17 SETTLERS WAY - BUILDING INSPECTION a rile Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Code, 730 CMR. 7'h a 'tion Retisaa/Jon"ary
Building Permit Application 'ro Construct, Repair, Renov a Or Demolish a
1, :IllIN
One-or Ttvo-Fomily Duel ing
f1 I This Secli For •ial Onl
V Building Permil Number: e A litd:
Signature:
Building Commissioner/Inspector of nuildi gs Dote
SE IT INFORMATION
1.1 Prope dd ejs: `"- 1.2 Assessors Map& Parcel Numbers
��
Ma Number - Parcel Number
I.1a Is this an accepted street?yes no_ P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use [,at Area(sq 11) Frontage(Il)
Zoning
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required I'rov ided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zane: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if XesC3
SECTION2: PROPERTY OWNERSHIP'
2.1 Owners of Record: I17 lJe�(_� w�" Ij��M ' 1A
�DNN 5 IANGUSSO tr �j- -t
me(P 'nt) Address for Service:
�. �
,I > . sa3 - 36aa
Si are 'Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupted O Repairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
44 /7-N M?%<W
SECTION d: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMclal Use Only
Item (Labor and Materials
I. Building S 7 `d 1. Building Permit Fee:$ Indicate ho w tie is Determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S L Other Fees:
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: 11 G��v7.�OD` [3Paid in Full ❑Outstanding Balance Due:
Gd A ail /�
SECTION 5: CONSTRUCTION SERVICES
5.1 Qcensed Coast III n Supervl r(CSL) �r vs �3
Qhr ( I.icense Number li p"'t,n Dale
Name ul GS I IulJer
�� Vist CSL I')PC(see below)
\ 1 ImX1 I Description
FrrestricieJ(Lip to 35,000 Cu.Ft.)
R Restricted 1&2 FamilyDwcllin
Si tore M 10asonry Only
RC Residential Rooting Coverin
Telephone WS Residemial Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
..2 egistered Ho Improv me Cont for C), /�3���
11 C 'om •ny Namgor f IIC Re istnml Natne Registraliun Number
���y c2 Cxpi tiun ate
5 na ore Telephone
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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, =Ul'fAJ S. /�Nl^uss , as Owner of the subject property hereby
authorize_ P�:p r 641 C LI&- n to act on my behalf, in all matters
relative to ork authorized bgthis building permit application.
1 II •S• I �
SignaW&Owner Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
I' Im ( �a o (�1/ asQwnerer Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
1 Qt. A
Print Name ----
Signature of hv under the alns aner or A IhorizeJ Agent Dale
/D
(Signednd penalties or 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 basement/attics,deAporch)
Gross living area(Sq. Ft.) Ilabitable 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 he substituted for"Total Project Cost'
6 CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
J\ua M:I aMit:, I L _ - -
\I\strg 12^.WMHINU I ON S I XEbT • Snu:at, M.\».ua11 vf.rn 0197^Z
alma:978.743-9595 • Fsx. 979•74C�184G
Workers' Compensation Insurance :V'6davit: Builders/Contractors/EIectricians/Flu mbers
I Ilicant Information Please Print Le ihlQ.
11i11TIC(8ucntesslOrganvarinNlndly uluuD. I f
Arab ress:
City,State,Zip: 1 t�), -f-r4 OI�l D Rhoneirk
Arc you an employer? Check the appropriate box: --I'ypa of project(required):
1.❑ I :un a employer with 4. ❑ I am a-enural contractor and 1 6. ❑ new construction
ent to yces full and/or art-mote).• have hired the sub-contracture
2,,. P y ( P �. ❑ RCIDOIIeImQ,
2.1�1 am a x]lu proprietor or Fanner- listed on the;attached sheet. ❑
l _ship;utd have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers' cum insurance 5. ❑ We are a corporation and its
I P• CXCfClsed their required.] of 10.❑ Electrical repairs or additions
tiCCfx have
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers'cunip. c. 152, q 1(4),and we have no 12.❑ Rouf rupairs
insurance required.j t cmployecs. (Ko workers' 13.0 Other
coinp. insurance required.]
•nay.yphcaut Ihot checks box dl must:d3o IIII out the ecituo igiuw axiwhlg their workas'eumpensiition trolley inlirtnwtiva
' I lemenwnen who vdlmit this affidavit indicating Ihcy are doing all work and arch him outside contractors must.uhmit a new affidavit indi".rig wch.
C.mtracurn that check this box must mlxhod m additional Acet shuwinu the umne of th¢sub�onlrxtors and their wurkun'cutup.policy infuntlauon.
/out at employer that Lc pravidir{K workers'cmnpenwuion insurance jar uty employees. Below is die policy and jub.cite
information.
1nlllranCe•Company Name:
Ilolicy is or Self-ins. Lic.N: ___.. _._ .__ Expiration Date:
-
Job Site Address: _ City;Slalelzip:
Attach It copy of like workers'cmnpemation policy declaration page(showing;the policy number and expiration date).
Failure to sucure coverage as required under Section 25A of SIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one-year imprisonment, is well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5230.00 a day against the violator. tic advised that a copy of this smtcmunt may be 1'urwarded to the Office of
I Il\'i alhallnlls UI tl,e I)IA lbr Invtuarce ca)vcfagc \criticallon.
/do hereby c rfy I, er it lilt. jettl IS ujperjury lrul the injunnullon provided abort is true and correct.
lit' 11C2
F
al fist tody. Oo not Ivrire in this urea, tat he completed by city ur torvn officiaL
r I'n]vn: Permit/I.gccnse q__g.w hority (circle one):
ardof Ilcallh 2. Building Department J. Cilyifonu Clerk 4. Electrical Inspector 5. Plumbing laspector
er
Cuawcl l'cr]ou; _ _ Phone:y:
Information and Instructions '
\Iassachu:eus General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emphuvee is detincd 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
)f the toregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,ptumership,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
,Iwelling 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 in employer."
N 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 tvho has not produced acceptable evidence of cumpllance with the insurance coverage required."
.additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
cuter into any contract for the perfomfance of public woik-until acccli'table evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till 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 contimhalion 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 he 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.cure to fill in the permidlicense number which will be used as a reference number. in addition,an applicant
that must submit multiple pennitilicense 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. it dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
I;he 0I lice of Investigations would like to thank you in advance for your cooperation and should you have:any questions,
please do nut hesitate to give us u call.
The Ucparnnent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Rt%ised i-26-05 Fax k 617-727-7749
www.mass.gov/dia
CITY OF S.3L&M, NUiss.kaiUSETI'S
• BULD]UNG DEP.ARTt&NT
' 130 WASHLNGTON STREET, 3"FLOOR
TEL (978) 745-959S
FAX(978) 740-9846
KI\®ERLEY DRISCOLL
MAYOR T HovAs ST.PtERRa
MRECTOR OF Ptmic PROPERTY/BCILDLNG COMMISSIONER
Construction Debris Disposal Affidavit "
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l l 1.5
Debris,-an Debri3,-and the provisions ofMGL a40;-S 54;-- -- --- --
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
w (name of hauler)
The debris will be diisposed of in
me o
ddress of facility)
signature of permit applicant
l� 2�-a /ia
ate
JcAnaair Jew