26 SOUTHWICK ST - BUILDING INSPECTION p4 The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
�) Massachusetts State Building Code, 780 CMR, T°edition Building Dept
Building Permit Application To Construct, Repair, Renovate.Or Demolish a
One- or Ttvo- #fidt Dsve( g
Thi tiort,For Official U e Only
Building Permit N mbb/er. Ite ppl'eci:
Signature:
Building Commissioner/Inspector o uill ngs ate
SECTIO E INFORMATION
1.I Property Address• 1.2 Assessors Map& Parcel Numbers
2� �o� 7-ww/ak- Sr t - 7 �� - umber
I.i a Is this an accepted street?yes no Map Number Parcel Number -
1.3 Zoning Information: 1.4 Property Dimensions:
Og
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided G
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipalq On site disposal system ❑
Public`F Private❑ Check if yesUil
SECTION 2: PROPERTY OWNERSHIP'
2.1 r
Ow /d
ner'of Record/J:
F/ /p tLCS/
Name(Print) Address for Service:
4 9f 2y4( 92-I/
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)V1 Aiteratiorl ❑ Addition ❑
Demolition ❑ Accessory Bldg. O Number of Units Z Other ❑ Specify: .
Brief es ri ion,ofPro�°s,ed orkr: :fix •f ! rl'/1 '1-/!'1 ..1'' ! ti' `tj/i �^,-
J if' Tou �/:'+- .•'�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
O Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S �d I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing E 2. Other Fees: 5
4. Mechanical (HVAC) S List: v
5. Mechanical (Fire S Total All Fees: S
Suppression)
/- Check No. Check Amount: Cash Amount:
`
6. Total Project Cost: $ "6o 0 ❑ Paid in Full ❑ Outstanding Balance Due:
,/
/ t own e, D�//. e�/ •
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /U 6 L
<y - License Number Exptration Duce
Name oFCSL- Helder n^p List CSL Type(sec below)
Addres ` r DescriptionFt
�U Unrestricted(up to 35,000 Cu. Ft.)
Signature R Restricted I&2 FamilyDwelling
CQS^7 �Y"f"� M Masonry Only
RC Residential RoofingCovering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Buming Appliance Installation
D I Residential Demolition
5.2 R t isere�d.H�aImprovementContractor(HIC) pj'n
P ( V 7 : /
HIC Com any Name or HIC egistrant ame Re}�istrat}°n Number
l a ✓l c1 Twm./ f! �/
Address^20� Iy�rJ
Expiration Date
Sitgature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
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 this building permit application.
6G� 3123 45'
Si nature of Owner Date
\ SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
.A that the star ents and inf rmation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
,;.
Print Name
pNIUP RA)Lff Aza ?b3M-5
Signature of Owner or Authorized Agen Date —//
(Signed under the pains and penalties ofperjury)
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 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 I O.R6 and I 10.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) 1 (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) ty 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"
yob
J
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I,u'. K I' IKht •'I I
fist •Kt 11 W,NrO�o:I,,TSI:t LLI' IfSAII'%4. MAVS%t III it l 031`7^;
I'ra. 7yt-,'li•,i•+5 • 17 tx 9711-74;:-J.446
Workers' Compensation Insurance 'i fidalit: Builders/Contractors/Electricians/Plumbers
fi rlylicant Information Please Print LeeihlY
V:IITC tBu.uwsl)r;tanlr.orim •Indn uls S�C �h' ����.
Address:
Cily.State.%ip /�Ja Szc� Phone
.fire y use an employer:' Check the appropriate boa: 'Type is project (required):
1.❑ 1 :un a employer with 4. ❑ I um a gcncral contractor and 1 f,. ❑ New construction
have hired the sub-cuntracturs
�,J ,III a sole
riclorindau part-tune). 7. ❑ Remodeling
2.uSI 1 ,III a sole prnpricox or persona- listed on the attached sheet. •
,hip and have no e,nployuu. These stub-contractors have g. ❑ Demolition
t.orkrng for me in any capacity. %workers' comp. Insurance. 9. ❑ pudding addition
No workers'corn insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
I rcyuircJ.) officers have excrclseJ their
ri ht of exemption ❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work per MGL I I.
P 5 P '
tnysclf. [No workers' comp. C. 152, ¢I(4), and we have no I2.❑ Rtwf rcpalrt 11
insurance required.) r ctnpluyces. LKo workers' 11.0 Other C1 l� • .�' is it
comp. insurance rcquired.j
•wn. .,,phwma ust d:ccks boa pl must also till our IN WC1.011 Iwluw,huwiny IN=wurktas•cumpens iwt pt licy mtinnuriu
' I wmauwrcn.vhu wlimil this atlldavit indicasina Ihcy are doing sell work mN Ibcn him twtwlde cauncton muss.uhmit a new elf:davit nlJiurma wch.
4-,mtracuK that tht,ck this box most Jnouhcd.m a waiund.-Nvi,h,-wioa tlw n:mW of tts sub-conu sciont and their wurken'amp.policy mfurmanun
l ant an emplayer that it prurfding workers'c•umpcnvation iurarance for troy eurplgyets. Below is the pulley and job.rift
atfurnmtion.
Ir.,urancc Company Vane: _.__ - -- - ----'----
Poli.v is or Sclf-inn. Lic. h: __.. .. . .. __ Ettpirallon Date:
Job 'Sile Address,: ___. CIty;Slate,Znp:
Attach it copy of the workers'cumpeniatiun policy declaration pale (showing the policy number and expiration date).
Imallure at secure cuserage as required under SCUIun 25A ul'.IGL c. 152 call lead to the imposition of criminal penalties of a
fine up to i1.54)0.00 iriXor une-year inpriminlnent• Js twc1l as ciwll penalties in the funn of a STOP WORK ORDER and a fine
Of op aI 5250.00:t J.ty against the violator. He advised that a copy of this slutnncnl may be forwarded to the 011ice of
1,1% ul :hc DIA :or io,ur,wcc cow cadge scl ifical:on.
l du herrby r crtif, u.lr rile pr r and penolliew ufperjary that flit infurtnallon provided buve 's true aad e'orrecl.
s)firiai ase ugly. Dd not write,in this area, to he t urap/rled by city or town ojjit'iul. 1
( ilv fir 1'owri: _... __. PertRityLicVnic 0,
Iswinu .xuilturiiv (circle one): i
I. IIl,ard of ItvalUl !. nuddiu;; Dcparuuent 1. 1iliAwito Clerk 4. Electrical hiipccror 5. Plumbing laspeclor
6. other _
Contact 1'c Phone h:
Information and Instructions
�Lus.r:huscus lit-ncral Laws chapter 152 rcywres all eu y,loyers to provide workers' compensation for their employees. �
Pursu.wt to mis ,tatule, all empluree Is dctined as " every Pelson in the service of another under.illy contract of hire,
express or onphed, oral or written."
0
An :jnpluper Is defined as "an Individual, partnership, ssociatiou.corporation or other legal entity,or any two or more
"I the t0reeou;g engaged it a prim entcrpr,se, and including the !cgal rcpresematives of a deceased emplu)cr;or the
recencr or trustee of a' individual, pwincnhlp, assoctation or other legal clinty.employing employees. However the
uwner of a dwelling house having not more than three apartments and who resides therein, or the occupagt of the
dwelling Iwuse of another who employs persons it)do maintenance,cunstruction 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."
\IGL 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 wbo has not produced acceptable evidence urcumpllance with the insurance coverage required."
Additionally, %iGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any :untract for the performance of puhlie wurk until acceptable c.'idence ul'cumpliance 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 yuur situation and, if
necessary, supply sub-contracior(s)narnc(s), address(es)and phone number(s) along with their certificatc(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 Depurtment of Industrial
Accidents for confiriation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
Lie 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
Mr-insurance license number on the appropriate line
City or'rown Officials
Please he 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 yuu regarding the applicant. -
1'I.ase be sure to rill in (he pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitaicetse applications in any given year,need only submit one affidavit indicating current
policy information(if necessa r,�)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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lu I l(ti:c UI wuuld line to dank )'ou In A%ancc fur your Cooperation and should yuu tease .my questions,
please do nut hesitate to give us a call.
fhc Dcp.unncnt's address, telephone and fax number
• R
The Commonwealth of Massachusetts
Department of Industrial Accidents
-- - Od1ce_of.Investigations—-- ------------,- ----_------
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/die
CITY OF SALEM
PUBLIC PROPRERTY
DEPAKT'' ENT v
'd .,„i: N,ni\�_oN?r1Ua-r • >.tii m. \I.t.;v i . _I'o _
I i: ')'a--4; 9;�); ♦ I %Y: '),% '4„ )84o
Construction Debris Disposal Affidavit
(required li,r all demolition and renovation work)
i
In accordance ith the sixth edition of the State Building Code, 780 Ch1R section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall be disposed of in it properly licensed waste disposal Facility as defined by MUL c
111, S 150A.
The debris
will be transported by:
(name of hauler) '
I he debris will be disposed of in : •
14 7-IG&- s
(name of facility)
le-e,. .
(ad(lress of Iacilily)
,ipnaturc of psmit applicant
Ja(e
L
Y
CONTRACT
Q&R Construction
Swampscott, MA 01970
Philip Bailey
26 Southwick St
Salem, MA 01970
Provide materials and Labor to raise first floor to its original location and re-support all
affected floor joists.
Work to be completed on or before by March 25t' 2009.
Total cost for this work shall be $4000.00
By my Signature below I Agree to have work the above work performed:
Philip Bailey
26 Southwick St
Salem, MA -1970