40 SUMMIT AVE - BUILDING INSPECTION (5) • 0. �
the Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
r 't m OFSALEM
Massachusetts State Building Code, 780 CMR,
Revised Autuorr
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tiro-Fomi(F Dwelling
(� This Section For Official Use Only
Building Permit Number• Date Applied: L
Signature: •--- �• /�
LJ
Building,Cu nissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
I. Pro erty ress Add • 1.2 Assessors Map& Parcel Numbers
1 I
1.la 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 It) Frontage(fl)
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❑ Private❑ disposal y
Zone: _ Outside Flood Zone? Municipal❑ On site dis l system ❑
Check ifyes❑ P P
SECTION 2: PROPERTY OWNERSHIP'
2.1 wneert of Reel, 45too 1n
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alleration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other 23,' Specity: W�ctbvr
Brief Description of Proposed Work--: Xn--4 .kl I WObalt:�.-... i-•z- �(«.ee InSc+'�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S 3 _•OD 1. Building Permit Fee:S Indicate how tee is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost'(Item 6)x multiplier
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) $ List: T `l
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /Z 1
c n roUS3 (
License Nwnher Fxp1iration Date
N:une ut C'SL- I IaIJr i 'M I.ist C'SL 1'spe(see below) v
I Clo:S S'— �'CttkW Y' t O All
C
/qr Tv Description
:lJykSss ,t lip
(�JI it Unrestricted a to 35,000 Cu. Ft.)
R Restricted INt2 Family Dwcllin
Sig/n�ature as NI Mon Unl
Yl� �S7fc RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
+- h
I1IC Company Name or IIIC RdSistrant N Registration Number
11� erncc ro- a9 �a b ��7�i
Address ! !
�70 J ) S — pU"(, Expiration Date
Signature y Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 AUTHORIZ ,IF-
TO BE COMPLETED WHEN
OWN'{E�R'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, .].2'imY— tN_\ as Owner of the subject property hereby
authorize (y 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, ,� 6M ,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
Signature of Owner or Authorized Agent Date
Si ncd under the pains and penalties of perjury)
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 root 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 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 hal"aths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"
~ "e CITY OF S:U.ENlj %LkSSACHUSFTI'S
BUILDL\G DEPAaTNLF_NT
120 WASHINGTON STREET, 3"FLOOR
�a,eef TEL (978) 74S-959S
Riix(9 7 8) 740-9846
j.\IBERt F_Y DRISCOLL TH01iWST.PIERM
,MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING COSLL.IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4 � Ilcant Information �'` Please Print Legibly
ValltelBmila�ss�Organimtiarvindividuaq: Z+'+- �N''�`t't�
Address: 11 CdUSS 5-4 gr;M.(K (440--
City/State/Zip: 2cirr4 (Mir oos Phone#
Are you an employer?Check the appropriate box: Type of project(required):
4. ❑ 1 am a general contractor and 1
yr ] I am a employer with g 6. ❑Now construction
r` employees(full and/or part-time).• have hired the sub-contractan
2.❑ I a sole proprietor or partner-
listed on the attached sheet. • ❑ Remodeling
ship
and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9.. ❑ Building addition
[No workerti comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
required.) officers have exercised their
b
ri ht of exemption r MGC I I.❑ Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work P per
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers' 13.0 Other
comp.insurance rcquimd.J
-Any uppllcam UW ddaka boa el mum alw,rill out the seafiao below,showing their wmkai compammion polity mturmatiun.
'I hvmuwmn who submit this affidavit indicating they ate doing all work and then hire outside contractors mutt submit a new atlidavit indicting such,
:Commium that chaok ibis box must anmhod an additional chat showing the mmm,of the subaantncton and Ihelr wurkmi ramp.put icy information.
I am an employer thatds providing workers'rompenradon brsurance jar my employers Below Is the policy and Job sire
information.
Insurance Company Name: e�k..��� Job•. Ww6)I. 1vrSw `�
Policy 4 or Sclf-ins,
//L//ic.d: /� Expiration Date: ,�7
Job Site Address: 7l) �vvsk&,_ City/Starr/Zip�Sn�W, V 1 VZL
,\heels a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failures to secure coverage oa required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
lint up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations ul'the DIA for insurance coverage verification.
/du hereby certify and th paja(�ailed penoldes of perjury that the information provided above is true mid correct.
S'o I l///� Data:
Q/)ivial use mdis. Du not write in thir area,to be cotupleed by city ur lawn agicial
City or Town: ___. Permit/I.Icense q_-___--
Issuing Authority(circle one):
1. Board of Health 2. Building Department J.Cilylruwn Clerk 4. Electrical Inspector 5. Plumbing Inspector �
6.Other
Contact 1'cnon: _ _.. . . Phone g:
[
Information and Instructions
%fassadwscus Gcneral Laws chapter 1 i2 acquires all employee to provide workers' compensation liar their culployces.
Pursu:utt to tills statute, an empluree is defined as"...every parson in the service of another under any contract of hire,
%press or implied,otal or wriaten."
An employer as defined as"an individual, partnership,association.corporation or tither legal entity, or any two or more
a the liareguing engaged in a Joint enterprise,and including the legal representatives of a deceased employer,or the
i"aver or trustee of.un individual,pmtncrshnp,association or other legal entity,employing employees. However the
owner of a dwelling house having not snore 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 in employer."
MGL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the Issuance or
renewal of it license car permit to operate a business or to construct buildings in the commonwealth for any
:applicant who has not produced acceptable evidence of cumpgance with the Insurance coverage required."
Additionally, MGL chapter 132, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomwnce of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely,by checking the boxes that upply to your situation and, if
necessary, supply sub-contractors) name(s), addresses)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,is 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
he retumed 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'rown Orftclals
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of cite affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
11Idase be sure to till in the permit/license number which will be used as a reference number. in addition,an applicant
that must submit multiple penniulicerse 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 ilia city or town inay be provided to the
applicant as proof that a valid affidavit is an 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 i.e. ;a dog license or permit to bum leaves cte.)said person is NOT required to complete this affidavit.
I he ()i lice lit Investigations would lake to thank you ill advance fur your cooperation and should you Ita%c:my questions,
please do nut hesitate to give us a call.
f he Daparuncnt's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
OIHce of lavesdgadons
600 Washington Street
Boston, MA 02111
Tel. 4 617-727-4900 ext 406 or I-877-MASSAFE
Fax #517-727-7749
www.mass.gov/dia
1
CITY OF S.U.&%l, ,L1SS.AufUSETTS
• BULDLYG DEPARTNMNT
120 W."JiNGTON STREET, 3"FLOOR
TtrL (978)74S-959S
FAX(978) 740.9846
KIN(BERLEY DRISCOLL
,)MAYORTHo.�us ST.P�tRs
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CO%WISSIONER
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 It 1.5
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 be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(natric of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
L
dare
dabnvlr J•�: