8 SOPHIA RD - BUILDING INSPECTION The Commonwealth of Massachusetts
�y ,� Board of Building Regulations and Standards Town of
k° ! Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tiro-FmniI Dtvell'
This Section For t to Use Only
Building Permit Number: Dat A lied:
Signature:
Building Commissioner/Ins or of Building
SECTION 1: SIT ORMATION
1.1 Property Address: S / 1.2 Assessors Map& Parcel NumbersI,
& edz �"(A
L 1 a Is this an accepted street"?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
,s4ne
Zoning District Proposed Use Lot Area(sq fl) Frontage(fl)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ep `.SoiO
�ar.PA/.l Y.v,eos�
Name(Pr� Address for Service:
370
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occup eed;;C Repairs(s). Alteration(s).❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
��. p TBCG
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building $ OZ , 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Su ression
/ y Check No. Check Amount: Cash Amount:
6. Total Project Cost: $/o'C r—& ZI. 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5./1 JLicensed Construction Supervisor(CSL)
CJ MA/0 4,11 Bh• C� •� , License Number Expiration Date
N me of CSL-Holder ,yJ
List CSL Type(see below)
Ad -vim� T Description
U Unrestricted u to 35,000 Cu. Ft.)
Signature R Restricted 1&2 FamilyDwelling
O�'�•-�' M Mason Onl
RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 egistV Home Im�rovemot�Contractor(HIC)
�,�. e / FS' Z.
HI Comp y Name or HIC Re istrant N e Registration Number
Expiration 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 ..........jK No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, 7`�j./.rrz Eu �. �C , r� as Own r or Au�horj;ed Agent her declare
that the statements and information on the foregoing placation are true and accur iF. ,. lfsTo my knowledge and
be�f''2�.fe /..o®e. q
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 I I0.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. FL) 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"
CITY OF SAL EM
PUBLIC PRUPRERTY
DEPARTMENT
,,%W. M:11' )Alit,'I I
\l wa Nl 12C \x`.4,lnn.\t:Ht\51:/Lh'1' • 5Al I W. M.\\1.\I.11t it I I,01')7_
I,1. )78-713-93'6 • 1:wx 978.741''1.146
Workers' Cumpensation Insurance %ffidul,it: Builders/Contractors/Electricians/Plumbers
t )ladnt Infunnrtion
Picace Print I eflihly
�181TC 10u.uwssa�rganlratinlvinJlw .luall: !/��/ma h/ � / /
' r
CiryS[atc,Rip ,&� VpoS 1'honr 27,sr`O A ' f
.%rc)use an employer? Check the appropriate box: 'r)pe firpreejcct (required):
i 4. ❑ 1 :an a general contractor and 1
a
1.❑ 1 :finemployer with 6. ❑ New construction
cngiloyces(full indlur part-vole) hake hired the sub-cuntracturs 7. ❑ Remodeling
2tI and a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub-contractors have 8. ❑ Dernolirion
working vier me in Any capacity. workers' comp. insurance. 1). ❑ Building addition
l No workers'comp. insurance 5. ❑ We are it corporation And its 10.❑ Electrical repairs or additions
required.) officers have exorcised their
ri ht of extol tion per MGL 11.❑ Plumbing repairs or Additions
3.❑ 1 om a homeowner doing all work 8 P P'
c. 152, §t(3),and we have no 12.❑ RWI rcpaus
myself. [No workers' comp. ,
insurance required.] r anpluyces. (Ko workers' 13.0 Other
comp. insurance required.]
•4uy.yq+bcaul dmldccks box ill most olio IIII UYl the wCIIJ111-low illowllla Iheir workins cumpenaation pulicy inlialmllika
't lamalwnen who wbmil this mTldavil indicming Thep am doing all.vurk and Own him oinslde Cp11rYlUb nlust.uhmit a new alfdavlt indilm,lmg.och.
-C',nlrxwr,ohm check this box mtrt allwhed an addiliunal.111Ce1,hawing like name of[hut suhronlrxlers and their uuhon'comp.policy information.
/our fill employer that is providing ivorkers'c•uarpcauntion insarance for troy employees. Belo is the pulfcy and job.rift
ill/ar,natiam - .DTP
Insurance Company Name: /9h %Z_
��p 7 ytaZ�Cf� EApirutlon Date:
Policy it fir Sclf-ins. Lic. ts: - --
Job Site -\dJress: J o/, 9♦��• ZeeC•nyiJlatVZIp: 1 .�crat►% ///�• 0I976
.\each It copy of the workers' cumpcnsation policy declaration pulse (showing the policy number and expiration date). -
I'ailwc to.secure coverage as required under Sel:lion 25A ul'.%IGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1.500.1M anlb'ur one-year imprisonment, ax wvcll as civil penalties in the furm of a STOP WORK ORDER and a fine
Of up to i250.00 A J.ry ,lguinsl the violater. He advi.acd that a copy of this statement may be lorwarded to the Cllllce of
I nw..u,a nuns of the UTA :or a»u1:u:cc a»a.Iyc wali vicuUun. _
l du hereby L.rtif odor the ahty and penulliev of perjury rhut the information provided above is true and correct.
il••'L1i41 d'
Nl
IJ/jiciul rue u,dy. Do tent write in this area, to be rmnplcted by city or town u//iriill.
('ivy or 1'novn: --_ _— Pcrinitll.iccnie 0_
Is,uirkg .\ulhurily (circle one):
1. Boardof IIc:JIh Z. Ihlilding Dcparunrul 3. C-ily.'fuwit Clerk 4. L•'Icxtrical lurpccvor S. Plumbinlq Iaryccror
b. Other
Gunnel l'c nun: -. _- Phone d:
Information and Instructions
\la�sachusclts Gcncral Laws chapter 152 requires all engrlo)ers to provide workers' compensation for their employees.
Pursuant to rus .tutute. an emplurce is defined as "._every person in the service of another under any contract of hire,
.-%press or Implied, oral or written." _
An employer is defined as"an individual, partnership, associatiou, corporation or tither legal entity, or any.two or more
of the toreLoing engaged in a Joint enterprise. and including the legal representatives of a deceased emplu)er, or the
recei\cr or trustee of an Individual, palttic6111p, 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 o1: the.--rounds;or building appurtenant thereto shall not because.of Such employment be deemed to be an employer."
u "AN.
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 ihe'corrimonwealth for any
applicant,w:ho'has not'prriduced.acceptable evidence of compliance with the insurance coverage required."
Additionally, hIGL chapter 152. g25C(7)srates"Neither the'conitnoiiwealth nor any ofits political s`'ubrlivisians 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 confirniation of insurance coverage. Also be sure to sign and date the affidavit. The alfidavit should
"It �` ` � %fie reettnied'io`the eiry 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.legnbly. The Department has provided a space at the bottom
of the affidavit fur you to till out in the event the Office of Investigations has to contactyuu 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 pennit•licerse applications in any given year,nieed�only subinitone`affidavit indicating current
.. 'Policy inibi malion(if necessary) and under"Job Site Address"the applicant should write"all locations in icily or
town).`', copy of rite�ffivavit that has been officially stamped or ma7ked by the city'of town inuy be provided to the
applicant as proof that a valid affidavit is on rile for future permits or licenses. A new affiduvitnwst 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. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. -
Iho t)dice u(Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do nut hesitate to give us a call.
The D.partinent's address, telephone and fax number
' Z. The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
TeL All 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPART'vIENT
'.I . r. I_': \\ .\+III.'I..IT ♦ \.\II \I• \I.\+i
Construction Debris Disposal Affidavit
(required 1br all demolition and renovation work)
In accordance %�ith the sixth edition oft lie State Building Code, 780 CMR section 1 11.5
Debris, and the provisions of biGL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(name othauler)
I'lie debris
/will
.be disposed ofin :
(name of facility)
(address of tacilit
r
1lg11ature of permit applicant
2 U /
2 J
date
aCORD_ CERTIFICATE OF LIABILITY INSURANCE OF In JL DATEaMIDOIwm
AYLEYBR 07/14/08
PRODUCER THIS CERTIRCATE IS ISSUED AS A MATTER OFINFORMATION
Dan Hurley Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Chestnut Green, Suite 24 HOLDER.YIPS CERTtFICA7E..DOES POTAMEND,EXTEND OR
'Seven Federal' street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers DIA 01923-3620
Phone: 978-777-9394 Fan-978-777-3306 INSURERS AFFORDING COVERAGE NAIC4
xasuasv ZMRMA: e_e2erred mutual 15024
asuRma: Granite State
Rile Brothers Construction ssRnat c
Bartholomew Riley DBA
36 cottantt SOt�3 WSURER U.,
Danvers MAa e
COVERAGES
Y THE:FMI=OF INSURANCE LISTED 3219a:H AVE EEETI FS—MD TO F.M"MftED'M—ED AECVE FOR T71E PCLICYPETRSRD MCATED.NUMTHSTANDM
j nyy pE011{f7EL4Q3T TFAtf OR CDP$IliO:d OF N5V L3iS1f:,4CS 9rvltiiNc::tiU4ilxcil t(atIWSLER171CJ4Te MAYBE(55!$D QQ
{ „'—.',iN,?ci^]5+^4^CE Af6f::3F.O BY Tiff PDt7GtE5 D�CRF�S N3�n7:5a'U9JELT TO At!TiL�i'E(p!S,EYLiVSOPL A'CO CO235TSIOkS O-NCH
PUUCIES AGGREGATE Le.UTS SHOWY:MAY MVE BEEN REDUCED BY PAM Cl"&1. 6
PWCYNL.i3Pf.N
lift A 7TTcOP ELSi1R9FGC= OAiE(MR.*J]]fYTT DALE laTR2l"VYYT LASTS
L GEM-A!L}h8+5.DY EACH OCCURREMCE s 3000DD
A X GlaERoAtceetALLRABLLOY CPL-0150564252 10116/07 10/16/08 PTTEeMMS(Evwcmeo¢eL $100000
CLAW MADE ODO= LIEDEXPIRmyUtlePm ) $5000--..
aGFNBM
6 ADV fAtAtRY $300000
iGREGATE S600000
G9M ACCREGATELWITAFRIES PEA' -CMRWPAGG $ 600000
$ POLICY PRO- LOC
ADTDBDBu.E LLA9SiYf
eded)COUDMED GLE LIMITS
aNYAuro LEA acemmq
ALL OVAEO AUTOS BODILY MURY
SCHEDULED AUTOS OlafP�) $
LNffD AUTOS
BODILY 14RW s
NONIDWNEDAUFOS "=ditrIQ
PROPERIYDAMAGE S
lvu aril
GWAGELGGWR AUM(MY•EAACCIOENT $
ANYAUTO
OTHER 7HAN EAACC $
AUTO MILY. AGG Is
EXCESSFU BRELLA LIASUN EACH OCCTMRENC
OCCUR ❑ LA CLAWS UADE $
AGGREGATE $
S
DEDUCTIBLE
S
RE7EN110N S
$
r WORKERS IO"R mmurAiRONAND $ UWTS ER
yy $ Tr.''C742$831 ®5J201®S 06/4-0,109 E.,eAcmAcmUEUT (s1oo000 OFFliEPMF.MBER EXCLgLREtYf SOD a zpa, P �y 0 VUs,aesnaro'mdv E.L.DISEASE-
E
FROL�SIONS Eris EL DFper EA3IPOYEE 810000` 0
OTHER 00 --[
6
ON OF DP6TATi0RSt LOCATIDNb11Fr,}TAEsl EACLUSOARIADDEiLBYEtBJR LTr sPEaaLP Ns
Sole PropzLietor -_Sclu`ed from woefers compensation.
CERTIFICATE HOLDER CANCELLATM
F;OGRINM SROULDAY:`DF 7FE A30'E DESCRIBED IOUCIES BE CANCBIED BEFORE THE EIMIRATTM y
=A7E7'iEFEDF T:�YsBUSdC'IWSUAER WfLLEABREpvoR TO IAAB. 10 DAYs WRITTEN p For 1a£omation purposes only. NOTTOE$D W CERTIFICATE HDLCER NAPL¢�TO T}¢,cz�.M.�r Ff+s.i:3 TO ED STdNCL i
Please contact agency for
individual Cert: cicaate. FbVDSE NO OBLIGATION ORLfABILITY MANY IMM UPON TTIE D MRg{DS AGEtST OR
REPRESEMries.
AUTHORfED RET�RESBV'OITNE
ACORD 2S RUOUrt� Da^;eT J Hurie
!a At` rnowow�......,....
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