Loading...
22 SETTLERS WAY - BUILDING INSPECTION The Commonwealth of Massachusetts F O Board of Building Regulations and Standards CITY ITYSAL Massachusetts State Building Code, 780 CMR Revised Mar 2017 1 'U Building Permit Application To Construct,Repair, Renovate Or Demolish a One or Two-Family Dwelling g Ttus Section For Official Building Permit N y Date;A x Bu lding'Pfficial'(P,rint Name) -Sig atur'� .:(Date SECTION 1' SITE INFO 1.1 Propert Address: ' ' 7 1.2VAsse rs Map&Parcel Numbers ail Y(' .wt1i u 1.1 a Is this an accepted street?yes no_ Map Number Parce!Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public ❑ Private❑ Check if yes❑ n2:;jPRO)?ERT�O,WNERSHIPi: 2. wnertoffcord: / ACTION,S � �/� �197t7 Vc`�L<� L7©l7GVIFi Ir Cl'—, t ,,. �'���/ Name(Print) City,State,ZIP`7" e}' fier ql iP 7z e' -�/1/ ;, u No.and Street \`` Telephone `'ate '-' mail rKiM ffis SECTION 3: DESCRIPTION,OF PROPOSED (clieck all that apply) New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief DAscription of Proposed Wo 2 SECTION 4: ESTIMATED CONSTRUCTION COSTS ; Item Estimated Costs: x OfficialtVse Only- Labor and Materials 1. Building $ �/- 1 Building Permit Fee $ Indicate.how fee is determmed:: O Standard CitylTown Apphcat_ion Fee _ 2. Electrical $ ❑Total—Project Cost':(Item 6)xmultip let x'- 3. Plumbing $ 2 Other Fees $ 4. Mechanical (HVAC) $ List 5. Mechanical (Fire $ Total ALI Fees $' suppression) Check No Check Amount Cash Amount 6. Total Project Cost: $ <����. d0. 'O Paid in:Full ❑ Outstandmg Balance Due: `. r SECTION 5: CONSTRUCTION SERVICES 5.1 Co struction Superviso License(CSL)P �"7(/Af- '&?Ai License/Number Expiration Date Name of CSL Holder List CSL Type(see below) No. and Street q� Type '.Description „1A �� V1 9 29 Unrestricted Buildin s u to 35,N 2d2f'�t �l/t R Restricted I&2 Family Dwellin City/Town, State,ZIP M Masonry RC Roofing Coverin WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5. egister�d/H�o�e Improvemector(HIC) —� Pr/V/�`„'a'u((/� �11 /�''�S He Registration Number Expirati nDate HIC Co m airy N e or HIQReoistnnt Name Neet d��/r Email address City/Town, State ZIP Tele honz SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152. § 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 ........C;G� No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTR APPLIES BUILDIING PERMIT I, as Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authorized by this uilding permit applicatio . /// #0.3tc L t2a a c 46ge'l �_�„ / ),y Print Owner's Name(Electronic Signature) `'Iaate�`�� SECTION 7b: OWNER' 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 tr and accurate to the best of my knowledge and understanding. � � r Mc q�d a 3 's or Authorized Agent's Name(Electronic Signature) Date 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 can be found at www.mass.vowoca Information on the Construction Supervisor License can be found at www.mass.eovrdns 2. When substantial work is planned,provide the information below: Total floor 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 of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts T 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 Apolicant Information Please Print Legibly Name(Business/Organization/Individual): S Address: 1 r I q o C City/State/Zip: C44 Phone Are you an employer?Check the appropriate box: p y 4. ❑ I am a general contractor and I Type of project(required): I am a employer with 1.❑ employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.�[am a sole proprietor or partner- listed on the attached sheet. 7. )ZRemodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.; 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 11. ❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13•❑ Other comp.insurance required.] Any applicant that checks box#1 must also fill out ate 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 a new affidavit indicating such, kContractors that check this box must allsched 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 information.an employer that is provtdmg workers compensation insurance for my employees. Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic. #: 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 ce r[he tns d pe Ines of perj that the information provided above is true and correct Signature. nn p Date: /3 Phone Officia/use only. Da 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 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 ficense 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 bum 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 Fax# 617-727-7749 Revised 4-24-07 www,mass.gov/dia i «. 1 CITY OF Sa1LEN1, LASSACHUSETrS t . BL ILONG DEPART WANT !� 120 WASHINGTON STREET, 3MO FLOOR TEL (978) 745-9595 FAx(978) 740-9846 Kl.%tBERLEY DRISCOLL +L�YOR Twsus ST.PIERRH DIRECCOR OF PLBLIC PROPERTY/BCILDNG COSOIISSIONER 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 It 1.5 Debris, and the provisions of NIGL c 40, S 54; Building Permit A 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 I It, S 150A. The debris/will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of Fa lily) signature of permit applicant P �. t ate 4.bn, i�J.w Michael Lutrzykowski From: s-jconley@comcast.net Sent: Monday, June 10, 2013 11:44 AM To: Michael Lutrzykowski Subject: Collins Cove window permits Good Morning, I just had a call from Peter Michaud about pending permits here at Collins Cove. As you know we do require owners to obtain a permitn and only use Andersen windows. John Finnegan in unit 4 is having Peter replace some windows and more recently Paul Bouchard in unit 22 is having a slider replaced. Both have the approval of the trustees. I thought I had sent you an earlier approval but perhaps not. We self manage here so we act as our own secretaries etc. If you have an question please give me a call - 857-488-5508 is my cell. Jeff Conley, President, Collins Cove Condominium Assoc. 13 Settlers Way, Salem o� �oCro� .��. �t/e 7J e t