7 STEARNS PL - BUILDING INSPECTION f ti
The Commonwealth of Massachusetts
(� �y Board of Building Regulations and Standards Town of
v kj Massachusetts State Building Code, 780 CMR, 7" edition Building
Building Permit Application To Construct, Repair, Renovate Or Demolish a *Ia"Vadmea
One- or Ttvo-Fandly-Dwelling
/ This Section For Official Use Only
Building Permit Num e . Date Applied:
Signature:
BuildingCommissioner/Inspector of Buildings Date
SECTION l: SITE INFORMATION
I 1 Propert�y"Address: 1.2 Assessors Map& Parcel Numbers
ST(Z( r_ _ E°I¢CP
I.I a Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information:- 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(t))
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 Zone: _ Outside Flood Zone? �I<
l7� Private❑ . Check if yes❑ Municipal 0 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.I Owner'of Record:
Pe 7 e is°vrs e 7 elice
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
�rA/I 17 l sJD,,J Cr
ag.11 ' rtc'wf wr o uJ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑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: $
22 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ UU6. 13 Paid in Full 0 Outstanding Balance Due:
P �
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 71 k.57y _�_.1
'K C r/os /__/\e3 License Number Expiration Date -
Ngme of CSL- Helder ��J y/ List CSL Type(see below)J
Cam^7YA/ Sf 40K " " T Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
o� R Restricted I&2 Family Dwelling
Si nature �3 G'/ M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improveme/n't Contractor(HIC) / 3 S
; Ip /✓Yn7` erS lrCYl S'fi�tJC�i'J.'� Registration Number
HIC Compan Name or HI Registrant Name,
S-`7 �Pn NA� 5't / Ce —/O
Address G�+
R/o -33s-3GJ/ Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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
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 /�-tC/ (Secl✓j 'e ,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.
Grrrl�s so•vles
Print Name 1,2
Signature of Owner or Authonzed Agent t� Date
Sign under the ains and enalties of er'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 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 10.116 and I IO.RS, 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
3. "Total Project Square Footage-may be substituted for"Total Project Cost"
�y S
CITY OF SALEM
PUBLIC PROPRERTY
DEP ART'.�f ENT
I I: 1)'8-'4 i s: 'i'S.'4;- 't.i L,
Construction Debris Disposal Affidavit
(rcyuired for all demolition and renovation woi k)
In accordance �%ith the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
. -5-jr4ak4N, L✓/qb- "c
(name of hauler)
I he debris will be disposed of in
-- (nume of facility)
(address of facda.v)
signature of prnnit applicant
/, - -o P
date
J
CITY OF SALEM
PUBLIC PROPRERTY
~" DEPARTMENT
L1\11:Y x!.1!Y J&IICULL
�f\Yt Nt 12(J W ASHI NGTON Six r.El' • SALt M,MASSACI ll l'l17'1 s 01970
'foil,978-743-9595 • fsx:97B-740-'J846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADDlicant Information / Please Print Leeiblv
Vime (BusilxssiOrganintioNlndivid /'ual): f Ay- IU1
Address: - 7 Ct'it7�/i4 Imo, S t p
CityiS[a[c;lip /'e��/i.L� / yr PI.Vo Phone 335 — 3,6!
Are you an employer?Check the appropriate box: 'Type of project(required):
4. ❑ 1 am a general contractor and I
I.El 1 am a employer with G. ❑ New construction
em)laces full and/or art-time).' have hired the sub-contractors
! Y ( P" 7. El Remodeling
2.ILy,1 ;un a sole proprietor or partner- listed on the anachcd sheet. :
ship and have no employees These sub-contractors have S. ❑ Demolition
working for an,: in any capacity. workers' comp. insurance. 9. ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required] utfiecrs have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL i l.❑ Plumbing repairs or additions
myself. [No workers' comp. C. 152, §t(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. LNo workers' 13.❑ Other
comp. insurance required.)
-Any yphcuut that checks box Mt must also fill out the u-ction Ixluw showing their workers'compensutiou policy infurmatiu2
l lomeuwnats who submit this affidavit indicating they areing do all work and Then hire outside conlnleton must auhmit a new affidavit indicating such.
C'ontncwr..owl check this box must attached an additional sheet shuiviny file 'auto of the sub-contractors and their workers'comp.policy information.
l our un employer that is providing lvorkers'coinpeiisation insurance for toy eurployecs. Below is the policy umd job site
infurrnution.
Insurance Company Name:---.--. .. .. . ... . ...... .....___--__.----._---
I'olicv 4 or Self-iris. Lic. r; _. .- __ _ Expiration Date:
Job Site Address: Cilyislate/Zip:
Attach it copy of the workers'wmpensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of`lGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S l.500.00 and/or 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 day against the violator. 13e advised that a copy of this statement may be lurwarded to the Office of
Investigaumis ulthe DIA for insurance cnvcragc ecrilwatiun.
l do hereby certify under the pains and petraltiev of perjury that the information provided above is true and correct. -
v S;c:,atllrc: Date /,2 - 3/-y
ph"re4 57k - 33S= 3�v1
official use only. Do toot Ivrite in this area, to be runipleted by city or town official.
City or Town: _ Permit/License
Issuing;\ulhorily(circle one):
I. Board of health 2. Building Department 3.Cityrfowu Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Pcnou:. - Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
c�press 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 an individual, partnership, 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."
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 the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.-
Additionally, bIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfiomwnce of public work until acceptable evidence 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 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(he pennitflicense number which will be used as a reference number. In addition,an applicant
that must submit multiple penniUlicense applications in any given year,need only submit one affidavit indicaring 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 Oliicu of lovesti.gations would like to thank you in advance fur 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
Offtce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05
www.mass.gov/dia