18 SOUTHWICK ST - BUILDING INSPECTION O ---- ----- -- I hr (',unn),n)„e.d(h ,d \I.)s,aehusens
�L t liffurd „I liulldin�: KrL!ulatlt IIS .olJ SIa111dAld, t
\\ I;y\ .y \I;usa.husrlD State 13miding Code. -So ( MR. 7 ' rd111,y1 i `II Sli si \I i I 1
liuildin_ Pcimll :\hplic.mOn -,m Iru.(. RrP.An. RCI)Iodle Or t)rnuJi h 1 "' 1
tb - nr 75c,1- funilr 01,,Milt! / _>4 N'
-- 'his Sera n For OIIielal I',e Only — -- .
LBuddlne Petnut NUlnhr _._ i D.ue Applied _ _-7�(/_�
BulidlnE l' nniul,.n nfc✓ It p (of I ILuldulgs Dale
F.CI'ION I: .SIIT INFORMA VIO:N
j 1.1 Prrnop,-v rrt�y�.'k cidt;eess:,.--- �• /- _ - r/1--- -i I.' Assessors Map S. Purtel Numbers -
'I �Jsnt/il WI�F-J-I-- J�LL/✓��.L=F1�-- I _ _ .---- .. -�_ _ . _ ._ .
I.Lt I, this .m ., I I rd ,n,-c, xr, . .. no-.-- �_-
1.3 Zoning Infor natinn: -_- _-- I 1.4 Property Dimensions: --_-- - -�--
C I. 1rrp Jlat :•"f'jh , J 1',C __ t. f I aa� t - fJii dlt 11:
�._.._. Building Setbwr;s ;fti
From tilde Yards �— Rear 1 uid
RryuilcJ Pr(.,IJcd Rryuned Pro Idrd ! Keyuu eJ
---
1.6 1i'nlrr Supply: ;S7 G (.r. +0. §j4zone:
Public 5� 1.7 Fwu.. Zone Informatiuu: 1.8 Sewa a Disposal Systeat:
0/ Pncatr❑ Outside Flood Zone"
— �Yium n up clpal O ,Ilc Jo,ai m, ;c ❑ {
Check it yrs❑ _-- --__--
SECTION ': PROPERTY OWNERSHIP'
=.1 Orenerl of Record:
i
(P� , sic4 ._ _LS,iOSJ» �t1z� SE
t37t
.-N iw,- f Print, Address for Set,ue:
Sfgr;Wre - -_ relephune
3 DESCRIPTION OF PROPOSED WORK2(cliciic ad that apply;
'slew C�nstrucu,nt ❑ Existing Budding 1Gr i)aslcr-Occupied Repairs(s) �I \I:erauunut ❑ T ` ' II .,I ❑
nrmnhtiun 7 1 ::ices,ory BIdNumhrr of Units Other 0 Spully
!3rie(Dcsctipunn of Proposed
I
SECTION 4: ES'rl St ATED CONSTRUCTION RUCTION COS i S
Ilan Estimated Cuts: I Official t'se Only --
II ah„r.Ind
j I 13ulJlne I. Building Permll Pee: S._— Indleate h,o, fee I, deiei Inowd.
---- ', ❑ Standard City/Tfnvn Application Fee
' ec_. F7tncal 5 M r,nal Project Cosh (item 61 x multiplier x
1 'hn 5 1 OlherPers: 5
�(ecmrul IH\'.\CI _
----- -
Iut:
,
i Mechamral (fire I
F.,taI :1I Fee, S
� Su ,IIr„Inn l ----
_�-_.__ ---+- -- � tlhe,k N,t Check \Inuunt C'1,11 \In:uul;
If total Project Copt .( 0 Paid In F.111 0 OuRlandow Balmi,e Uue
SEC'CION 5. CONSTRI CTION SERN R ES
5A Licensed Construction Supervisor lC'SI.1
I
LI„u,c \uwhir I.,pl Lllunl Il,lli
i
IhdJcr
LI ItlSI. 1\pe llci hi lm,I
\,LIIi,. -_ __.___- ._-_____._—- ---_-_ .Lt ><• Di lit alnn -- _- _�
l l nrt',In,IiJ
R Re,mocd LC_' F.ulnl, 11"illlne _ -_-I
i c:l.Ilwi f-k
Itl+hit .-____-__ � t-i 'FI` 111.
uIIJI in'IIJ I lu
I tic ks
llni_y\i,L i.uL_ n_L, i_tl: n
It
5.2� R istc ve lame Im ruva•mrnt Contractor IIIIC'1
P
/ 2 I
Rrgl?II JIIUI IIIIIhCI'
HIC tom tury Nauli or IIIC Rigu NIIl•lranl a i
Sr 1&zRe1L)P,-e ,1nA
F, uauou 611te
Signature fcicphone
SECTION 6: WORKERS' COSIPENSATION INSURANCE AFFIDAVIT IM.G.L. c. 152. § 25CI611
Workers Compensation Insurance affidavit must be completed and ,ubmitted with Ihu application. P.ulure to poi,Ide
this affidavit will result in the denial of the Issuance ot'the budding permit.
Signed Affidavit Attached" Yes .......... v 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 inatlCrs
relative to wou k authorized by this budding permit application.
Signature of Owner Date
/ISECTION 7A: OWNERt OR AUTHORIZED AGENT DECLARATION
1 �C l/a fey , as Owner or Authorized Agent hereby Jec tare
that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
behalf. -
Print Name Si
.Signature of Owncr or Authorized Agent Dal i'
I Si ned under Ilse aln,and penalties of (u I
NOTES: _
1. An Owner who obtains a budding permit to do his/her own work or an owner who hires :ul unrogl,teted coats, 1,11
knot registered In the Home Imprilsement Contractor (HICI Program). will not ha,e acre„ to me Jthitraoon j
program or guaranty fund under M.G.L. c. 112A. Other important Inhlrmauon on the I lft' Program .Ind
Construction Supervisor Licensing WSLI can he found in 780 CNIR Regulations 1 10.R6 :md 1 10 R5. ic,peco,cly �
When ,uhNtantial work is planned. pn„Ide the mformalion helow�
Total f1mos area iSy. FL I including garage. finished haxmenl/a¢Ics. decks ur pnrchl
t iro,s living area I Sy. Ft.I Hahiteble nmin count
I Numbered ureplaces__ Numher ,d hedromn, _
Ninnhei of hathnu,nls - Numher in h.dlihalhs
I',IIe of hearing ,,Item ------- Numher Id Jcck,i III It, -
I ,peiltsl ,�hng „stern----- ------ 1`n,l,,seJ -- -------- - upul
i7. "r„tat Pmlect Square Fol,lage" may he substituted far ..5,1al Pmlect
Page# of pages
/yam/
Proposal Submi d To: _ Job Name Job#
/J A O r ,e _
Address _ f y Job Location
Date Date of Plans
Phone# Fax# Architect
We hereby submit specifications and estimates for:
We propose hereby to furnish
material and labor—complete in accordance with the above specifications for the sum of:
Dollars
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs will be Respectfully
executed only upon written order, and will become an extra charge over and submitted !/
above the estimate.All agreements contingent upon strikes,accidents,or delays
beyond our control. Note—this proposal may be withdrawn by us if not accepted within days.
2cceptance of i3ropoo5al yn
The above prices,specifications and conditions are satisfactory and are ....,J �,� �I�e_Signature
hereby accepted.You are authorized to do the work as specified.
Payments will be made as outlin�ed�above.
Date of Acceptance Signature
&--,NC3Bt J MADE IN USA - _
" •'' CITY OF SALEM
A PUBLIC PROPRERTY
DEPARTMENT
I \S: 'i78 '4:_ I.i{n
Construction Debris Disposal .affidavit
(required lbr all demolition and renoyaliun work)
In accordance \%ith the sixth edition of the State Building Code, 780 C NIR section 1 1 L5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit if is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility ds defined by MGL c
111, S 150A.
The debris will be transported by:
L L2 / yz�ABC;
(name of hauler)
I he debris will be disposed of in
(name Of facility) I/
q� wrz5r-3 r AO.Z;2���r
taddress of funlity!
- .Iglmture o(permit applicant
O
�I
CITY OF SALEM
a
PUBLIC PROPRERTY
DEPARTMENT
\Liim I \C l • i.v
-I'I.t: '1-g-'i j. JS'Ii #
Workers' Compensation Insurance Af ida,I,it: [Builders/Contractors/Electricians/Plumbers
%nnlicant Information y� // �// /J� Pleapse Print Legibly
`;Illle tnneme,slhgant�anon.Imhc tdu.rl l: —y��"/ ` r" �jy e `--- -
Alldl-CSS: f-. _21lLFI�� �rt - �y
('fly. St:lte2ip:zj&lj / e ,A4 29 0& Phone 4:_� ✓� r� �2S
.tire you an emplo)er? Check the appropriate box: Type of project (required):
I. fV/ I atn a employer with�3 -__ 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and%or purt-time)." liaye hired the sub-contractors ❑ Remodeling
2.❑ I till a sole proprietor or partner- listed on the attached sheet.
7.ship and have no employees -Chew sub-contractors have 8. ❑ Demolition
working for the in any rtpacity. workers' comp. insurance. y. ❑ Building addition
No workers' corn insurance 5. ❑ We are a corporation and its
I e P ❑
required.) officers have exercised their 10. Electrical repairs or additions.
3.❑ I am a homeowner doing all work right of exemption per MGL I I. Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.5/Roof repairs
insurance required.) r employees. [No workers' 13.0 Other
comp. insurance required.)
*Any Jpplicant that checks boa NI must also till out the section below showing their workers'compensation policy information.
t I lomeowncrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:('untraciors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l ain air employer that is providing workers'compensation insurance for try employees. Below is the policy and job site
information'
Insurance Company Name:
�+t �1C0�1p�!�IAJ��C/�/YrC'C Oi // fjyss' �c �7W� -rLC t�BM�✓U�
Policy # or Self-ins. Lie. #:��i wl 6(Jl7,�t��^/1 14Q 00 Expiration Date: AA
Job Site Address: IliSoo w I e k S / CityiState/Zip: -e� 44-1 -
fi
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Ftilurc to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S I,500,00 andtor one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a fine
of up to S250.00 a day against rile a'tolator. Be alivtsed that a copy of this statement may be forwarded to the Office of
Inl ,tie:uions of the DIA fix insurance coverage.aerilication.
l do hereby certi[)• under dte pain. ind pe ties ol perjur-that the itfirrtmtiorr prrrvided aboveitity true and
correct.
iie-miture: Dal �z// tl�
�7
I'I,nne
01.1irial use only. Do not write in this area. to be completed by city or town officiaL
('it% or I oan: - --------__..._ ___ Permit/License #-- _--_--- —_ ..--
[%suing Authority (circle one):
I. Board of Ileaith 2. Building Department 3. City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
('on tact Person:____-- -----. - --__—_-- Phone #:-----
Information and Instructions
\I:15Aai huseus General I_:nvs chapter I>' requues all cmplohcrs to pro%ide workers' compensation for their emplo)ees.
'i'unuant„ii)'this statute. in i•urphrree is dclincd as -. C%cry
cvpres ormp
person in the sen ice of another under ;thy contract of hire.
' ilied. oral or wrinen.-
.\n onrplo-Ver is defined as "an indi\idual. painicrship, association, corporation or other le__al entity, or arty two or more
of the folceoing engaged in a joint enterprise, and including the legal representati%es of a deceased employer. or the
rrcei\cr or trustee of an individual, p:umership, association or outer Ieeal entity, employing employees. l lowever the
,�mvner of a dwelling house haying not more than three apartments and hvho resides therein, or the occupant of the
dwelling h0USe of another who employs persons to do maintenance, construction or repair work on such dwelling house
or ant the grounds or building appurtenant thereto shall not because of such employ nieni be deemed to he an employer.'•
\IGI_ chapter 15?, §25(-(v) also states that "esery 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 cunimonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter I52, j25C(7) states"Neater the eonuuonwealth nor any of its political subdivisions shall
enter into any contract for the perfm Malice of public work until acceptable evidence of compliance with the insurance
requirenments of this chapter hate 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-contractors) 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 till in the permivlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemmit1icense 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
6 e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
the t)dice of Investigations would like to thank you in advance for your cooperation and should you hate any questions,
please do not hesitate to give us a.all.
I he Dcpaitnhent's address, telephone and fax nunibec
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
Re%iced 5-20-0 Fax # 617-727-7749
www.mass.gov/dia
f
. lie (�o n�nrc�inee<i/!fir n>�� l��.uac�inw,lld ,
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
t
Registration: 153284
Expiration: 11/14/2008 Tr# 253330
Type: Individual
MARK CORA
MARK CORA
199 WILLOW ST.
LAWRENCE, MA 01841 Administrator
1