24 SCHOOL STREET CT - BUILDING INSPECTION $2;2'I 5 Cr, 3"7'6 z,
The Commonwealth of Massachusetts CITY OF
of Board of Building Regulations and Stapl VV 18 A $ 2 SALEM
Massachusetts State Building Code, 78 Revised blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
'This Section For Official Use Only '
�! Building Permit Number: Date.Applied:
building Official(Print Name). --,Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
- Y Scl.r�o I -ST2z�{ C,
1.to Is this an accepted street?yes—kof no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(11)
1.3 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(Iv1.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTYOWNERSRIP,
2.1 Owner of Record:0 „ �_ m �n
i/fe BCC.K-C ti l S{91'm Yl�f r Q/C/N
(Print) City,State,ZIP
A9152 &4i A ouve
No.and Street Telephone Email Address
SECVeN 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New ConstructionV Existing Building❑ .Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.Cl Number of Units_ I Other D Specify:
Brief Description of Proposed Work-: AAeU2 nt iD/f X
17,3__.i < —l �� ti `I
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building $ 3 pa 0 1. Building Permit Fee:S Indicate how fee is determined:
D ❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cose(Item 6)x multiplier x
3. Plumbing S Coe) 2. Other Fees: S
4.Mechanical (hIVAC) S List:
5.:\(echanical (Fire S / Qt7� Total All Fees:S
Su ressiun) C�
Check No._Check Amount Cash Amount:_
6. Tolal Project Cost: S 3 O00 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) _ 6
r License Number Esp' ation Date
Name ofCSL Mulder List CSL'rype(see below)
�J71o..d r, ye Type. i_ . . . Description .
No.and Street - ,/� U Unrestricted OuilJin u -to 35,000 cu. It.
�/� �� R Restricted l&2 F;unil Dwei
City/fwvn,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
oLDd yy6 ScHolev Ce&V0112ve 1 Insulation
Telephone - &11011 auuress ;D Demolition
5.2 Registered Home Improvement Contractor(HIC) lr vuhl
v-r— V HIC Registration Number :tpumtion Dole
f l Cmn any Name or 1 ilC Registrant Nnme
No, and Street Email address
�c-Ale T rril9 di�i7U S7f- %2n5w
Ci !Town,State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 23C(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 Istuance oDhoBuilding permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR
//BUILDING
IPERM IT'
I,as Owner of the subject property,hereby authorize -BL 1pl
t9 act on my behalf,in all matters relative to work uthiprized by this building permit application.
MI Ke� 6t fzl;� /6
Print Owner's Nance(ElectiotilCTignatufif Date
SECTION 7b:OWNEW 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 the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do Iris/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 can be found at
oVww mass eov!oca Information on the Construction Supervisor License can be found at AAAAIjas�
2. When substantial work is planned,provide the information below:
'Total floor area(sq. R.) (including garage,finished basementlattics,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 Enclose) Open
1. "focal Project Square Footage"may be substituted fur"focal Project Cost"
�Ac�-tom o�FM �a2 �gl - Z�t� - 2�,g1
The Commonwealth of Massachusetts
Department of IndustrialAccidents
a I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / Please Print Legibly
Business/Organization Name: S0/1/1 ygy
Address: &gp(,-e
City/State/Zip: yt U Phone#:
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
or parr-lme).* 6. ❑Restaurant/Bar/Eating Establishment
2. am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers'comp, insurance required]* 11 ❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
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 50.00 a da against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigati s o the Inv surance coverage verification 11
.
I do hereby c\' l
unde he ainsandpenaltiesof p ury that the information provided abo—vee is true and correct.
Si nature: p r Date: /
lo
CT
Phone#: 1 D y a MIA b
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.City7Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
Information 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 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 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 affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply your insurance company's name,address and phone number along with a certificate 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 permit/license 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). 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 burn leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Fonn Revised 02-23-15
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COAS& IOn Debris Disposa/Affrdovit
(required forall. demolition andrenovation wort)
in aocordanoe With d►e sbrth edition of dw State Bundfrg Code, 7W CINIt, S"M 11LS Debris
and 111e pro► dons of MGL coo,S 54; Building Perm*if is Issued wkh the
condign that the debris res*ft from this work sha0 be disposed of in a property If med
waste deposit fadNity as.defined by UGL c ill,S is6A.
The debris will be transported by:
(4�A�A
(name of hauler)
The debris will be disposed of in:
(name of fadilty)
(address offacilit
S at re f applicant
ate