32 SUMMIT ST - BUILDING INSPECTION The Conunonwealth of Massachusetts
I OR
it 13um'd of Bwldmg IZe'gUIHIIUnti and Standards 91l'NI('ll' \I.I'IY I
t L`a MassachnSe85 State Building Code. 7SO CMR, 7"' edition SI:
Building Permit Application To Construct. Repair. Renovate Or Demolish a Rr riso/,himno c
Otte- or Tit u-Frurtil t, Duelling 1003
This Section For Official Use Only
Building Permit Numb Date Applied:
Signature: 0��
f3uilJin Conuni..ional/ Inspector of Buildings Date
I --- SECTION 1: SITE INFORMATION
1.1 Properh :%ddress: 1.2 Assessors Map & Parcel Numbers
Sum
I.la Is This un accepted strct? y.es_� nu s1ap tiwnhrr -__ P:u.cl `wuhrr
i1.3 Zoning Information: 1.4 Property Dimensions: _----- 1
Zoning Distnr;. Pn;puseJ IIsc I:r j
1.5 Building Setbacks (f )
Front Yard --- Side Yards Rear YwJ
Pcyuirrd Provuled R,qLare Provided Required Prutidcd
1.6 !Pater Su ply: (!vt.G.L c. 40. §54) L7 Flood Zone Information: 1.8 Sewageage Disposal ystem: I
—/ Zone: __ Outside Flood Zone'
Puhlic li Private❑ Check if yes❑ Municipal�On nite Jisposai .y>tenl
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnerr of ecor t 2 C
"J 2 ` u m nn
N tat Print l Address for Service:
2-1 Li
LSienrtu-;=— Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKz(check all that apply)
New.:un>trurtion ❑ Existing Building Owner-Occupied Repairs(s) 19�1 .41terrtionLsi ❑ Addi!ion ❑
--- 1
• C>:mFrudtioa 0 Accessory Bldg. On INumberof Units Other ❑/Specify L.rltOd Cr Cl rn4
Frief Description or Proposed Work': QCPA.t
SECTION 4: ESTIMATED CONSTRUCTION COSTS �I
IIII Hem Estimated Costs: Official Use Only
(Labor and Materials) _
L Bwldmg $ O0 p , dp I. Building Permit Fee: $ Indicate how, tee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost (Item 6) x multiplier- _ x
3. Plumbing $ ?. Other Fees: $
4. Mechanical (HVAC) .$ List:
�. Mechanical (Fire It I
Suppression) Total All Fees: $ 2
Check No. Check Amount: Cash :\ntoune
6. Total Project Cost: $ 3 y,000. OV Cl Paid in Full ❑ Outstanding Balance Due:—__—_..
1531
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number F\pirauon Date -
1
Name of C'SL- HulJcr i
List CSL rcpc Ugc below) �
T .e Description
Address
L UnrcstncfeJ(tip to 3i,000 Cu. Pf_i
R Restricted lyC'_ Family Dskclline
Signature M .Masons Only
RC Residential Roofing i'o�enne
'relephone \\'S 1?cmdemial Wnid')" ,md SiJinc_
SF Residential Solid Fuel Burning Insf.dl.unn�
D Residrnu:d Demolition
5.2 Registered Home Improvement Contractor(HIC) i 31
HIC Company Name or HIC Registrant Nam' Registration Number
grt�yi Slcl� �- DWWA. ALA CL?3 -? 11 1 (200 8
.address r�T-1-�—
_ Expiration Date —�
"Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)I
Workers Compensatiop Insurance affidava :must be completed Lind Submined with this, ,: • f is❑tion. Failure to (.,tide
completed � NP• I-'t I
this aYYldavit will result :-i the denial of the Issuance cf tic building p-ri
•. _ _ __
,,gned Affidavit :1[:achcJ? Yes .......... ❑ No .........- ❑ ----- --_--- -
Sc>CTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN i
V ER'S ':GENT OF. CONTRACTOR APPLIES FOR BUILDING PERMIT
( 1/\Ib,l��W as Owner cf the-sutjec! proper¢y hereby
ri>e � Kam. _ to act on my behalf, in all matters
alai, to work authorized by :his buiidiag p rani! application.
Sip_mt- re of _Owner _._ _._._._D�'• -- —__ ..—. .._J
SECTION 7b: ON N ER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statement; and information on the foregoing application are true and accurate, to the het of my knowledge and
( Print Name -
Si uiature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury) —_.__...
_ NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor I
snot registered in the Home improvement Contractor (HIC) Program), will not have access to the at
program or guaranty Hind under M.G.L. c. 142A. Other important inli iwation on the HIC Program and
iCnri:urucror. Supervisor Licensing (CSL) can be tix:rd in 780 CMR Regulations 110.R6Lind 1 10,RS, respectisely
_'. When substantial %ark is planned. provide the infitrmatiun below:
Total flours area lSq. Ft.) (including garage, finished basement/attics. decks or porch)
Gross living area iSq. Ft.) _ Habitable room count
Number of fireplaces Number of bedrooms -_
Number of bathi.)oms _ _ Number of h:tlf/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed —_.__. Opcn
3. -Total Project Square Footage- may be substituted for 'Total Project Cost"
y CITY OF SALEM
PUBLIC PROPRERTY `
DEPARTMENT
A l.ldl.,..,1\♦:.: III • V! m, NI ,
triber
N% orkers' Compensation Inswonce :*,flidacit: l3uilden/CuntractoniEl Please Pript Legibly
t )hunt Information
\,title trio Jne„ I h,_mvuu,m hldlll.hl.11 is f--`
('it} State.Zip: /An\teL�> Phone #:
\re you an employer? Check the appropriate bur:
Type of project(required):
❑ I :un a employer w ith
4, ❑ I :un a general contractor and 1 6 ❑ New construction
I ..
VInployees (full and'ur purl-fines) ' Ila%e hired the sub-contractors 7. [ Rcmodeling
listed on the attached sheet.
I ,on a sole proprietor or partner- I-hese sub-contractors have 8. ❑ Demolition
ship and have no employees workers' comp insurance. y. ❑ Building addition
working for me in any capacity. 1. ❑ We are a corporation.and its
[No workers' cutup. insurance 10.❑ Electrical repairs or additions
Utticers have excrclled their w�
required.[ i i ht of exemption per MGL 11.0 Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work b �;.
I . e. ploy ep [ and we have no I_'.❑ Roof repairs
nyself: [No workers' comp
insurance required.) t employees.s. tic workers' 13 ❑ Other
comp. insurance required.)
•,qny.ipplicam that checks box NI must disc)till out the section below+hawing their workers'compensation policy information.st submit anew afffdavil indicating such.
r-
* I lomeuwners who>ubmit this affidavit indicating they are doing all work and then hire outside contractors and
'c,mira Unrs that check this box must attached an dddll ill nal Sheet showing the name of the sub-contracturs and their workers'Comp.policy Information.
I air utr employer that is providing workers'compensation insurance for my employees. Below is the policy and job site N
information.
Insurance company Name: Expiration Date: n '�
Policy x or Self-ins. Lie. "?"22 �r Y VV City state/Zip:
Job tine Address:
.\ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of,161- c. 152 an lead to the imposition of criminal penalties of a
title tip to S 1.5oo oo❑nd,'or one-vear imprisonment. is well as civil penalties in the Ibrm of a STOP WORK ORDER and a tine
of lip it)S-150 00 a day aLalrbt the %iolator. Be advised that a Copy tit Ill's statement Illay be fimvarded to the Office of
Insc,tluatiarls of Lite DI:\ loot- itisur:ulce courage scrilicarton.
/dip herrhy rrn' ur the pair unJ 'r shies n perjury drat dre injbrntatitnr prueided aA,rre is true and correct.
Date
�iin,nive_T
I'I.,ulc
t 1(/icial use only. Do not write in this area. to he rnnydeted by rity,n anrn ufjiriuL
PermivlAcense M
( Its or town: _ :_...- .. .. -- - -- --
Issuing \uthurity (circle one):
ment 1. ('ihil'nssn Clerk J. Electrical Inspector S. Plumbing Inspector
I. Board of Ilealth 2. Building Depart
6. OtherContact Person:
-- ----- - ---------_._
----.--
Information and Instructions
V.I, .Ic I',u,cu, (is tie raI I its chapt>er I Iryu lrc, .ill cng11o%cr, to I)rol ide workcrs' conq,c n,a tl,in for (heir employ ces.
I'w.li.u/i to this statute, .Ill Ivnpluree I, JcGr.ed a, r)er1 person in the ,en ice of mwilier under.Ills contract of hue.
:VI c,, or till I,! cd. Oral or w rI lien."
\:: empim er is Jelined as %Ill ulJn adual. p.un:cr,h 11). IN I,u It'll. :orpllrat on or of Iter Iceal entity, or ill% two or more
,-I the lot:_Inng cn :I_ ged In a joint cnlerprue. .oid inclu.hng the iC,al reprr,ematnes of deceased employer. or the
c:cncr or IILI IeC of an 111,11%iJual• partner,hlp, auo:I,u/on or other legal cnnty, enylloy mg employees. I Iowcser the
.,IIcr of a Jw elhng house has Inc not :pore Ih.ut Three .I par tile nts ,Ind w ho reIRIC, Therein, or the oc:upani of the
,h,ci!ulg house of another w ho enq,lo„ person, to kill m.untenancc. :,m,trucuon or repair work on such Jwclling house
„1 011 the _rounds or holding appurten.mt Ihercto ,ltall noI he:au,c of.uch entplosnlrnt be Jeculed to he an employer..'
\1(iL :haptcr I i_1• �25(.w) also .tates that 'csery state or local licensing agency shall ssithhuld the issuance or
rcnessal of a license or permit to operate business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable cs idence of compliance with the insurance coverage required."
\dditionally. NIGL chapter 152. j25C1-I ,[,ties 'Neither the conunorlvveallh nor any of us political uhdivi,ions ;hall
deter Into ally Contract for tile pCrf Ul"111a11CC of pul)lll work lentil acceptable e%t&nce of Col11pliallce with the Insurance
rrqulrcnlcnts of this chapter leave been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) nanle(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
nrrnlbers 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
,elf-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. Tile Department has provided a space at the bottom
of the affidavit tier you to till tnli`innhe eceni t!lce( lficc �f Irrvestigatioh has to,clintact you regarding the applicant.
-�, hlouss: be.Sung,to till in the permit,license number which will be used as a reference number.. In addition, an applicant
musf submit multiple permit/license a
Ihotpplications In any g1'ven'year, neeJ'iinly sdilmit'one•affidavit indicating current
policy intbrmation I if necessary) and under"Job Site Address•'the applicant should write "all locations in (city or
tow n).- A copy of the affidavit that has been officially ,tamped or marked by the city or town may be provided to the
applicant as pruut that a salid 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 i.c. a Jog license or per to burn leaves etc.) said person is 'NOT required to complete this affidavit.
fhe t Mice of Imc,tigations would like to thank you in advance tier sour cooperation and should you hale any questions,
plca,c do nol hesitate to give uS a :all.
I he I)epattmcnt 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
Il:, ,cd 'o-u5 Fax k 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
-
\1'.i It 12:' U`.\iI II\G:CINSIRLI T • SAI 1'\t, \L
Construction Debris Disposal Affidavit
(required (or all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the,debris resulting front
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
Inamc of hauler)
The debris will be disposed of in
(mac I /C/
(name of taahty)
S Iadtlress u(faclll
sienature of permit applicant
,late --
IoLi n�^•!u�