32 SETTLERS WAY - BUILDING INSPECTION 4
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
O �y Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Building Dept
1 Building Permit Application To Cons ct, Re air, Renovate Or Demolish a 413-596-2800
One-or T+ -Fa nily Du Iling Ext 118
T ' Sect' For Offic 1 Use Onl
Building Permit Nu ber.
" Df7f e pplied'
Signature: /a qlyz
Building CommissioneIrflnspAtor of Build s Date
CTIO 1: E INFORMATION
I.IPr a S�Y ddrs •�� �YS 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?ves.! n� Map Number Parcel Number-
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: — Outside Flood Zone?Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own erI of c �rL�
Name P t) Address for Service: -
97e �s�f--a � J
Signa!ez Te ephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
T v P qcP_ / •- r 4 x > >b—v
-- �
SECTION 4 ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined.-
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 600 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) eSj/9�J�
Licensee Number Expiration
ACSF�? Lis[CSL Type(see below)
T Descri tion
� � U Unrestricted u to 35,000 Cu. Ft.)
R Res'tricted 1&2 Famil Dwellin er7 M Mason Only
��✓ / RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Register improvement Contractor(HIC)
HIC Comnany Name IC e i trans me 'y� Registration Number
Address 5,/'�// UT Expiration� `
Date
Signatur 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 A 11idavit Attached? Yes .......... ❑ - No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by t is bu permit application.
Si nature wn Dat /JC�'7
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 1/ /na.�t/..o 011---, ,as Owner or Authorized Agent hereby declare
that the statements and in ormation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
—JG .rvJ�G
Print Nama
Signature of Owner or Autho Date
(Signed under the pains and penalti of per'u
NOTES:
1. 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 1 I O.R6 and I IO.RS,respectively.
2. When substantial work is planned, provide the information below:
Total Floors area(Sq. Ft.) 5YX7 -(including garage, finished basement/atttics,decks or porch)
Gross living area(Sq. Ft.)%�Ckj Habitable room count
Number of fireplaces / Number of bedrooms
Number of bathrooms Number of hal"aths
Type of heating system E G Number of decks/porches /
Type of cooling system Enclosed Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
,y; PUBLIC PROPRERTY
"a. DEPARTMENT
"WK. M'IN':)Milt Ur r
vl sll Mt IY Wa,tu�clli.S tx LL 1' a SA tFvt,Mn>_�.uJu a I n0197�
f ra. •l7111-7i5.9393 • 1:\x 978.741'-+x16
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
\ t )lic�nt Infonnalion
Please Print Legibly
Name tall�llle\S 1)lrtanl J1111111L+IndII HIYJI): -
7
Ilhone
.\rr sou an employer? Check the appropriate box: '1)pe of project (required):
1k1 ant a employer with 4. ❑ I :nn a general contractor and 1 6. ❑ New construction
have hired the sub-cuntracturs 7. ❑Remodeling
employece(full and/or part-time).' listed on the anachcd sheet. :
?.❑ I ;un a sole proprietor to partner- tors have S. Demolition
ship and have no employees These sub-contractors ❑
working for me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
5. ❑ We are a corporation and its
[No workers' comp. insurance officers have exercised their lo.❑ Electrical repairs or additions
required.] I I. Plumb repairs airs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MGL "P'
Myself. [No workers' comp. c. 152, y 1(4),and we have no 12.❑ Roof repairs ,\
insurance required.] ' mployccs. INn workers' 13.❑ Other1
comp. insurance required.]
•�m.ypi,caut rhah ctccks box ill nunt:Ilbo IIII YUI the 5eciloll IKIYw Showlllu their workm!eumpunsaliols policy mtllrnuriun.
' I lomeuwrwn who submit Ihis affidavit indicating the)um doing o11 work mW then him outside colarnelom must.uhmit a new Jlr:davil iDdiuling.ach.
thin check this box mull auwhed an addilion I.Ixet,hawing the nanm of the sub• onlracloni and their wurkun'cutup.rxthcy mrormatinn.
/run wt eurpluyer rhuf is pruridinq rvur/cers'c•mnpensnnon uh.rurnucr jar uty emp/uyrecr, Brhnv is tier pulmy and job.0e
injurrn cc C --
Ir.,urance Cuntpuny Vamr --._..- ------.---
Policy H or Self-ins. Lie. r=: ,�j-,�- -
�� Expiralhon Date:
Job Site -lddress: ^,\��2LL�i_y N City,State/zip:
.\ttach.n copy of Ibe workers' compensation policy declaration pul; showing the policy number and expiration date). ...
Failure to sccurc coverage as required under Section 25A ol'>lu c. 152 can lead to(he imposition of criminal penalties of a
tine up to sl.5no.00 analur one-year imprisonment,a9 well as eivll penalties in the form of STOP WORK ORDER and a fine
of up to S'_50.00 a day against the violamr. Re advised that a copy of this,iatcalcnt may be forwarded to the 011ice of
I n,:ou�aunns uf;lte UTA :or tnlurarcc c,.%cragc ,ciiticanon.
/du hereby sCn' nnJer the pains h a la/ticx of perjury that the injurtnatlon provided above 's true Ilul!c• rrecl.
U/jiciul oar mh y. / lot Ivrite in this urea, to be cunrpleled by city or to Ives aVicidit
( itv or I'nwn• Permit/Liecnse d_
1\\uing.\ulhurily (circle tine):
I. 1lllard of Health t. Iuilding ncparunent .1. Cill.'funu Clerk 4. Electrical Inspector 5. PI inbing Inspector
6. Other
Contact 1'crsu Il: -. -. Phone tl:
r'
Information and Instructions
Ma�sachu:etts General Laws chapter I i2 tequires all clnplo)ers to provide workers' compensation for their employees.
Purmiant to this ,141ule, all empruree is defined as"..:every person in the service of another under any contract of hire,
c vpress or Implied. oral or written." _
An employer i.defined as"an Individual, partnership, associanou, corporation or other legal entity, or.any two or more
,a the G,reWing engaged in a Joint enterprise. and including the legal representatives of a deceased employer, or the
r"ci%er or trustee of all Individual,puirllcbhip,association or otfler legal cnnty,employing employees. However the
owner of a dwelling house having not more than three .apartments and who resides therein, or the occupant of the
Jwelhng 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 slate or local licensing agency shall withhold the issuance or
renewal of it 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. NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomlanee of puhlic work until acceptable ev ldcnce of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants -
Please rill 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 nuniber(s) along with their certlficatc(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
.>ccidents for contimtation of insurance coverage. Also be sure to sign and dale 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 it 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 :Ind printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
1'Iaase be sure to fill in the pernil/ficense number which will be used as a reference number. In addition,an applicant
that must Submit multiple penniblice,se 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 i.c. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he I)I lice Ut lllv'e\tlgations would line to diank )flu ill advance fur your cooperation and should VUII have any questions,
please do not hesitate to give us a call
The Dcparuncm's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oflllce of Investigations
600 Washington Street
Boston, MA 02111
Tel. q 617-7274900 ext 406 or 1-877-MASSAFE
Fax It?617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
r
DEPAR"I' �IENT
III 'i'8.-J;. ,;•,; I ��: ,;79.'4_ ,YL
construction Debris Disposal Allidavit
(rciluhcd lur all demolition and renovation work)
In accordance %%ill, the sixth edition ul tltc State Building Code, 780 CMk section I 1 1.5
Debris, and the provisions of AGL c 40, S 54;
is issued with the condition that the debris resulting from
Building Hermitt
this work shall he disposed of in a pruperty licensed waste disposal facility as defined by MGL c
t I I. S 150A.
The debris wiII be tianiported by:
I nomc ut hauler) v
he debris will be disposed of in
(name ut Iaedity)
I:uldres<u(1]nlilvl
„ • tm 7i , ,it applicant
Jatr