ y 'n ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
�L-) �Gr'1 Sr m,PSo n
Name(Pant) City.Stale,ZIP
2 1�2 9,0,P S T
Nu.and Street Telephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Numberof Units_ Other ❑ Specify:
Brief Description of Proposed work': Tl is C !'eA o
$Itlriaa Shin9/rl' ton not Sr` u�- ho✓SC_
SECTION J: ESTIBIATED CONSTRUCTION COSTS
Item Pff7nF
:
ls) Official Use Only
I. Building I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical ❑Standard CitynTosvn Application Fee
❑Total Project Cost't Item 6)x multiplier _ x
7. Plumbing '. Other Fees: Sa. .\Icch;utic.II 111\' 1('1List: — ---l IFin .----- —'- -__ _ionl Total \II Fees: S ___Check Nu. _('heck Amount Cash \mount:
Total Project Cost: ❑Paid in Full ❑Outstanding Bahmce Due:
S '
SECTION 5: CONSTRUCTION SF.RVICF.S
S.1 (bnstructimt Su ren'isor License(C'SL)
License Numhcr f\pirnion(late
N;unc ol'C.til. I lulder
Zeq';T rn �Y� Ii.stC'SI. 1)pc(see helow)
�D------- -------_..--- ----------- 'I)pe Description
No and.`(rect
It I Unrestricted(Iluildin gs li l0 15.000 ol. It
Restricted I:CS Famil) Melling
Cigifoen..titule.Lll' SI �lasun
RC' Rlnllin Co%crinit
...—. WS and Siding
SF .Solid Fuul Ilurning Appliances
(s-LrR 1)1) 1 Insulation
'fete hone Fmuil address D Demolition
5.2//R''egistered Home Improvement Contractor(HIC) 1 / / p ? Z S'^ /I_/Z
(9 ,e4 r me (r ( Y IV-- ) IIIC Registration Mmllxr INpirtliun Date
IIIC Compan nName or lilt' Itcgisuunt Noma
D g-S-r( !n �VL
Nu.and Street Fmuil address
C5se v-
Ci /Tow—P fete hone
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 .......... CY' No...........O
SECTION 7a: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.
Print Owner's Name(Electronic Signature) Data
SECTION 7b:OWNERI 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(he best of my knowledge and understanding.
("Df,2 (-/A'aS /, / Q-1 Z
Print 0%%ncr's of Autlanired�\gent's Nance(hlec(ronic Signature) Dale
No'rES:
I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
I not registered in the Hume Improvement Contractor(HIC) Program),will 1 have access to the arbitration
program or guaranty fund under I.G.L.c. 1 4_'A.Other important information on the HIC Program can be round at
„t mr., ,t .% i Information on the Construction Supervisor License can be found at%%wk in.l.:�_o\ .Ip,
2. When substantial work is planned,provide the information below:
Total Iloor area I sy. ft.) - I including garage, finished basement attics,decks or porch I
Gross lis ing area(sq. 11.l _ _ Habitable room count
\wnl+eroflircplaccs.--- Number of bedrooms _
i \umberofbathrooms - . .. _ _ -- \'umberofhalfha(hs .. . . _ -
I')lie of heating i)stem _ . _ Number of decks, porches ..
i
I\lie of o,ollll_4' >Ielll I'Mosed Open
1, "l oral 1'rnject Square Footage-ola) he substituted tirt"Loral Project Cost-
CITY OF SAL&Nfo Akss.ICHUSETI'S
9LUDLNG DEPARTMENT
120 W'kS)'LVGTON STRUT, Jw FLOOR
rM (978) 74S-959s
KIMSER[BY DRIMOLL F,Vt(978) 744984d
MAYOR I}Io.�4Lf StFtEiu
DIREcrOft OP Pl'BLIC PROP E RTY/OL MM NG CO\L%IISSION ER
Construction Debris Disposal Atfldavit
(required for all demolition and renovation work)
In accordance with the sixth edition ortha State Building Code, 780 CMR section I 11,S
Debris, and the provisions of MGL a 40, S 14;
Building permit q is issued with the condition that the debris resulting from
I 11, S I JOA.
this work shall be disposed of in a properly licensed waste disposal racility as defined by MGL c
The debris will be transported by::
(name of'hbular)
The debris will be disposed of in
—_
(name Of facility) _. 1
�le,,1
Wd or ra,�l ty)
�iy eofpermir�ppliunt
A
CITy OF &Uu E.NVI, tiL1SS.ICHL'SEM
Y BUILDING DEP.\RTMEINT
120 WASHIINGTON STREET, 3te FLOOR
TEL (979) 745-9595
FkX(973) 740-9846
KI\IBERLEY DRISCOLL
A•-M& Tuos1AS ST.Pm na
DIRECTOR OF PUBLIC PROPERTY/BU MDr%G CONMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician&/Plumbers
lirnlicant Information Please Print Leaibiv
.Name t0usiltess,Organiratiun,individual): &Fo t Y /Y Jl 91
Address: � ,9 Z4CT2-rh A ye, p
City/State/Zip: 5 L:L Z f MR 012 24 Phone le: d/� 02 O f S— l? J � 7
Are you an employer?Check the appropriate box: 'type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6.Type
New,construction
employees(full and/or part-time).' have hired the sub-contractors
2.[` ,1 am a sole proprietor or partner- lived on the attached.sheet.t 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. 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 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL ME] Plumbing repairs or additions
myself.(\a workers'Gump. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers'
cum.. insurance...... 13.❑ Other
I Any applicant due chocks box rl must alw fll uul the suctiue bulowshowing their workeri compenudun policy inlurmarion.
I hvneowtwvx who sabnnit this atiltlavit indicming they am doing all work and then hit;outside contractors trial auhmit a new anfdavit Indinling such-C,mwwors that chuck this bux must attached an addiliurad wheel showing the notne of the mb-conlruWm and their workers,wmp,policy inromulion.
fain an.earpluyer that is providing workeri'compensation Lrsuranee for my employees. Below informadoa /s the policy and Job site
Insurance Company Name:
Policy N or Sclf--ins. Lic, 4: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaratlan page(showing the polley number and expiration data).
Failure to secure coverage as required under Section 23A of sIGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 tine
of up to S230.00 a day against the violator. lie advised that a copy of this statement may W furwarded to the 011ice of
Invcsligatiuns oldie DIA for insuran///ce coverage verification.
I d e'eo hereby the pu( rd penuirles of perjury that the fnfurmution provided ubuve i.v true and c•urreca
si'Imilllrc' /�^—
OJJicial use mdy, Donor write in this area,to be completed by city ur town ajffcia1
Cityar lawn:
PermitI7.Icense,Y__.
Issuing Authorily (circle onc):
L Board of INalth ?. Building Department .1. Cityi town Clerk 4. Electrical Inspector 5. Plumbing brspeetor
6.Other
i CufnlaGt I'ersun:
(
Informati®n 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
uwncr 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 fill out the workers'compensation alTdavit 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. 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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/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 ctc.)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
fhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofllce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-7274900 cxt 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05
www.tnass.gov/dia