5 SALT WALL LN - BUILDING INSPECTION One or Two-Family Dwelling
WV The Commonwealth of Massachusetts
Board of Building Regulations and Standa' GEI
Massachusetts State BuildingVED Code- � �1 NAC SERVICES
Marhlehead Building Department 0
This Section For Official Use OnIv A.
Building Permit Number Date of ap cation
Signature 3
Building Commissio er/Local ec[o Date
SECTION 1: t SITE INFORMATION
1.1 Prop y dres 1.2 Assessors Map& Parcel Numbers
Is this an accepted street? Yes ❑ No ❑ Map Number(s) Parcel Number(s)
1.3 Zoning Information 1.4 Property Dimensions
Zoning District Proposed Use_._ Lot Area(sirft) Frontage(ft)
1.5 Building Setbacks(feet)
Front Yard Side Yard Rear Yard
Required Provided Required Provided Required Provided
1.6 Water and Sewer Municipal ❑ 1.7 Flood Zone Information 1.8 Conservation Commission
Private ❑ On site disposal ❑ Flood Zone N/A❑ DEP Number 40- N/A ❑
1.9 Old & Historic Commission 1.10 Site Plan Review 1.11 ZBA Special Permit
COA Number N/A❑ -Date tiled - N/A❑ Date filed N/A❑
SECTION 2: PROPERTY OWNERSHIP
.1. 9w er of Rervird
AAJ5
Name Print '
( ff Address for Service
V
Signature o wner - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check allthat apply)
Existing Building ❑ New Construction ❑ Accessory Bldg. ❑ Addition ❑ Alteration(s) ❑ Repair(s) ❑
Demolition ❑ Owner-Occupied ❑ NurnbA of Units Other ❑ Specify:
Descrjption of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COST — BUILDING PERMIT FEE
Item Estimated Cost This Section For Official Use Onlv
(labor andr�"m,�aterials)
I. Building $ � (D Building: $10/$1000
2. Electrical $ Q Building+Plumbing: $12/$1000 Building+ Electrical: $13/$1000
3. Plumbing $ Building+Electrical+Plumbing combined: $15/$1000
4. Mechanical (HVAC) $ Total project cost(labor and materials)$
5. Fire Suppression $ Fee multiplier from above$ /$1000
6. Total Project Cost $ �� Permit Fee$ Receipt Number
f
s
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Licensij(1Cs L), r� l��•7C '] g- ,[ �—
/� -+ j� License ll J 1 Expiration Date -1 f-
<t �y, 10c7F VR4;1 rA ur,r. ..._
Name of C�L/ - ('1 "" r�J7<• Type ._Description.
b �J �� U Unrestricted(up to 35,000 Cu.Ft.)
dress / f '�, {� ',f S �AI� �y'Of R Restricted I&2 Family Dwelling
�-. ANY 3 M Masonry Only
Si r' rre t RC Residential Roofing Covering
g WS Residential Window and Siding
111 SF Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition
5. o e Im ovement Co/q.(ract(o§Registration(HIC)
Registration o Sb() 1 Expiration Datel
HIC Comp y u+eeFl-I. tC Ij�egistrant N ne
des drs 4tgJ ��� T _ !•/+/Vrx/' e�C
afore 6 f) 7 /
Telephone '•—�
SECTION 6: WORKER'S COMPENSATION INSURANCE AFFIDAVIT(KG.L.c.
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affidavit may result in the denial of a building permit.
Signed affidavit attached? Yes ❑ No
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHENOWNER'SAGENT OR
CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf in all matters relevant to work authorized by
this building permit application.
Signature of Owner Date
SECTION 7b: OWNER OR A Tr1HpO,R,IZED AGENT DECLARATION
as Owner or Authorized Agent,hereby declare that the statements
d for a`tion on the foregoin application are true and accurate,to the best of my knoy ledge a ld belief.
r L-I
Sign ofOwne r Authorized Agent (Signed under t e pains and penalties of perjury) Date
SECTION 8: DEBRIS DISPOSAL
All dumpsters of six(6)cubic yards or more are required to have a permit from the Marblehead Fire department: call 781-639-3428.
In accordance with the provisions of 780 CMR and MGL c40,§54 a condition of issuance of this building permit is that debris
resulting from any work performed shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL e111,§
150a. I
DEBRIS DISPOSAL LOCATION
SIGNATURE OF APPLICANT
NOTE
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.
s
t The Commonwealth of Massachusetts
F Department of IndustrialAccidents
}. Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
pWorkers' Compelisation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aplicant Information Please Print Legibly
Name(Business/Organization/Individual): V1�. ) ��✓� �`�
Address: �� CAS
City/State/Zip: - jJ l� ca
Are you an employer?Check the appropriate box: Phone
G I am a employer with 4. 0 I am a general contractor and IL
project(required):
G employees(full and/or part-time).* have hired the sub-contractors ew construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. modeling
ship and have no employees These sub-contractors have molition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp. insurance.: ilding additionrequired.] 5. We are a corporation and its ectrical repairs or additions3.0 I am a homeowner doing all work officers have exercised their mbing repairs or additionsmyself._[No workers' comp. right ofexemption per MGL ofre airs
insurance required.]t c. 152,§1(4),and we have noPemployees. [No workers' her
comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site
information n _
Insurance Company Name:SS 6 L f C �fa �
Policy#or Self-ins. Lic. Expiration Date:
� c
Job Site Address: ''[ City/State/Zip: '
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby r1ify under the pains and penalties of perjury that the information provided above is tru and correct.
Si ature: 1 (" ��� 2
p G; Date:
Phone#:
Official use only. Do not write in this area,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 i
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
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."
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 unfit 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),addresses)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
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 pernitilicense 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 bunt leaves etc.)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.
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
Tel. 4 o17-727-49"v"u ext406 or 1-877-1viASSAFE
Fax 4 617-727-7749
Revised 4-24-07 www.mass.gov/dia