21 SETTLERS LN - BUILDING INSPECTION D
• C
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
?� Massachusetts State Building Code, 780 CMR, 71"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *bmommowft
One- or Ttvo-Fonri(t•Duelling
This Section For Official Use Only
nSignaturre:
umber: Date Applied:
/ /12 b
'�/ I �( 6�
g Commissioner/Ins t r o 'it ings Date
S N 1: SITE INFORMATION
dre s: 1.2 Assessors Map& Parcel Numbers
,°�s
Ma Number Parcel Number
1.1 a Is this an accepted street?yes_ o_ P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard
Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L C.40,§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesC3
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own r'of Record:
erne JCYiL
Name r t) Address for Service:
Signature Telephone
SECTION 3: D RIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work': 2
ti
so
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor uand Materials
I. Building $ 9 [ SV e -6,— 1. Building Permit Fee: s Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S O Total Project Cost'(Item 6)x multiplier x
J. Plumbing s 2. Other Fees: s y� ��-
4. Mechanical (HVAC) s List:
5. Mechanical (Fire s Total All Fees: $
Suppression)
a Check No. _Check Amount: Cash Amount:
6. Total Project Cost: s / �!C'� (/Qr. 0 Paid in Full 13 Outstanding Balance Due:
t
S N SERVICES
5.1 Licensed Construction Super.jsor(CSL) nc s���
P >?r V� c license Number Eap nt,,nj
N,grrjc ofCSL-Helder/ � List CSL Type(sec below)
T'U Unrestricted u to 35,00Signature R Restricted 1&2 Famil D
tJ -7 /r� M Mason Only
3 tl'oa . RC Residential Roofing Covering
Telephone P WS Residential Window
ndo and Siding
SF Residential Solid Fuel A
m
in Appliance Installation
D Residential Demolition -
5.2 Pst Home prov mentC t (HIC)
A a n r0
,2 7 /J
H lc/CfDaIIY Name or HIC Re istrant N Registration Number _
Y a-/A 7/, //o
ss �
pirati n Date
"gnature 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........... ❑
I
TION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
NER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�� a
O � G� ) , as Owner of the subject property hereby
rize to act on my behalf,in all matters
ve to r authorized by this building permit application.
ture of Owner DateSECTION 7b: ERtOR AUTHORIZED AGENT DE LARATION
' ,as�ror Authorized Agent hereby declare
e statements and information on the foregoing application are true and accurate,to the best of my knowledge and
f. / �I c/
C�iamere Owner or uthorized Agent Date I/(Signed under the ains and penalties ofperjury)
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 IO.R6 and 110.115,respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage• finished basement/attics,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 ofheating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost'
CITY OF SALEM
PUBLIC PROPRERTY
No
DEPARTMENT
11. W,\,I I * S It l-\1, IY1.,1\N 111 Nil JIY7]
1 A, 'pa.,'t>'yrS a P,v 9,111 l'1J-Is46
Wurkern' Cumptnsation Insurunce \tfrdarit: Builders/Contractors/Electricians/Plumbers
\ 1 Ilit:ant Information 1. Please Print Le ibly
_ V111nC ,,Il//n��nVlndl,�,luull: ham.,,
rg
ri d
city,Stale,zip. /�••A �N �l l�— Phone •!: iY-7�/LI'—o�3 JvZ _
.\re t ou all vmployer'!Check the:ylprnyriale bus: 1'ype of project(required):
d ❑ I :tin ]general contractor and 1 6. New construction
I.❑ 1 Jnl a employer with ❑
M 110 cgs lull Jntl'ur art-tune).' hate hired the still-contractors
y ( P listed on the tnacil l shcct. y CO] Remodeling
2. .tat a sole prnpriettr or partner•
,lop mild have no anpluyws These sub-contractors have V. ❑ Demolition
working lie me m any capacity. ,workers' comp. Insurance. q. ❑ Building Jdduwn
5, ❑ We;lie a cmporatinn and its
No workers'comp. insurance officers have en,:rcisaJ their 10.❑ Electrical repairs or additions
1 required.) 1 I. Plumbin•repairs of adJlunru
3.❑ 1 and a hnlncuwncr doing all work ght of uemptinn per hICL ❑ b P'
myself. (No workers' comp. c. 152. q1(d),anJ we hllvc no 12.❑ Ruul'rep/airs
insurance requited.) r cinpluyees. (No workers' 1),❑Other / �n�r.C-$ '
comp. in.,urancc rcquired.l
•,ul ....ph,,ul llwt chucks hat cl must also till tolls the vanou Iwluw.huwuly 1111w•sr+vurkui cumpun.W iwl lwhcy nniynYtiWL
' I Ium.urn,:n whe,uhmil this amdavll indicJuna ilwy arc Joiny we .it a,w Ihcn him outside cullmulYb must.uhmil J new•If:cavil inJi"ma+I.h.
.t,.nlratuu,shut the,*this bon mtW.ntschod.m a,!dlIiolt.l.hwn,loswioa the nmila of the suh<ollUX1ara..ind their wurkon'cutup.p,dtcy mttrm+imon
l,tie tin employer thut is pruriding workers'rurepen enders ioserancr/br ury empluyeex. Befoly is the pulicy urld/ub.00
iujunntaiun.
I'nlicv A or Self-ins. Lic. N: ___ . . ..__ Enpirauon Date:
Jub one -\ddrcss: City:State/Zip.
.\Ruch is copy,of Ills workers' cumpensatlun pldicy Jeclaraiiun page(showing the policy number and expiration date).
I-Jllure is) ccurc cutemge as required under SeLtiun 25A ul'MGL c. 152 can lead to the imposition of criminal penalties o(a
tine up 61 i L500.00 Jmb'ur une•)ear impris.insmilt, At\well as iris II pc'Ilallics fit the form of a STOP WORK ORDER lend a fine
of up tit S250 0(1 a Jay .Igamsl the violamr. Re aJwmcJ that a copy of this,Idictncnt may be lorwardeJ to the 011ice of
I:1,;,n._J unro of '.he DIA :or u1,w.o:cc a't cr.hu tcl II itJLun.
/du lr• y :rriw under the err,nn prnu/iic•c u/p rjery,rhur the rtr/brinuNon provided�ubu/tie a true urrd core
Dale
I'I•,.� , .YVI1 C1-1.N
t iul /),+,ties ,write in Mir urru, tube ruurp/reed by a iry ur town..//it iu/.
try or loltol: Per miOl.iccn%e 11
I„uing \ulhurily (circle noel:
I. II„arJ 'd Ilc.dlh !. llud,hu- Dtp.iruocut I. ca.,,'fuon Clerk J. L•'lcclrical lu,pccror S. Plumbing Ilnpcclor
6. Olbcr _
('�uu Jcl I'c null: .. . . Phone d:
r
i
Information and Instructions
vt.ts,ashmcttl GcncrJI Laws cI,Jpter 1 52 n•qutres all cmplo)crs to provide workers' e.unpensahon for their cotpioycel.
P"rnu.un to I:us slitule. Jo rmplutre Is &Tied ai " escry rwlsoa to the iervl.e of inulher uu.ler any cuntract of hue,
:%prc,s or ripliol. oral or wI❑tcro .
\n .-mill Is detined as "in Individual, partnership, .usoclJbou. corporation or other legal cnnty, or any two or more
.,t ICc Lrtc_eowl; engaged it a pant enrerpnse, and Including the legal represeotanves of a deceased cmplu)er, or the
rcvclser or trustee of .ur Individual, partnership,aiwclalrorf or other legal cmnly, employing employees. However the
owner of a Jwelhng house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of anorher who employs persons to Jo maintenance,eunstrucuoo or repair work on such dwelling house
or on the,rounds or budding appurtenant thereto shall not because Of such employment be dcemeJ to be in cmplo)er"
\tGL chapter 152. §25C(6)also hates that "every stale or local licensing agency shad withhold the iswance or
renesysl of a license or permit to uperate a business or to construct buildings in the commonwealth for any
applicant wbo has not produced acceptable evidence of compliance with the insurance coverage required."
\ddinonully, MGL chapter 132, a25C(7)states "Neahn the conunonwcAth nor any of Its political subdivisions shall
enter into any contract for the perfomnance ul'puhlic work until acceptable evidence of cuntpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
applicants
Please rill out the workers' compensation affdavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) 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 assurance. 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
.%ccidents for confirmation of insurance coverage. Also be sure to sign and dale the alfdavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the L4-pariment 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'rown Orrlclals
Please he sure that the affidavit is complete ;end printed legibly. The Department has provided a space at the bottom
of din affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'I::uc be sure to till in the penniulicense number which will be u,ed as s reference number. In addition, in applicant
that mu,t submit multiple ponnitlicetue 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 lucatiuns in (city or
town)."A copy of de affidavit that has been officially stamped or marked by die city or town may be provided to the
applicant as proof that a valid iffidavil is on file for future permits or licenses. A new affidavit must be filled nut each
vear. Where A home owner or citizen Is Obtaining a license or permit not related to any business or commercial venture
f I.e. :I .lug licuue or permit to burn leaves etc.)said person is NOT required to complete thn affidavit.
I lW I)Illee nt lit le rl,Jttunl would Ilse to thank )mu III ad�alrcc fur your woperallon alyd should you ha\c arty quellioni,
p icase do nut hcsmatc to give us a call.
the Derarnncof's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investlgadons
600 Washington Street
Boston, MA 02111
Tel. q 617-7274900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mas3.gov/die
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.. r:� .. 'I: I �_[ \\ \-.III`.1.. ••..l::Ulf � l\II \I, \I\mil\i .. I • .I'� .
III '1'Y.'J i. .�: � I \\ 'i'X.•J. 'ii l�
Construction Debris Disposal .affidavit
(icquiied Ibr all demolition and renovation work)
In accordance \sith file sixth edition of the State Building Code, 780 CNIR section 11 L5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I1I. S 150A.
The debris will be transported by:
�:Ie//__7
(name of hauler)
I lie debris will be disposed oof'in
lld_ _5,i �3'f' � )7
.� fualnr ul IScJny) � //I
fuddr ur I�nlityl
.I�natwcIllif pu nut.tlyihc alit
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