8 SABLE RD WEST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Number: Date Applied:� /Signature: - /0 1 l rP ` D V
ILO
C\y\{f\ Building C issioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
IJ Pr pe ty Ad res Wes/
Assessors Map& Parcel Numbers i
L 1 a is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fit) 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 Disposal System:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal's On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[ _
2.1 Ownert of Record:
Name(Print).i s \ Address for Service: /
SigiTe Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) Si Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: A';&Lei, J:+,'sN04-
BriefDescripfionofProposedWorkZ: e J e. eA7,
r / ce �'e r, JN o:.tl � efcar�r' r/z�,,./�/,-/� e� w [:�:<ir�r-- ^n� r. /✓L�1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building g O O 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g r ❑Standard City/Town Application Fee
��J p� ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 0 D 0 2. Other Fees: $_
4. Mechanical (HVAC) $ List: �'J�) ( (/(✓
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ SD(� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1LLiicensed Construction Supervisor(CSL) 01/Z/c:�>
/�'/iC�y F,/ GF]<sdl,✓'h License Number Expiration Date
Name of CSL-Holde
-/ AC/ � I List CSL Type(see below) V
Address cJ T e Description
i U Unrestricted u to 35,000 Cu" Ft.)
•�/' R Restricted 1&2 FamilyDwelling
Signature M Masonry Only
1171,- RC Residential Roo tingCovering
Telephone WS Residential Window and Siding
SF Residentia! Solid Fuel Burning Appliance Installation
D _Residential Gemuiitiou _
5.25.2 t4 rgtg stered Home Imprgvement Contractor(HIC) c�-
/?.��/ors% tioi
Hie Com any,Name or HIC Registrant Name Rcgietralloti Nwnbri
Addres
$igna re Telephone _
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT LVI.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted wide ibis appli• itioa. Failure to provide
his affidavit will result in the denial of the Issuance of L'te building permit.
Ir`lened Affidavit Attached? Yes .......... k(„ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, j G� as Owner of[he subject property hereby
iauthori-e �7 a ef oo���:n_ _to act on my behalf, in all matters
l -^lative to work authorized by Ihie huiiing permit application.
Si alur 'of Owner ----- Date
I SECTIO 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
r1, /'✓]ie C—L G n�ak " ,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
behalff.�.��ff.
/C/iGLt,Gj E'/ Goren e/,L�Jn'iz
Print Na e
Signature of Owner or Authorized Agent Date
Si med under the pains and penalties„f perjury)
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(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total Floors area(Sq.Ft.) (including garage,finished basemenuattics,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 SALEM
f
.,. s PUBLICPRc�PRERTY
It
DEPAK"I'tiIENT
1i'9 V: ,ib-
Construction Debris Disposal .affidavit _
(re\luircd li,r all demolition :md rcnu\mion work)
In accordance \%ill, the sixth edition of the State Building Code, 7%("KIR section I I I S
Debris, and the provisions of IvIGL c 40, S 54;
Building Permit t is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by V1GL c
111, S 150A.
The debris will be transported by:
t name of hauler) ., -
I he debris will be disposed of in
A f'Jt nainr u(faulny)
taddrra� ,;f I]cililvl ��
.;gnawlo of pennu .lphh.aul . . . . .
date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
V P.;M f I' M h(.,-1 1
I.I oa ILL W,weur,(:nt.\S l:<LL 1' • SAtfM,MA\S\(.Iu ill n31`)7-�
TLI: 978.7ii9595 • f.tx 978-741'd1846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
> ylicant Information ,�ram�/ Please Print Leeihly
Naint lBu,ute,vl�rganvatinNlndtviduull: 11/ 4"c G/ �cr� dC✓)h
Address: led
Ciry,Stale,%ip: L Oylii7�o w� Phone il: 91?V ZZ,-z3-
Are you an cuiployer? Check the appropriate box: Type of project(required):
1 ,® I :un a employer with�
4. ❑ 1 neral Colllr:telOf and t New construction
. . _ urn a ge 6. ❑
cntpio%ecs(full indi'ur put-tin,c).• have hired the sub-contracture 7. ® Remodeling
2.❑ I ❑m a sole proprietor or partner-
listed on the:coached sheet.
ship and have no employees These sub-contractors have K. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q, ❑ Building addition
[No workers' comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
I required] officers have exercised their
light of exemption per MGL I I.❑ Ptumbing repairs or additions
3.❑ i :cot a ho o owner doing all work c y152, i 1(4),and w have no
myself. [No workers' comp. � 12.❑ Ruul'npairs
insurance required.) t cinployces. [No workers' 13.0 Other
colnp. insurance required.l
•M. .,pphc4ul thus cheeks box 01 must also rill Otte the sectma i,eww ihow10a their workGx',unlppniauivit pulicy inliurrweiu2
' I6rmeuwtwn who wbmil this atlldavit indicating they Ate dying all.Turk atMl then hire umside vomrxton must euhmil a new al'f,lavil indiubng such. _
-Cememm�that dteck this box man(aaachcd an addlliooal..fuel+hawing the name of the
sub:ontractyrs and that wurken'eontp.pu6cy mfurmatiun.
/urn cot employer that is pro vidinq ivord'ers'cmupcnsntiou insurance jar my employees. Below is die policy and job.vite
htfonnatioes. / {
Insurance Company Name: C0,7 ,;e"i _a
Pulicv 4 or Scif-ins. Lic. r: S y0a' 7 9�50` . ...__— Expiration Date::'��'�%�
Job Stie Address: 5 .S 61 xi Lve .71 Clly;slateizip:
Attach it copy of file workers'compensation policy declaration pale(showing the policy number and expiration date).
hailure to secure coverage as required under Section 25A of>1GL c. 152 can lead to the imposition of criminal penalties of 3
ring up to SIS110.00 and/or one-year imprisonment, as evcll as civil penalties in the fuon of a STOP WORK ORDER and a fine
of up ut S'_50.00 a day against the violator. Ile advised that a copy of this statement may be furwardcd to the Office of
lu(csu,am nb ul the DIA :or o,ur:uxe ,ancragc tuitical;on.
I do hereby terrify under tthe pains lied penallie-v
iedpenrdtics ofperjury that the information provided above is true uud correct.
U/jiciul use only. Do not nvhter in this area, to be completed by city or relives o/jitiul.
('itv or Town: __ Permit/License 0._ ..
Issuing Atalhurily (circle (ene):
I. hoard of llcallh 2. Building Deparuncat J.City:-futtit Clerk 4. L•'lectrical luipector 5. Plumbing; Inspector
6. Ol her _.
t
Contact ftrnun: _ _ phone r:
Information and Instructions
.V;15i.Ichusetts General Laws chapter I i2 requires all employers to provide workers' compensation for their employees.
Punu;ult to finis,tatuic, an einplgree is defuud as "...every person in the service of another under any contract of hire,
cypress or implied, oral or written."
An employer is defined as"an individual, partnership, associatiou, corporation or other legal entity, or any two or more
of the t regoing engaged in a Joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee ul as, individual, parnlership,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."
.IGL 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, :NlGL chapter 152, §25C(7)stiles"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomlance ol'puhlic 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 cerlificate(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 rentmcd to the city or town that the application for the permit or license is being requested, not the Department of
I ndustrial 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'rown.Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at Lhe bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
PlL asc be sure to fill in the penni0icense number which will be used as:r reference number. In addition,an applicant.
that must submit multiple pennitllicen-se 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
tuwnl." 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 he filled out each
year. Where a home owner or ciliZetl is obtaining a license or permit not related to any business or commercial venture
(i.e. it dog license or permit to bun leaves etc.)said person is NOT required to complete this affidavit.
I he i)flied of Investigations would like to thank you in advance fur your cooperation and should You Ila\'C any gUCstluns,
please do nut hesitate to give us a call.
fhc l3 partment's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
i
Board of Builing Rc6o6s and S d urd
S Construction Supervisor License
License: CS 81670
Birthdate: 8/8/1965
i Expiration: 818,2009 Tr# 3685
Restriction: 00,,
A MICHAEL F GOOD WIN
7 HOLT RD
` EPPING,N_H 03042 Commiuioner
.�\ Board of Building Regulatiof,s and Standards
HOME tMPon: 105 29 CONTRACTOR
Registration: 105029
Expiration: 7/16/2010 Tr# 271296
Type: Individual -
MICHAEL F.GOODWIN JR.
Michael Goodwin Jr.
7 HOLT RD. p ...�.
EPPING, NH 03042 Administrator