10 SUMNER RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C R, 7t'edition OFSALEM
Revised January
Building Permit Application To Construct, Repai Renovate Or Demolish a 1, 2008
=1 One-or wo-Family Dw ling
(V],J Th' S tion For Ofyial Use Only
Building Permit N ler: I D e Applied: p �p
Signature: "
Building Commissio r/Inspector of B i di gs Date
SECTI 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I O 5�w.NtL tc. �-r)C .
L l a 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 ft) Frontage(ft)
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:
Publi Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)A I Addition ❑
Demolition ❑ Accessory Bldg. 0' 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : V Xt s-ri N y 7 45¢o Y c-0 CA-%E — c N uN4 t PA
P2G�sF..•. 5eo'Q.00— lt-1Tb ^L_ q,Nn..oL C/L 6¢o n�tG SN5 3 Er7,,tortoyM,.s
OV; ey.6Je�� ,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ ;00 1. Building Permit Fee: $ 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 (fIVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ C j Qrj ❑Paid in Full ❑Outstanding Balance Due:
7a/- v�'� i mil/% v
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7yyo!�#y
License Number Ex va ion Date
Name of CSL-Holder 1• n List CSL Type(see below)
Type Description
Addres� U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
:77$�/ — u S— 0017 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement ontra for(HIC)
/I'Ig3�iir fi sa�"s C �,� !S'S $Yy
HIC Company Name or HIC Registrant Name Registration Number
Addres
EApirdtion Date
Sigriffrine 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 ..........toNo........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, -*N iv h� O , as Owner of the subject property hereby
authorize /i, ! e / to act on my behalf,in all matters
relative qo a ri t is building permit application.
Si ture n Ow Dater _/�na
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I, t`— Iel_,-- l r.f, m �,as Owner or Authorized Agent hereby declare
that the statements and information o the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Own r Ant r'led Age Date
Si ed under th ains d enalties er
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 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.R5,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"maybe substituted for"Total Project Cost"
CITY OF SALEM
; , PUBLIC PROPRERTY
w`' DEPARTMENT
.ion: a:I'Y:)A 1AX it n.
\t.Nlat I2.C.WMHl.Nci l US5 to ELT • 5ath.m. lvl.%&%.%cin if Is0197C
)78-745-9593 • F.sx. 9711•74C.Ix46
Workers' Compensation Insurance Affidavit: Builders/Cuntracturs/Electricians/Plumbers
%onlicant Information Ple
ase Print Leeibly
.Ial-ne lBuulw;tiyQr�anilati/nNlndlvlduall: pf'Y-n r�/ S r.S u-C�hf-�
City,Starci/sip: -zzJl /� Phone il:
:\rc you an employer? Check the appropriate box: 'Type of project(required):
4. ❑ I :can a general contractor and 1
I.❑ 1 :can a employer with G. ❑ New construction
employees(full and/ur put-tinic).• have hired the sub-contracturs
listed on the attached sheet. 7• Remodeling
/`��+ 1 :can❑sole proprietor or partner- `
` ship and have no employees These sub-contractors have S. Demolition
working for me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
No workers'comp. insurance 5. ❑ We are a corporation and its required.] oft !0.❑ Electrical repairs or additions
iccrs have exercised their
3.❑ I ❑ni a homeowner doing all work right of exemption per MGL I l.❑ Plumbing repairs or additions
myself. LNo workers' comp, c. 152, §1(3),and we have no 12.❑ Roof repairs
insurance required.] r cmployces. LNo worker 13.❑Other
comp. insurance required.]
•lay.ypheant that chucks box nl must also fill sun the w-clion below showing Ihcir w•unkcai cumpenaaUun policy inllantutiun.
' h lomw,wmn who atdtmil this affidavit indicating Ihcy ate doing all aunt and then him outside coninwton .at.uhmit a new arrdovit indicating.)ch.
-C'emrwmn that chuck this box mast:nlachcd an addiliunal sheet.hawing the none of the cub<ontraoors and their corkers'comp.policy infurmadun.
/run can cuq�(uy¢r Uruf lr prurfdin•K rvurkers'cunnpcnsntinn inrurmnce jar u+y eroployecr. Below is the policy and job vile
lufori nation.
Insurance Company Name: _- .. . . _...-------__.--.--
laolicv If or Sclf-ins. Lic. if: __. . _ ._ .._ Expirullon Date: -
Job Sitc Address: _ City;State/Zip:
Attach it copy of file workers' co tpeaxation policy declaration page (showing;the policy number and expiration date).
Failure to secure coverage as required under Section 25A ul'1tGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one-year imprisonment, .ts well as civil penalties in the form of a STOP WORK ORDER and a fine
of up ro S250.00 It day against file violator. He advi.ed that a copy of thus mitteincra may be lorwarded In the OIf IL•c of
I nwrangannns ol'the DIA for insur:u:cc coverage wcrilication.
/do hereby ccrlify Wider tlr hrs and penuhics ofperj++ry that the infonnution provided uboce is bile and correct.
Dote:
O/ficiui fie only. Do flat write in this ureo, to be completed by city or town W/ficiul.
Cily or Towrn: Permit/I.lccnse 0_
Issuing Atilhority (circle one):
I. Iloard of IIcallh 2. fluildiny Department 3. Cil.s fown Clerk a. Llectrical Inspector 5. Plumbing luspector
6. other _.
C'aatacl 1'crwun: _- __ Thole'l:
Information and Instructions
%lass.lchusetts ticneral Laws chapter 152 Requires all employers to provide workers' compensation for their employees.
Pur;u:mt to tilts,latule, an employee is defiled as"...every person in the service of another under any contract of hire,
evpress or implied, oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or inure
or the foregoing engaged in a Joint enterprise, and Including the legal representatives of a deceased employer,or the
receiver or trustee uI .ul individual,parmership,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."
licensing a gene shall withhold the issuance or
"every rate or local
�iGL chapter 152. . _SC(b)also states that a cry s agency P �
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
aNP licunl who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, ivIGL chapter 152, §25C(7)states"Neither the commonwealth nut any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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 atfitlavit should
he retuned 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 Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of die affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple penniu'licease 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lie of lice of Investigations would like to thank you in advance fur your cooperation and should you have:my questnolls,
please do not hesitate to give us a call.
The DepartincriCs address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OIHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Ravi,ed 5-26-05
www.mass.gov/elms
r
Office of Consumer Affairs and usmess.Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement contractor Registration
-_-- Registration: 159849
_ Type: DBA
Expiration: 6/3/2012 Tr# 299045
MERRILL & SONS CONSTRUCTION SERVI
CHRISTIAN MERRILL
9 HILLCREST AVE.
LYNN, MA 01904
Update Address and return card.Mark reason for change.
❑ Address ❑ Renewal 0 Employment ❑ Lost Card
DPS-CA1 0 50M-09 G101216
y Office��o-fime'r`Wais'A96bEdvi-91-Tie License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 159849 Type: Office of Consumer Affairs and Business Regulation
Expiration 6/3/2012 DBA 10-Park Plaza-Suite 5170.
VL
Boston,MA 02116&SONS CONSTRUCTION SERVICES -
CHRISTIAN MERRILL =
9 HILLCREST AVE.,,
LYNN,MA 01904 Undersecretary - of valid wi ore
E �' to Toanr»rsauae¢l� ���G�nwutf4uJed73 �v
-}i •Board of Building Regulations and Standards
Construction Supervisor License I
Cleanse: CS 99044
r A„ Expiration: 115/2012 Tr# 99044
" a --a Restriction: 00 -
CHRISTIAN MERRILL -
c 9 HILLCREST AVE:"
LYNN,MA 01904 Comrilssioner 1
W z