24 SETTLERS WAY - BUILDING INSPECTION /1� I The Commonwealth of Massachusetts Town of
n 1/ Board of Building Regulations and Standards
't Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a �
One- or Two-F iili Dwelling
This Se Fo Official Use Only
Building Permit Number: ate_Applied
Signature:
Building Commissioner/Inspecto of Buildings to
SECTION 1: SI 1 ATION
1.1 Pr tire /ka� /,/dam 1 ss sson Map& Parcel Number
c S (/v Ma Number Parcel Number
1.1 a Is this an accepted street'?yes_ n
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.(j.L C.40,134) 1.7 Flood Zone Informatlon: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private Cl Zone:
if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 r ne 'of Recor
r Q
I
' Address for Service:
/./�.
�8 Signatur Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Matcrialsl.
I. Building E I. Building Permit Fee: 5 Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical E ❑Total Project Cost'(Item 6)x multiplied
3. Plumbing E 2. Other Fees: E
4. Mechanical (BVAC) S List: ti
5. Mechanical (Fire b Total All Fees: f
Su ression
���� Check No. Check Amount: Cash Amount:
6. Total Project Cost: 5 0paid in Full ❑Outstanding BalancrDur.
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constructs Supers or(CSL)
fix � as'zy`�
f ����],�71, License Number Ezp rat
N4mc of CS ..It plder
�• n AA List CSL Type(see below)
Ad •ss
l v"i �Rcstricted
Descn Lion
'. 2 Family Dwelling
Signutur M Masonry Only
�a RC Residential Roofing Covering
Telephone IF
Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2/R3g(aJgred Ho, Imp ent tr o IC) n• ) O 17
H Cpinnppaan Namee lyrHIC Reg 1 Name Registration Number
Add Add ss !V U/ beg
/
9 �f �a Et iralio Date
Signature Telephone
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 .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
WNER'S AGENT OR� CONTRACTOR APPLIES FOR BUILDING PERMIT t � 1, 1 1 L>--� as Owner of the subject property hereby
authorize /• a to act on my behalf,in all matters
re veto work authorized by this building permit application.
Si na of Ow er Date
SIkC/�TION . OWNEW OR AUTHORIZED AGENT DECLARATION
1• 101 r r"r ,as0=Xki *&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. / 4 )
Print Name
/ D
Signature ofr or Aulh ized Agent Date
(Signed under the pains and penalties ofperjury) j
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 ngt 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 I 10.115, 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 of heating system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"may be substituted for"Total Project Cost'
-� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
l i-.1. )71 "6•13.13 a 1:s.r 979 74' rx Ur
%Vurkcrs' Cumpensadon Insurance lfftda�iC Hui lders/Contractors/Electrici ions/Flu mbers
I tlicant Infonnrlion Please Print Le ihly
Vi11Tld lllu•uw\Y 17r�aN),//I')�n^n'InJl� .luul l:
�1ltlrass: r ✓ r
Clty,.Stare.Zip d. Phone ;/
.\re y uu an gin player:'Check the appropriate box: -Type urproiect(required):
i 4 [1a aI m ecneral cauu g_ construction
and 1 New tmnsucun
1.❑ I .tin a empluycr with
m tlo cch I-all antL'ur tin-time).• huce hired the sub-cunlracturs
( P listed on the anicheJ slices. 7• ❑ Remodeling
2,4el am a sole propricttr or partner-
pluyces These sub-contractors have g. ❑ Demolition
,Itip:tlwl have no el
working tit inc in anynpl capacity. workers' comp. Insurance. 9. ❑ Building addition
❑S. We:re a cnlporstion and its
Ino workers'comp. imumice 10.0 Electrical repairs or additions
I required.) otlic[n have c:ercisxi their
tight ofexcim Lion r NIOL 11.0 Plumbing repairs or additions
3.❑ 1 ant a homcowncr ailing all work K P Pe
m)sclf. (Ko workers' comp. c. 152, l(3),and we haul:no 12.❑ Ruul'repairs //
inwrance reyuircd.J r anpluyees. (Ko workers' I3.❑ Other Nr✓scvSd J94' '
comp. inwranct:required-1
•s u. ..,grLc+nt rhet chcckx box xl moat+tau till"n the wclWu I»luw Jluwuta their w•urkrai cumpens,Jiw'lnnccy nJians+l AM
' u„Inca"ran uh„ ,lLimit thb x(MJavil indic,linj Ihc) ac Joina m work a,bit dove him"bide c"IrOxIO'S mull xuhmil+new drJavit mJiW ms wch.
'f.Mir#aM�that lh.,k this box T\W+[IYhpl ran Add,I,UMI J gal Jnlw,,,a the itaing•*(the IubtiomrichNl and their\1urllam cvnp play mfurmm,m
/,tin an emplayer that is prm•idbq workers'curnpenvrrdon%naarance for lily erap/uyeex. B[/ory is the pu/ity un✓/ub s%le
%IlfalnlallrrlL
in,orancc Company ?lame —._ - -- - --'------
I'nlicv d ur Sclf-ins. LiC. N: -- Expiration Date:
lob Site -\dJrvss: Cray:SlalaZlp:
Attach a copy of the workers'emnpensitlun policy declaration page(showing the policy number and expiration date).
fadurc to secure cu\erage as required under Secliun 25A c. 152 can lead to slur imposition of criminal penalties of 2
tirlc op(.l S 1.50.04 and/ur une•)ear finprisonmcnt, a+\yell as cis 0 penalties in the form of a STOP WORK ORDER and a fine
of[lp ru i230 00 a Jay .Iga[list the vi,tlJtor. Ile advLacd that a copy of this,lutcmcnl may be Ior%irded lu the 011ice „f
I t\:.n•p u'nb ul :lie UL\ :or ut.ul.[ltcc c,ncahc \attic aLun.
1,10 her y 1. it v hailer the p finc tin✓ + n,drler u/prr%nry thW the lnfurindllion provided above is true tin✓correct.
L
J�/ia iul a\[tin/y /)d run ,vrlr[%n drir urru, !u be cunrp/rIr✓by i iq•ur torvn n//it ioL -
iPci mittl.icc me at
Issuing \ulhur,iv (circle uuc):
I. II„arJ d Ilc.lhh !. DudJiny Ilcp.lruucul 1. l.a%.Tunn Clerk J. Electrical lu\pcctor i. plumbing luspecror
6. Oillvr _
.. l'Inllxl 1'ynmc .. Phone It:
r
Information and Instructions
V.te,.t.hu.Ata (icncril Liwi chapter I*52 requires all auplo)ers to prrn ide workers' cot npensatutn for their cmpluyees.
Pur.ti.um to ':its astute, an rmplutee a dctuied as - et cry pei,on In the servi.e ul'anoiher tinier .my contract of hire,
;.pre„ or imiplicd. oral or tvutien."
(n :mpluy,v iv Jefincd as "in individual, partnership, is3ociatiou. corporation mr other Icgal crtiry, or any two or inure
.a the t,treeou:g engiged it a point enictpnie, and including the !cgal represewitivcs of a Jecei,eJ emplu)cr. or the
fc,civer or trubice of .at mclivIJUJL putttictship,asi lciamion or other legal cnnly, cmpluymg employees. However the
owner of'a dwelling house having not more than three ipartmcnts and who resides therein, or the occupant of the
Jw.Ilutg lou.ve of another who employs persons W Jo maintenance, cumtruciion or repair work on such dwelling huuie
or on. she--rounds or building appurtenant thereto ,hall not because of such employment be deemed to be in emplo)er "
MGL chapter 152. §23C(6)also stares that "every state or local licensing agency shall withhold the issuance or
renewal of a license or penult to operate a business or to coostruct buildings in the cumutunlvcallh for any
applicant w too has not produced acceptable evidence of compliance with the insurance coverage required."
kddiuonally, `IGL chapter 152. 4, 25C(7)Males "Neither the commonwealth nor any of ila political subitiviswns shall
cmer into any contract for the performance uf'puhlic work until acceptable ct idence of cuuipfiance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Pleasc rill out the workers' cumpensation affidavit completely, by checking file boxer 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 -
msui ante. 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 dale the altidavil. The affidavit should
be icnmied 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 if 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.
('fly or Town Officials
please he ,tire that the affidavit is complete cold printed legibly. The Department has provided a space at the bottom
of the of idavd fur you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'Ica.c be .urc to till in the penniulicense number which will be u,ed as a reference nunther. In addition, an applicant
that must submit multiple pennitilicetue applications in any given year,need only submit lane aBiduvit indicating current
pulley information lif necessary)and under"Job Site Address"the applicant should write "all locutions in (city or
town)." % copy of the affidavit that has been officially stamped or marked by cite city or town may be provided to the
applicant as proof[flat a valid affidavit is on tale for future permits or licenses. A new af7davit 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 i.e. a Jug license or permit to burn leaves cte.)said person is NOT required to complete this atFdavit.
I It. i it lice tin Imvc,n--uiiuna would It" to thank )tau in advance fur your cuoperauon anJ:Iiuuld you ha.c .my que)uwli,
Blessc Ju mot hesitate to give us a call.
ncc DJ partincnt's aJJres, telephone and fax number
The Commonwealth of Massachusetts
Department of industrial Accidents
OfHee of Invesdredans
600 Washington Street
Boston, MA 02111
Tel. Of 617-727-4900 ext 406 or 1-877-MASSAFE
'nui Fax N 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12,, U lr � lul \I, \1
03y5 # I 'i'9 '4_ "iJ;,
Construction Debris Disposal Affidavit
(ie!quircd l'ur all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 780 C'MR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit It is issued with the condition that the dcbris resulting from
this work shall he disposed of in a properly licensed waste disposal I'acility as defined by MGL c
I1I. S 150A.
The debris willbe t/r�nsported by:
(name Lit hauler)
The debris will-be disposed of in
i :
f oal nr uI
5
Il1dre",d lit11ily)
aplalw c of pi nna .gythcant
/ O
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