47 ROSLYN ST - BUILDING INSPECTION The Commonwealth of Massachusetts
�• I`. ,� Department of Public Safety
� Vassachusa•lts State Budding Cude 1780 C�1R)Se%enth Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwellin
(This Section For Official U.se Only)
f Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block N and Lot N for locations for which a street address is not available)
No.and Street Citv Town Zip Code Name of Building (if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here or check all that apply in the two rows below
Existing Building ❑ Repl- I Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: 42
'e
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): — Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ - A-4❑ A. ❑ B: Business ❑ - E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-IO R-2❑ R-3❑ R-4 ❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA too IIA ❑ IIB ❑ IIIAO 11160
IV ❑ VA ❑ VB ❑ .
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone information: Sewage Disposal: Trench Permit: Debris Removal:
PP Y
Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will nut 6e Licensed Disposal Site❑
required ❑or trench ur,pedfc:
P[1%'ate❑ ur indenlif% Zone: or on site,%'stem ❑ permit d 0ise Or t rd ❑
Railroad right-of-way: Hazards to Air Navigation: %IA IG.Inncc nnmi„i „ Ko,6++ I'n r,..;
Not Applicable• ❑ L Stro"mi,t%,%hut airF+net approach arc•,%' Is their re%'ic%% Completed'
ur Cun,enl 1„ Rudd l-116"ed ❑ Ye, Cl ur No❑ Ye, ❑ \'n ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
li.lntnn ul C site•: L,e Gwtjpl,l: i%pe of Cunatrucunn: Occupant Lo,id per Flnur:
[),w, the building omminan Sprinkler Sc,lem': SpeClal Stipulations:
r s
9
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
.Name(Print) No.and5treet City/Town Zip
Pruperte 0%%ner Contact Information:
Title Telephone No. (business) Telephone No. (cell) a-mad addreNs
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip "
to act on the pro arty owner's behalf, mail matters relative to work authorized by this building permit application. 1f
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,L)OU Cu. ft.of endosid space and/or not under Construction Contrul then check here O and skip Section 101)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cu an Nam G f
ame of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town - State Zip,
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152. 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? - Yea O No 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
l..Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor) =$_.
-
3. Plumbing $
J. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enchvse check payable to
6. Total Cost - $ �•O J (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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 lrue.md accurate Ur the best of my knowledge and understanding.
lPlea�e print and sign name fide Telephone.No. Date
';ticel Addres Cit% Toren State Zi
Municipal Inspector to fill out this section upon application approval: Q
\'ame I7 to
+ CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I hut:a:f 1•:)NISCt-I 1.
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l'iA;978-743.9595 Is F%x. 97g•74C•9346
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
%onlicant Information Please Print Leeibly
VaITC IOutuhavtlr�ani�alinNlndrvtduul):
Ciry%Starc;%ip: Phone #:
Arc. to an cutployer? Check the appropriate box: Type or project(required): -
1.LE I am a employer with 4. Q I um a general contractor and 1 6. New construction
employees(full and/or part-time).• have hired the sub-contractors
_.❑ ! :can a sole proprietor or partner-
listed on the attached sheet. ; 7. Remodeling
ship and have no cmployccs These sub-contractors have 8. ❑ Demolition
working for Inc in any capacity. workers' camp. insurance. 9. 0 Building addition
I No workers'comp. insurance 5. 0 We are a corporation and its
required.)
ofricers have exercised their IO.0 Electrical repairs or additions
3.0 1 ani a homeowner doing all work right of exemption per MGL I LC] Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no I2.0 Roof repairs
insurance required.j r employees. [No workers' 13.0 Other
comp. insurance required.] -
•Any.�,pbcaul Ilmt chucks box III must:dsu till uut the section Wuw showing Choir wotkui cumpunsution policy inturnu tiors
'Ilumcowncrs who sobtnil this aOWavit indicating they are doing all work and Ihcn him outside canracton mual.uhmil a new affidavit indicating vlch.
-C\mtracn,rs Thal check this box mWtt anxhtd an additional..hail..hawing the mmno of the sub�contracton and their wurken'comp.policy infurmatiun.
/dnr an catpluyrr drat La providing rvorkers'comprn.auinn inr(grnnre jar dry enhp/uyecs. Behnv is the pu/icy and job sill
iujdnnutidn.
In,uranceCompauyNmne: _ __--._-----__--
Policy is or Sclf-ins. Lic.tf: __.. .. .. _._ Expiration Date:
Job Site Address: _ C•ityt5tate/Zip:
Al tic Is 11 cupy ofthe workers'compensation policy declaration page (showing the policy number and expiration date).
failure to secure coverage as required dotter Secliun 25A ul'}IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.5110.00 and/or one-year imprisonment, as well as civil penalties in the I•orm of a STOP WORK ORDER and a fine
of up to S250.00 a day aguinsl the violator. He advised that a copy of this smteirwril may be l'urwarded to the Office of
larr,tjgjiwns ul the 0IA t'or insurance coverage\crilicalion.
Ida herchy certi r larder thelMiinns weedd pena/ties u/'perjury that the injunnullon provider/above is trite(gild correct.
Si• :wwre' _ Date• 9/a 7//0
O[/icid/use duly. Do not n•rite in this area, to be completed by city or town official
City or l'own: .._ Pcnnit/l.icvnse 0__
Issuing;Aulhurily (circle one):
I. hoard of I le:dth 2. Building Mp:lrtincut .1. Cilyi fog\it Clerk 4. Llectrical lnspector 5. Plumbing; Inspector I
6. 01hcr
Canlacl Tenon: _- -- Phone B:
r r
1
Information and Instructions
..\Iltssacltusetts Cenral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplorea is defined as"...every person in the service of another under any contract of hire,
.xpress or implied,oral or written."
.\n employer is defined as"an individual,partnership,association,corporation or tither legal entity,or any two or more
of the toregoing 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 repair work on such dwelling house
or od the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL 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. NIGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the per fomtance of public work until acceptable evidence of compliance 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 the boxes that apply to your situation and, if
necessary,supply sub-contractor(s) name(s), address(es)and phone nuntber(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 sore to sign and dale the affidavit. The affidavit should
be retuned 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till nut in the event the Office of investigations has to contact you regarding the applicant.
111-:ase 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 ponniu'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.
1"hc d)ftice it Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please du nut hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'Ce1. 11617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Ravi>cd 5-26-05
www,mass.gov/did