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9 SETTLERS WAY - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM pileMassachusetts State Building Code, 730 CNIR Revi.red.thir 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish u One-or Two-Family Dwelling This Section For Official Use Onl Building Permit Number: Date App o s �niy Building Official(Print N:une). Signature' Duce SECTION I:SITE.,, O_, IATIOiF 1.1 i'roper.y.-'.ddress:(� <��M 1 7 i 7� l� 1,2 Assessors Map& Parcel Numbers / J r 1 Vt/ t M1fu Number Parcel Number 1.la Is this an acce ted street?yes ao P I.d Property Dimensions: 1.3 'zoning Information: 1 y � Zuning District Proposed Use Lot Area(sq 11) Frontage(R) 1.5 Buildittgsetbacks(R) Front Yard Side Yams Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c.40,§5 i) 1.7 Flood Zone Information: LS Sewage Disposal System: Zane: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ SECTION 2: PROPERTYOWNERSHIPt' 2.1 pvnert of Re7d: ^ q 1f5tC(Iaycf jVaserv4G plme(Print) City,State,ZIP 9 Se & '-7_�ao- 5 Nu.mid Telephone Gmuil Address Street SECTION 3: DESCRIPTION OF PROPOSED WOR[e(check all that apply) ` New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterntion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Br Description of Proposed V#,WK-: -- 1 Grit-Phil1/1 r4 vl 0 w I P1 ow SE TION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials) I. Building //'' . I. Building Permit Fee:S Indicate now fee is determined: S 700 ❑Standard City/Tuwn Application Fee' 2. Electrical S ❑Total Project Cose(Neat 6)x multiplier x 3. Plumbing S 2. Other Fees: S d. Mechanical (HVAC) S List: i. mcch:mical (Fire S Total All Fees:S Su )ression) Cheek Nu.,_Check Antaunt: Cash amount:_ (,.Tutul Project Cost: S c2 4/09- (y9` ❑Paid in Full ❑Outstanding Balance Due:_ a � SECTIONS: CONs,rRucrloNSERVICES 5.1 n'truction Superviso License(CSL) >S r� ClS'' a-tAcj License Number Expiration Date Name et'pCSSL Holder List CSL'rype(see below) !�l �� r✓ Q �� �� 'Type Description No. ,md S eet U Unrestricted(Buildings Lip to 35,000 cu. It. R Restricted 1&2 Family Dwelling City/fawn,State,ZIP ,\I Nfasonry RC Rooting Covering WS Window and Sidinut Solid Fuel Burning Appliances 9 7V Insulation 'role bone Email address `) Demolition 0t egisterre/d tloryye Inrpro en t C tractor(IIIC) d3 O bs, P i rl C/ r �S k"P4A IIIC Registration Number Espirution Uate I11C Compm Name yr IC Registr nl Name r r N � S� -yam/� � � �o. nd:tree a t-2127a �W-/ ' % pc_iu�• Email address Cit /Town,State ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 AGENTOR CONTRACTO PPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Z ��o t9 act o i y behalf,in all m ters relative to vv rk authorized by this build g permit application. O oar's N;une Ele Ironic 'ignature) D e SE ION 7b:OWNEW OR UTIIORIZED 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 cunt to the best o my wledge and understanding. Prii"f%opw's or Authorized Agent's Name(Electronic Signature) Dote NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty Ibnd under bI.G.L.c. I42A.Other important information on the HIC Program can be found at www.nmss,flov:'oca Information on the Construction Supervisor License can be tound at www.mass. ov'JL � �. When substantial work is planned,provide the information below: Total floor area(sq. It.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. It.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms ?lumber of half/baths Type of heating system_ Number of decks/porches l'ypeof cooling syAem Enclosed Open i. "Total Project Square Foomge"may be substituted liar"f ut:d Project Cost" ► . The Commonwealth of Massachusetts ] Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aw2licaut Information Please Print Legibly Name(Business/Organization/Individual):_ r Yvl t SSO)1 Address:_ ] a r I try, 0 S r r City/State/Zip: Q tv] /V )a . n/of]U �_ Phone #:_ 9 —'�/�f a3 if a Are you an employer?Check the appropriate box: 1.El am a employer with 4. 0 I am a general contractor and I Type of project(required): 2.[<mployees(full and/or part-time).* have hued the sub-contractors 6• El New construction am a sole proprietor or partner- listed on the attached sheet. 7. O Remodeling ship and have no employees These sub-contractors have 8. F1 Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.t 9• ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their l L[]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.]t c. 152, §1(4),and we have no 12.❑Roof repairs employees. [No workers' 13.❑ Other comp.insurance required.] 'Any applicant that checks box NI 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 time of the sub-contractors and state whether or not those entities have employees. If the sub-commcmos have employees,they must provide their workers'comp.policy number. /am an employer that is providing workers'compensation insurance for my employees. Below Is the policy andlob site information, Insurance Company Name: Policy#or Self-ins.Lie. #: Expiration Date: 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 c nder the pains an aloes of pe ury that the information provided above is true and correct Si Iature; y r� Dates Phone Offteial 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 Persop: Phone#: t , 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 sub-contractor(s)name(s),address(es)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 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)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 burn 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. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax# 617-727-7749 www.mass.gov/dia �ryvT CITY OF S'uLE',f, >tiL1SS'xH'USE-rrS 7 t ©I:ILDLNG DEPART"ONT 120 WASHLNGTON STREET, 1'FLOOR TaL (978) 745--9595 F-JLX(978) 740-9946 IfIJtBEitLEY D2ISCOLL NLW0111 Tt-tOtGU ST.PMRAa DIRECTOR OF PGBLIC Ptt0PERTY/3L:MoLNr,C0\W055IONER Construction Debris !Disposal Affidavit (required for all demolition on and renovation work) In accordance with the sixth edition of the State Building Code, 780 OAR section l t 1.5 Debris, vid die provisions of to fGL c 40, S 54; Building Permit tl this work shall be is issued with the condition that the debris resulting m 1, S 150A. d fro disposed of in a properly licensed waste disposal racility as defined by tbIGL c t! The debris will be transported by: 1 (name of hauler) The debris will be disposed of in (name of facility) (add ss of racility) signaturrd ofpermit.tppficant