47 SUMMIT AVE - BUILDING INSPECTION The Conunonwealth of Massachusetts
i Board of Building Regulations and Standards I'e llz
r ,i, kl(;NII'IP.11 I IY
�.' Massachusetts State Building Code. 780 CMR. 7 edition
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Building Permit Application To Construct Repair. Renovate Or Demolish a R,n9cd Atim , I
One- or Tit o-Fan)ih, Dtcelling
This Section For Official Use Only
,�\\) Building Permit Nut ec Date Applied:
Signature: _ . -
Bui mg Convnuuoned Inspec for of Buildings Date
�-- SECTION l: SITE INFORMATION _
1.1 Prgpy�r Atd ress: we 1.2 Assessors Map & Parcel Numbers
I.la Is this an accepted street'? yes no Map Number P:ucel Number
1.3 Zoning Information: - 1.4 Property Dimensions: - —
7mmiP Disin" Proposed Use Lot Area tsq it) Fro::;ale i!il
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
! Required Provided Required Provided Required Provided
I
1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood"Zone? MLJ113ci JI ❑ On site dis xual s xcm ❑
Public CY Private ❑ Check if ves❑ p I y
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record: -
Name(Print) Address for Service:
Signature Telephone -
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building Owner-Occupied epairs(s) ❑ 1 Alteration(s) E-- Additi"11 ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': -
�i++,rt �r�h - Ceb i�, '�•✓6Ge 5/a-eP.(^v5 ® rat oe�' P/.vas
-- SECTION 4: ESTiMA'I'ED CONS KUCFION COSTS j
Estimated Costs:
Item Official Use Only
I (Labor and Materials) _
I. Building $ 7/ �- t. Building Permit Fee: $ Indicate how fee i.c determd:ine
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (item 6) x multiplier x
i
i. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) .$ List:
5. Mechanical (Fire $ Total All Fees:
Su ression)
Check No. Check Amount: Cash .\ntounc j
o. 'Total Project Cost: $ 37 1 f ❑ Paid in Full ❑ Outstanding Balance Due:__.___
3
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SECTION 5: CONSTRUCI'IOiJ SERVICES
5.1 Licensed Construction Supervisor (CSL) C> 9S T JD 3, 6 , aA,/G
�i,✓.re a212`C4,iiiio- License Number Hxpir:uion Dale
Nanic of CSI_- I lolder
e List C'SI_'fcpc(scc hclow)
I l t d (7.F�r1�at• �1'. t>re/g..> i''t4.0/.1 y
\ddrcs- rN��✓ / f ° D nun
C (:nrestnctcJ (tip to i5,(K)ON)0 Cu. ht.l
R Restimed 1&"_' Family Diiclhne
Signature M Masons Onlv
>41• RC Residential Roofing C'osenny_
'fclephone N'S Rcsidcnliul \1 ndmi .lid S.Jut
SF Residential Solid Fuel Bunim�� 1 i ihanii 111>L11.11U,11
D Residential Demolition
5.2 gistered Home Improvement ntractor (HIC) ors,` Y7
HIC Conipany Nano or HIC Reg Wralu Name Registration Number
ha 44c a t . Gres�e _ e M,c G(u3s , o/a
s �
Address
_fig 3</ 7a Yd Expiration Date
Signature _ 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 AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i
as Owner of the subject property hereby I
authorize __ to act on my behalf. in all matters
relative to work authorized by this building permit application.
Signature ofOwner __ -_-- -- _-- - - Dale__
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, . // G'Fo 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. n
i2ek.+.o� � f . Goo Gave/Lc { C>>-Sbrv � U /r
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of per u )
NOTES:
1. 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 Lund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL)can be tiiund in 780 C'MR Regulations 110.R6 and 110.R5. respectively,
2. When substantial work is planned, provide the information below
Total floors area tSq. Ft.) (including garage, finished base men t/attics. decks or porch)
Gross living area iSq. Ft.) Habitable room count _
Number of fireplaces___ Number of bedrooms _
Number of hathrooms Number of half/baths
Type of heating system Number otdecks/ porches
Type of cooling system Encb)sed Upen _
3. "Total Project Square Footage- may be substituted for -Total Project Cost"
C
':5--
� CITY OF SALEM
I, i; PUBLIC PROPRERTY
? � DEPARTMENT
\1\�,is 12-WASHIX(;iON S I XLL I' • SAH M,MAs!SA(-i II it I'IS ui 97.�,
11-.i:978-.'4i-95`r5 s ICsx. 978-74C-9846
Workers' Compensation Insurance :\ffidavit: Builders/Contractors/Electricians/Plumbers
% t slicant Information Please Print Leeibiv
V 81Tt: y0—pv_/C/ rJQ co,-' CJ / r`J
Address:
11 L+,i
City,Stara%ip
(rrovqif zt/'Ia•O/4,3Y1'huneI": 518 ' 3 � 3 1 as 3
:\re you an clnployer? Check the appropriate box: .._1
'Type of project(required):
4. ❑ 1 am a general coulractor and !
1.❑ 1 am a employer with 6. ❑ new construction
employees(full und,or part-lime).• have hired the sub-contractors 7. ® Remodeling
2.❑ 1 inn a sole proprietor or partner- listed on the attached sheet.
These sub-contractors have 8. ❑ Demolition
ship-and have no einployecs
workers' comp. insurance. q, ❑ Building addition
working tilt me in any capacity.
No workers' comp. insurance 5. We ore a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
ri ht of excn, tion a MOL I I.❑ Plumbing repairs or additions
3.❑ I ion a homcuwrke s' co all work S, P P. 12.❑ Roofrepairs
myself. (Ko workers' comp. c. 152, §1(4),and we have no
insurance required.) t eminloyeus. (Ko workers' 13.❑ Other
caiip. insurance required.I -
-Wiry apphcaor train checks box AI must also rill oat the fiction wow showing Ihvir workets'compehsmion pule y intitrmatiun.
'i lomcuwta m Lelia suhmil this affidavit indicanns they are doing all work mul dlen him.oulside colprnetom must.,Ahmil anew al'Ldavit indiulmg.nch.
-('>nlraeltm OWL check this box ratan ailachal an additional.abed lhuwing the name of the sub-contractam and their workers'comp poky infix manun.
1 am its employer that is providin•q rvorkers'cmnpensatiolr insurance jar my employees. Below is the policy and job site
information.
Insurance Company Name:____.
I'olicv :r or Sclf-ins. Lic. ri: . ___ Expiration Date:
Job Site Address: __-- City,State/Zip:
Attach it copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
haiiure to secure coverage as required under Section 25A of>IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 andlor one-year imprisonment;as well as civil pcnahiis in the form of a STOP WORK ORDER and a fine
Of up to S250.00 it Jay agalllst file violator. Iic advised that a copy of(his statement inay be forwarded to the Office of
Inresugaunns ul the DIA for in;oral•xc .a,vcrayc Icriticatiun.
/ to hereby nrtif4 order the is m penal 'r. r rho he information pDatrovided above is Prue and correct.
It✓aliul d: --
-Z } 3
5ZY 37
Official uae only. Do not write in this area, to be cmoplered by chy or rolvn official- _
City or l'osvn: ___. - Permit/License 0
Issuing Auillority (circle one):
I. Board of Ile:dth 2. Building Department 3. (:ih:rl'own Clerk 4. Electrical Inspector i, Plumbing Inspector
6.01her
Contact Person; --_ - .-- Phone q:
I
S
Information and Instructions
,Vassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pnf>mant to this statute, an empluree is defined as "...every person in the service of another under any contract of hire,
express 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 toregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an mdlvldual,panmership, 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 buildingappurtenant 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 a license or permit to operate a business or to construct buildings iri[he Commonwealth for any
applicant %%ho_has not produced,acceptable-evidence of compliance with the insurance coverage required."
.additionally. MGL chapter 152, §25C(7) 'cries"Neither the comtnoriwcalth'no1`any`of its political subdivisions shall
enter into any contract for the perfornwnce of public work until acceptable evidence of connpliunce 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 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 Lit the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pldasc be sure to fill in the pcnnit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple ponnit/license 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
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he t)(lice of luvestigations would like to thank you in advance fur your cooperation and should you have:my 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 „
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
�-2ir-US
Fax # 617-727-7749
RaviseJ -
www.mass.gov/dia
•' CITY OF SALEM
PUBLIC PROPRERTY
DEPA[ZT�IENT
Construction Debris Disposal Affidavit
(Ivyuired litrall dontolitiun :uld renuVation work)
In accurdance ith the sixth edition of the State Building Code, 780 CNIR section 1 1 L5
Debris, and the provisions ut'IviGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The dchris will he transported by:
(name of hauler)
I he debris will be disposed olin
(name of lacihty)� n
cm SSe6u- ^-,
/' v=
I,n drew of l]cili(v)
+mnatmc pit permit .y±p hcant�
'lice