2 SOUTH ST - BUILDING INSPECTION (2) r
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
Uy j
' Revised Junuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. =0MY
One-or Two-FumilP Dwelling
((( This Section For Official Use Only
^ Building Permit Number: Date Applied: !�
Signature: "`�Ll�'� ?/ 'VIA
Building Commissioned Inspector of4uildinip Date
SECTION I:SITE INFORMATION
t.l Property Address: 1.2 Assessors Map& Parcel Numbers
1.l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
From 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?
Public O Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Rec99��d:
�^PFan k J- GSr'r dze�ff 0-ea:1 Z So ci �Z ST
Name(Print) Address for Service:
C) V- �qq-
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ AdditioJO
Demolition ❑ Accessory Bldg.Cl Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': 7'1,oc-k -4- ir.vr. !/✓7 hPd Ay.v,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMclal Use Only
Labor and Materials
I. Building is So, c, 1I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing I 5 2. Other Fees: S 10PI�� ,\
4. Mechanical (tIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Coat: S C' SD, 'Old ❑Paid in Full ❑Outstanding Balance Due:
C
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL) (,Z2 3 tf
0 e- ( q ��r IV of l.iccnse Number Expimliun Date
Namc of CSI.• I lolder I.ist C'SL Type(see below)
r) i J t ?Y C r-(3- T aG
F1 De Description
Addres
/e_7,7 9t;� U Unrestricted(up to 33.000 Cu.Ft.
R Restricted IR2 Family Dwellin
Si ore M Mason Onl
rocs
RC Residential Rootin Coverin
I'd• e WS Residential Window and Siding
SF Residential Solid Fuel oumin Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(RIC)
111C Company N eUr-111C Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.f 2SC(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 .......... O No...........O
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.
Siansiture of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, &e 9-re7 Q- C I y A/o -% ,as Owner or 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.
Print Name /
b,� 3o- �tl
Signal ofo uthorized Agent Date
under t ails and penalties of 'u
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 H¢f have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.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 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
7�M Ur i
'd ,)��r. t_' �C.�;nl�,,.,,n�r:u:1 r • tiAII -M,
III: ')78-74i.9;95 ♦ 1:\Y: 'i,,8.174-19846
Construction Debris Disposal Affidavit
(MILlhed Iix all demolition and renovation work)
In accordance with the sixth edition ofthe State Building Code, 780 CN1R section 11 1 5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it 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
I11. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of'in
(name of facility)
(address of facility)
`1
.iglr of permit applicant
/eq --
date
CITY OF SALEM
y�
PUBLIC PROPRERTY
DEPARTMENT
'nl\tn'.RLIfY I)RIICVLL '
MA. Oa 120WMHUN IONSfnELT4SALEM.MASSVAIt NEJ1s01970
'rta.:978-745-9595 • 1-:(x: 978-74^•9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
\pplicant Information Please Print Leeibly
14,lMe (Busiocss/OrBanizatioN /`lndivictuul): t `i' PO AGO J Cj n s 7n/c T/.o ,
:address: � Un
Cityi'S[n[c/%ip: S� �P/r7, n �- Phone yS 7 1
:%re you an cinplayer?Check the appropriate box: 'Type of project(required);
4. ❑ I :un a general contractor and I
I.[I 1 am a employer with 6. New construction
employees(full andilor part-unic).• have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 ant a sole proprietor or partner- - listed on the attached sheet. :
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. [:] Building addition
No workers' cum insurance 5. We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exert r exemption e MGL I LE] Plumbing repairs or additions
3.El I am a homeowner doing all work b P P
myself. [No workers' comp. c. 152, ¢1(4),and we have no 12.0 Rouf repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any:ytplicant that chucks box In must also till out the section Wow showing their w•urkuss'cumpem:aion policy inlinnuriun.
?l tumcuwners whu submit this affidavit indicating Ihcy am doing all work and then him outside contractors must nuhmit a new affidavit indicting such.
�Comraaurs that chuck this box must attached on additional steel showing the name of the sub-contractors and their workers'comp.policy information.
l aor an employer that is providing workers'c•ornpensation insurance for my employees. Below is the policy and job.site
infurmatfou.Policy A or Self-ins. Lie. fi: __..._.___ Expiration Date:
Job Site Address: City/Stateizip:
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`IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 andior one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a Jay against [lit violator. Be advi•cd that a copy of this slutement may be forwarded to the Office of
Inv'estigatiuns ufthe DIA for insurance coverage vciincation.
l du hereby terrify on, the pain. td penalties ofperjary that the information provided�zabove is true and correct.
Sicnautre: Dal(;. O ' -3 - O
official useonly. Do not write in this area.to be completed by city or town official,
C'ityorTow•n: Permit/License 4--_--- -- .-_-- _ .--_-- - .
Issuing AW hority(circle one):
1. lluard of health 2. Building Department 3. Cilyi fown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Coutact Person; _ Phone 8:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fix their employees.
Pursumtt to this statute,an ertrplgree 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:m individual,psumership, 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."
SIGL 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, b1GL 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 or cofnpliunce 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 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 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 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 ;n the permit/license nnnber which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicease 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 burn leaves etc.)said person is NOT required to complete this affidavit.
I he OI'f icc 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-NIASSAFE
Fax # 617-727-7749
Revised 5-2fi-US www.mass.gov/dia