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71 SUMMER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts - - CITY OF Board of Building Regulations and Standards SALEM >t,y Massachusetts State Building Code. 780 CMR Revi,sed.ilur 011 L., Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Fannl.v Dwelling This Section For Official Use O Building Permit Number: Dale App Building 011lcial(Print Name) Sig l SECTION II:SITE INFOR IATION 1.1 Property Address: ,y- 1.2 Assessors Nlap& Parcel Numbers ,Ce 1.1 a Is this an accepted street?yes_ no_ Map Number Parcel Numbcr 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Propowd Use Lot Area(sq it) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rcar Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)s stem ❑ Public❑ Private❑ al Check iryes❑ P P >' SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: I IS- �\ KarH1E:=�✓ -09alA�%f�d SiII l9gtKeYJ /. 119A 6)1VI Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition Elf Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work-: L. l= K 1 i B G SECTION 4: ESTINIATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1. Building S O(J 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost(Item 6)x multiplier x i. Plumbing S 2. Other Fees: $ � 4. Mechanical (UV:\C) S List: S. .\Icchanic:d (Fire S Total All Fees:S - --- Su Check No. _Check Amount: Cauh :\mount:_-- 6. Total Project Cost: S /�CIG)r ZO 0 Paid in Full 13 Outstanding Balance Due: r , SECTION5: CONS'rRUCTIONSERVICES 5.1 Construction Supmisor License C'SL License Numhcr --- I[Xpir:Lion Date N Lillie of C'SL I folder List C'SL I)pc(see below) _ No. Laid Street Type Description I htrestricted(Buildin+s uO ate 35,000 cu. It) Cigi Town.State.ZII'� / - R Restricted IXQ Pantil Dwclin+ M blason RC Roolin,C'overin WS Window and SiJin SF .Solid Fuel [turning Appliances I Institution Tole hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) I IIC Cwnpa! Name or I IIC I egislrant Name I IIC'Registration Number 1[spi ;ni, , Uule Syt✓�c'��C�/r/t 0.Laid Street 17S � df l � _ Ne% Emm Cicy/Town, State,Zip 'relc hone 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 .......... d No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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. Pnnt Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information c I at d in this application is true and accurate to the best of my knowledge and understanding. '7�1f f/� Pr ll( wcr' or Authorize)Agent's Name(lilectrunic.Signature) Dale 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\I.G,L. c. 142A,Other important information on the HIC Program can be found at g„p i,cn Information on the Construction Supervisor License can be found at,t y,o ma s.,in 'fp; 2 When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage, finished basentenCattics,decks or porch) Gross living area(sq. 11.) __ Habitable room count `'umber of Fireplaces-_____-__-._ Numberofbedroonis -- tint erofbathrooms ---------------- - Numbcrof half"baths I)Pe of heatine system --_--__.-----. _._ Number of Jecksi porches__-- T)pe tit'Cool ing system __ _.--------____ Enclosed —_-- Opcn -------- — - 3. "Tolal Project Square Footage-ma) be substituted titer"Total Project Cost' CITY OF SALEM " ' ' /r PUBLIC PROPRERTY DEPARTMENT MI1 Y:)MI41III Id:WANIII1\G IV\jIXIL•T a 3.\I f:.N, M.111.w.111 V.I Iwl'/7: 1'el: 77/.71Svin3 a 1:\x 979-7442•9a16 'iVorkers' Compensation Insurance Aflldavit: Builders/Cuntractursiciectriclrns/Plumbers \ 1 IIIcant Inrurmrtion Pleas Print Le 'hl V:IITO II1rnuM:.ii)r;tanvatiaNlnJlvJuull:_ ��75,{%j�/f `% iJ/�ir ��yj% /p� �w �, r'. cily,$fzlmzi(f:C Py- n' une .\re)nu an vutployar'!Check thor appropriatt bus: I I.© Ion a cm lit ur Wilk 4. I')Pt sit project(regttlrrd): cm I P y �_ ❑ I;un a yencol coulraztor and 1 t p uYiI(full and/ur putt-time).• have hired the sub-cunlrauturs2. t. ❑New cwJMtructiun ❑ 1 and a tole prioprictor or partner. listed ad on the artaehcd..hcct. ❑Retnladoling ship and have no mn lit cam Thr P Y st sub-contractors have g, v ❑ Oemolirion arkin liar m g aman w u•' w Y Patty. oaken'comp• insursnct. INo workers'cum , insurance 9• Building iddit ones S. We• ❑ IUII P ❑ are a corporation and its II rcyuired.) Otflcers have mtan:i.Med rh ' 10.❑Electrical re 7. Ian clr pain or additions ❑ t r hot nutwncr u'd mg all work right ofeacmption Per h10L 11.❑plumbing rcpuirs or additions myself.[No svpAcn'comp. C. 152,¢I(Q.and we have no insurance requited.l t .mpluyceM. [No workers' 12.❑ Rttu►'repuirs comf% incurancu myuiravl.l 12•❑Usher 'sly.yollivaW nip chucks ba rl soup:14a fill SW the volall whaW dW Wltle thyr WWkles,cantim"Ama m Itutivy luhamptwe 'IlumwtWrgn-he Submit this atllJsvir inatutine t11My+te"all ill WYA and from halt Wlede c1M MI•f MttraatSrl IhM.Mrk this fq�map sashed.m adJiliwyl ahwl Sllulvtne Ihv naMN of the tubeemraa•ISxs and than rurkms"Affidavit indianainy.tai. /flan art employer that It pruvldinK my rinp/r .J'arrr. Bdow Is M /ky un0/ab s//, ia`arutulutnt InsurancuCumPauyNalne: 1 T` S/�� /�7� Policy As for Sulf--ins. Lic.to: -/ - Expiration Date: C U, Job Jiru.AddntM: � Sld4dA/i�Q s'l�yl T City, \each it citify of the workers'cumpematlon policy declaration page(showing the policy nuntbur and explrstiuo date). I�ailure lit scours cusemye as required under Section?SA u►'SIOL c. 132 eau lead to nle imposition otcriminal penalties of a fine up m S1.3n0,aM an bur uae•year nnprisnnmvnt. us well av civil penulllea in the form of a STOP WORK ORDER and a Pint of up m i230.00 d Jay.il(ainat Iht viularor. Ile advised that a copy of this autclncln may bit lurwirded to the 011ice uY Inreshgauuns ul';hu UL1 for m+urara:uvcrugu \crilieahun. /da herrhy t crfify trader .tiny itrad prnufNrs of par/ury�h'a9�r tr in/brmallon pwvided above is true uad cornet J G t)//lriu/asr on/y. qd nor rvrlrr in rhis urea• ru be rmuplrtrd by city dr talvn a//h iuL ('icy fir 1'nwn: __ Pcnnit/Llnmsr 1 I I.vuing.\uhuriry (circle unit): II. 11luJ of Ilvahh ). Iluddinq Ihparuncul I. t:if):'futsn Clerk J. Llectrical tltspcctor ;, Plumbing Impeetor 6. 1)IIuT _ il'.wucl l'e nuu: I i information and Instructions >I;ts;achu;etts t.;cneral Laws chapter I i2 reyulres all evnpto)e in the ry ce of another emuter+nny ll +e their y contract of hire. Pursuant to this.++atuta, in empfos'ea is defined as".. every person c%press or unplicd, oral Jr written." or mt two or more �n ernpfoyer, Is defined as"an Individual,partnership,assaeiamoe,corporation or other legal eased Y t the G,regJmg engaged m a)eras enterprise, and including he legal representarives Jt deceased tees I Howavcr he ant of the I eCCIVer Jr lraalCa of.Vt Illdlvldual, plumersh+p,assoe+atioo or other leg'rl cnory,employing ' D owner of a dwelling house having not more than three to do maintenance.jpa steds and construction eur repair work oe such dwelling house dwelling house Jf another who employs Persons ar,Itv the grounds or building appurtenant Thereto shall not because of such employment be deemed to be an employer." MGL chapter 112. 425C(6)also states that"wary state or local 1lcensing agency shall withhold the Issuancefany renewal of r))cease or per to operate a business or to construct buildings Ia the commuowaalth for aaY :Ipplleant"lie has mat prods, §IJCa7►states esable Y Neither he commonwealthce of not any of u politicalwith the insurance R ubdivdons shall Additionally, %IGL chapter l3_, 3- enter into any contract for the partornwnea of public work until acceptable evidence ul'cuntpli ulce with the Insurance requirements of this chapter have been preserved to the contrgcving purhority."_ Applicants -king the boxes that OPPIY to your situation and, if please rill bat the workers' compensation alltdavit compleetely y oc number(,)@irmS with their certiHcute(s)of necessary.supply salt-eontrrctor(s)n arse(,),add r Limited i ): P with no employmm insurance. Limited Liability Campania,(LLCworkari teompansatioe iluumnce'(If an)LLC or LLP does have otherthan the members or partners, are not require)to carry employees,n policy is required. Be advised that this affidavit may be submitted to the affidavit. of industrialridevit 10 ortment of bit re�ieimad to the confirmation ity or tow the upplication for the peon Me or licensenis being frequested,not he Mpartm shoo I ndustrwl Accidents. Should you have any yuestioam regarding the law or if you are«yuired to obtain u workers' eompensatiun policy,please call the pe any t4u at At the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate lino. City or Town Officials v+t is complete :u+d printed legibly. The Department has provided u space Lit the bottom please he.ore that the affida Jt the affiduvit fur you to IiII nut in the event the OQica of Investigations has to contact you regarding he applicant. I'Ituse be sure to till in the permit/license nurnbar which in awilg en be used ear,needonlycsubmitunor. satT'tduvit addition, tcurtent Mat must submit multiple pannio'licmtsa applications y y Jf the affidavit that has been officially stamped or marked by tile city or town may be provided to the policy information Of necessary) and under"Job Site Address"the applicant shnuW write"all locutions Y o town)." \coDY. applicant as proof that a valid affidavit is on file for ILturo partr+its or licenses. t now a business must m filled out each venture Year. Where a home owner-or ciiizcn is obtaining a license or permit not related to any business d commercial vertu« I i.e. r dug license Jr permit to burn leaves etc.)said person is NOT required ro complete this affidavit. uaauons, I he t)slice kit IJvesrigations would like w thank you in advance for your cooperation and should you have any 4 please do nut hesitate to give USA Call. fhe Ucparun¢IIt's address, telephone and fro number: The Commonwealth of Massachusetts Department of Industrial Accidents OfIlee of[svesdgadons 600 Washington Street Boston, MA 02111 'ref. # 617-727.4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 t,..,„d 5.20.115 www.maw.gov/dia •J I CERTIFICATE of LIABILITY INSURANCE 19,1q,7g1D "i us CVnwcAle Is La As A PATER or N6rD;wrn W aar ua S Pro M%WTS UPON"COMFOGArF MMLOWn• TNIa i CERTWICAII WES NOT AFMRE,ATNRT OR HOGATA$T AMIEND, ETrfb OR ALIM THE W'WA0t APPOROW WT "0 wuCas � GROW. TRfa CWRTWICATY OF rbURAND9 DOES NOT CONS"m A COIPIRACr wrWw W me Im"G INWRaRtSI. 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Azohard bortolino Jr IneuSanCs A40ncy i ._.. 1200 males St 0121 iynnfield, Hk 01040 *Fn1fR04M . wuweP ressFAArbeila Mntaol :)osepts Me[s.l Carpentry IfawlP3rsnits StstarAZC 65 anstsan A" lot cArbella rnsuranne Swampscott Mass 01007 w=~-a� NnsM1 C0Y[RA(i!$ CflFrPrICA NO ERA _ RINt370//N09ER: � 4o' ___ TNC aaT2 � rtir AN^ RgaYw r7d 'dFC+Ia O Y :P�fe P r ND",060 N E 1 AN C n CR A C R ' OR "tmaO ODICf lYlrn 7EtP C1 q ,fl THIS IS _ERtlf CA'E LAW F ISSUEC OF, Mt IS INSURANCE- AVFnRDEO DV rHe vnUCIES OFSf r.NEU ` vq;.N IS SJtE^ "I ME -� TERMb, EXCLU,WNS AND CON01➢0N50F S.OCR PRI IfS UNIT eHOV-4 iWy HAUf eeeh FEULCEO a-PAO^'AIMS 011111 fiHr.YM11e1M1 � INwtNtlttVM} MaNV/ifYr'_._. r.._-__ t1MI7f _ _, A M"W'L LAaN. __... 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Swer pmCott Was D1907 wuiwAOap rax to 7OL-396-3713 ACORO 26 tAmmi Ito ACCORD 00m and"0 ets?W"?Pd InmllM Ot ACOR t •d Al/ f7SF&f)L6 21C ouc [o7.lee P��4JIt! r39k: �i0 OI ki [ 4�p ,T r CITY OF S.UY.AvI, Uiss.-kafUSE-ITS BCILDLYG DEPARTMENT 120 WASHLNGTON STREET, 3i0 FLOOR TEL (978) 74S-959S Fix(978) NO.9846 KIJBEAIEY DRISCOLL MAYOR THO.NAS ST.Pimm DIRECT01t OF PLOLIC PROPERTY/aUnMe4c;CO\p1ISstOYER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit Al 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 111, S 150A. The debris will be transported by: <kdc 1 (name of hauler) The debris will be disposed of in (name of facility) (address of facility) 93;lra—rureof permit applicant ��1/y data \t1I141 .I.IM1