0000 WASHINGTON SQUARE SOUTH SALEM COMMON - BPA-12-67 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised.Ilar 2011
IA Building Permit Application To Construct, Repair, Renovate Or Demolish a
W Otte-or Ton-Falp ilv Dicelling
This Section For OtTleial Use Only
Building Permit Number: D to Applied: 12
Building Official(Print Nam Signature Date
SECTION 1: SITE INFORMATION
1 roperty Ad ress: 1.2 Assessors Map& Parcel Numbers
f'r�-. prvv m0(l
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1 Owner'of g�co d:
N:une(Print)l City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of7roposedWork': 1V.5-rr.U1r,5 0rt,- - crrt
—
SIL-rS w W 4
2r2` � /—r '7 i.t-."7A�.- vs:�,-^n_oo E
t7l.J sSil/) '7 tom` ew)Lt e,V
SECTION 4: ESTIMATED C NSTRUCTION COSTS
Item Estimated Costs:
(Labor and \laterials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. ❑Standard City/Town Application Fee
Electrical - S ❑Total Project Cost'(Item 6)x multiplier x _
3. Plumbing S ?, Other Fees: S /�
a. ,Mechanical (11VAC) S List:
S. Alechanieat (Fire S
Su iression) Total \It Fees: S
Check No. Check Amount Cash Amount:
6. Total Project Cost: S / 000. 0 Paid in Full 0 Outstanding Balance Due: -------
k
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction SupervMisor License(C'SL)
MP,t/1 License Numher I:.cpiration Date
Name of CSl. I folder
List CSI.T)pe Isce below)
o.a d Street Type Description
M,RC
Restricted IX?Fantil Dwelling
C'ity(Ibwn,Stave.Z P Masonry
Rootin CovcrinWindow and SidinSolid Fuel Burning Appliances
Insulation
'relc hone Finail address D Demolition
5.2 Registered Home Improvement Contractor(11IIC)
I IIC Registration Number lispirttion Uate
I IIC Company Name or I IIC Registrant Name
No.and Street Email address
City/Town, State,ZIP "rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 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
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) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
y entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Ag4oKs Na ne(Electronic.Signature) Dute
NOTES:
I. An Owner who obtains a building permit to do hisrher 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. 1 q2A.Other important information on the HIC Program can be found at
%%N"%. trca Information on the Construction Supervisor License can be found at .%N_t�.ncu�.aq� '�Ip_
2. When substantial work is planned, provide the information below:
Total door area(sq. ft.) I including garage, finished basemenCattics,decks or porch)
Gross living area(sq. tt.) Habitable room count
Number of fireplaces_ Number of bedrooms -- ----_----
Numberofbathroonhs _ _ _ _ Numbcrofhalhbaths ----------------
l)pe of heating system _ _ _-- __-- Number of decks, porches - _—_--__—_--
l'ypeofcoolingsystenh Enclosed -_- Open
3, Total Project Square Footage-nnay be substituted fix"total Project Cost"
CITY OF SALEM
050Z PUBLIC PROPRERTY
DEPARTMENT
nm.X:I Y:IXIV ul1
\I vli nt
12C \VAHIlMi IN^)I,v CtT it 5,1u•.N. M.i».a.rn Y I nJl vl.'
1'I•A- 0{.713•9393 r p is v7v.)4C•'Ly46
Workers' Cumpenaatlon insurance :Ufldavit: tiullderyCuntractura/Electrlc)anyMlumben
\ 1 lllcrn In unnaflo
p \ Pl riot a m
V;IInCllluure yl)rlan'rninvindrvuluuU:�J3 U ) it
�tldresv: 47,S CRoor �r. Cu r=E 3
City,sr:�rc,Zip-_as-'L ,; IL o19/S ort,
'-'� I hunr il� 7�'/-,3 Off'.
\re I )vu an vulployer:r Check the appropriate boa:L 0 1 ;um a employer with d. 01 illy,a gcnunal contractor and I t)I""(Project(required):
❑ enipluyccx(cull and/or put-lime).• have hired Ilia sub-cunlraciors b, 0 New construction
I and a sole priprichsr or partner- lisrod on the ay,ached sheet 7• ❑ReinodelinS
ship and have no utnpluycv's These subcontractors have
working Air Inc In any capacity. ,vorkero'camp.,nsursncst g' 0 Mmolirion
I No wodturs'cuinp. Insurance 5. 0 We are a emporatine and its 9, ❑Building addition
3.0 requircd.j .07cers have vNimiaed their 10.0 Electrical repairs It additions
1 ant a homa+'vner doing all work right of oaalnpdon par NICIL 1 I.0 Plumbing rcpuin or additiory
mysolf.INO workers'cuinp, C. 132.¢I(i)•and we hnvd no
insurance required.j t cmpluyeea.IKo worker' 12.0 Roul'npuire
comp. insurancenquind.J 1)•OUtltar
•4 nr.,;rphc"X this ghuckudiou hua a man:Jw till uw IM..lebun 41aw'h"wury rhwr wwkini cum
'Iiumw'wrwn.hY"a'nut ihir r/Tdrvii inalu'in r prnt'alun Iwliey ru0un'wi'na
r,rnirwarn 1AM aMre ihir tpa m'w'naI ae a IliiknJ auine'll.vu,and thus him a ssulo cunrnaae,m"I.Ward a nine'lllarvit indivatine uqh,
Jww Jluwin iM r,anw ar am tue.e'eraehre and thew wwlM'amp.P'lKy"itwternw
/am un a ulylayrr/her/r pruviJ/nX merkera'evtnOenm//on Larantare/tJr my rtnp/uyrra Br/ew lr rhr pu/lay un✓/uI alb
- Lt/yrvnul4nt
Invurancc C'untpany Vmne:�_� .. _ .
Ihdicy a or Sclr•ins. Lic.n: — -
Expiration Ditto:
lob SiW ,\ddrt:sr:
Attach is en _ Cllyiswle!zip;
py of the workers'eulnpvnsatltin pnllcy-declarullun puke(showlnq the Polley nunlbvr and expiration date).
1+atlun:lu secure cuveruyt as required midcr Section:JA ui'JIUL c. 132 eau lead to the imposition of criminal penalriea of a
tin,up nt SL.3n0.(x)and/urua m
e-year iwpris,tncnt. as well ua civil pcnalltu in the lunn ofa STOP f WORK URGER and a tint
o up rn '254 rNI a Jay lyuinat the ")"'kir. Ile advi.'cu shut i copy of Chia dutclncnt may be turwarJuJ Ill the Office a a
Inr,ah�aunna uY ilW I11.1 IOr nlvurai'ce:r.Kra}e tCl ilicalutn.
/rlv heresy aerr;/y nrrJar r/rr p'rina rrnJ prnn/iivt vfprr/nry/her the in ur'nvNtrn/• pravided ubuve is true rotd correct
I'I r r: • n v
IrJ!/Iriu/rur ou/y. /)a nor wrirr in Uilr urrur ru be rumpleted by wiry up/onn a//lrivL
r
(!rr or
' - Pcrmibl.ln•nae tl
Ivvuinq .\ulhurity (circle nnc):
I. Ihrardorllra0h ), Ihuldin. Ikp.irnnv'nl I. (:ill•'I'onnC'Icrk J. Lhrtriallln'pa'tur ;, pluwbin
6. 011
y Invprcror
___ I'Anne Y• r
I
. i
i
sill IJ ee 'information and Instructions
rton to the service Jf another under.Iny wiltrict of hire,
�I,Iss.lchuseus General Laws shaper I s2 reywrcs all evglluyas to provide weaken eompen+shun to(their V
I'arsu.utt to viva'talutd, an atepfuVed is defined as"._every pa
%Press or unplicd, oral or written." or an two or more
�n e,npluyar t 1 defined b"an individual,Partnership."Acelauoa,cerporesew ur veer legal eased Y
rise, and including he legal represa ly,91es'u a'n`m'Ioyces.IHowever
ow�er he
o the 1,trcgJulg engugcd in a joint enterp of flu
,ecelvar or treated Of-" 111d" �cWtnatehhan three+aparm+enu IIiall or anJ whotreside therein ur the occupant
owner of a dwelling
uIQY' t hereto sha nor because of such employment be deemed to be an e+nployer."
Jwclhng Iwuss of anaher who empPloys persons o 11 do maintenance.cunsttuctiPn�r reputr work on such dwelling house
or .m he grounds Jr building app shag withhold the Issuance or
�IGL chapter 152. 425C(6) also stares that"every stets or local Ilcensiog agency
Owdvltb for
ny
ce of grog with the insurance,coverass required.'
renesvel of r Ilcaass or permit to operate a business or to coostruat buildings la the comm0cal subdivisions shall
:Ipplicant who has not produced415C+P)sbaesle rlNeaher he commonwealth not any of its p
at
\dditionally, `tGL chapter 1 S_, S- l
anger into any contract tot the perroman a or Pit
he cone dt Y authorityv knee ol'contPliartee wife he msuranc
requirements of his chuplar have been p'
Applicants y s 1 to uursimationavd if
address(es)and Phone numbers)along with their cartificae(s)of
pla;lsa rill,wt the workers' compensation affidavit completely.by checkin the boxes thatapp Y LLP)with era ether than es
necessary,supply dub-contractors)n une(s), '
insurance. Limited Liability Companies(LLCworkers'Limited
compenaa oe insurance.(If an LLC or LLP does have
ndustrial
members or pamelts- an not required to carrybmitted to the employees.a policy is required Se advised that 1 Also be sun to alto and ate the wflidavlt•ns7ltel°affidavit should
unit r license is being requested,not the Department of
\eeidene for eontlnnation of insurance covenosit thd the low or if you era reyuirad to obtain It workers'
hd rcn;1ntdd to vile city or town that the applicationToros regarding
Industrial Aecidants. Should you hive any q at the number listed below, Self-insured compaaias should enter their
compensation policy.plea"call the Department
sclr-insurance license number on the o ro rirte tins.
C'Ity or Town Officials
please he sure that the affiduvit is cutnplate and Printed legibly. The Department has provided a speed at the liCanL
applicant
.If tea affidavit for you to Till out in the avant the Ofltea of Investigations has to contact you regarding the apphcaht.
Itcarions in any given year, need only submit one ut)tdavit indicating current
I'I:ase be sure to till in the pennitilica+se number which will be used as s reference number. In addition,in is aP `r Jt
dint must submit multiple pannit""ceusd app provided to tie
policy int'orma,10111 afYtdrviryhut has been offtc ally a moped or marrkedtbyi lu city or townnay beP in Y
town)."A copyPermits or licenses. A new 1111duvit must be tilled out each
applicant as proof that a valid afflduvit is On file far tLturt a or t lore dug remain r ow er Or ro bum citizen is obtaining
leave taini g J person
a NOT requited o complete his atfidavitmaurcia venture
I het)flies ui cooperation and should you have.my 041,110111.
Inve,Iigatiuns wuuld like to thank you in adv;utce for your
pka,e du nut hesitatd to give us a call.
f he U.panment's addte+s, telephuna and Th ax Cn number
of Massachusetts
Depu=cnt of(nduttrial Accidents
Office, of levesdQadoes
600 WasshinBton Street
Boston, MA 02111
'rel. N 617-727.4900 eat 406 Of 1.877-MASSAFE
Fax q 617-727.7749
d ;.1,,.us www.mam.gov/dia