7 SUTTON AVE - BUILDING INSPECTION . i The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'"edition
Building Dept
g� Building Permit Applicatio o:Cons ruct, Repair, Renovate Or Demolish a
e- or vo-F roily Dwelling
\ I This do or Official Use Only
\y\�\ Building Permit Number: Date Applied:
Signature: �7` �( ( L— t d y
Building Commissioner/lhvect,r u Idings Date
SECTION l:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
� Tu l_✓1 .��� G
I.1a 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 fit Frontage(R)
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: ICI
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Recor /
Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': �c
/v�00M IN
T SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ ndicate how fee is determined:
❑Standard City/Town App ica ion Fee
2. Electrical $
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check mount: Cash Amount:
X6. Total Project Cost: $ OG D p D 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name o�SL-H/elder / List CSL Type(see below)
Type Description
Address / U Unrestricted(up to 35,000 Cu. Ft.)
1-7 7 -S �' �� r` ,e R Restricted I&2 Family Dwelling
Signal - _ M Masonry Only
RC Residential Roofing Covering
TeleplIone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
�h �/� V
HI C Company Name or HIC Registrant ame Registration Number
.46' /Y
Address
7 0/5;/f 1/7f=-5ja 7—,r-l/`f Expiration Date
Signatur 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
1, 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,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
(Signed 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 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 I IO.R6 and I IO.RS,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"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\1 41 12: W,%Ntunu I,).SGsu1' a in19v1,M.v',.vs In it I IN JI97--
I CI. ')7/-71i-7i'd * I�%.X 97X-741''1346
Workers' CumpensWion Insurance liffidn.it: Builders/Contractors/Electricians/Plumbers
Jlnlicant Information / Please Print Leltiblr
NamclButtewt�ranv,uindVlndt,„luall:
Addfcss: S r2arS c
City,State,Zip- 4, 7 01i; Phone k: q� �— /�� 7 Iq&49
.\rc)uu an cmployer:r Check the appropriate box: '1}pe of project(required):
1.❑ 1 .1111a employer with 4. ❑ 1 ❑m a guncral contractor and 1 6. ❑ New construction
ell tlo ccs Tudlur art-ante).• have hired the suh-amtricturs
1 y ( ll an P 3.Z I .tm a sole proprietorpriproprietoror partner- Titled on the attached sheet. 7. 0 Remodeling
ship and have no employees These tub-contractors have S. ❑ Demolition
%corking for me in any capacity. %workers' comp. Insurance. 9. ❑ Building addition
No workers'cum insurance 5. ❑ We are a enipantion and its
I P� � 10.❑ Electrical repairs or additions
I rcquircd.) O iccrs have exel'e1NCd their
3.❑ 1 am a homeowner doing all work right of exemption per MOIL I.❑ Plumbing repairs or additions
myself. (No workers' cunsp. c. IS 2. §1(4),and we have no 12.❑ Ruof repairs
insurance required.) r unployces. LNo workers' 13.0 Other
comp. insurance required.)
•,,I+ ..,gJ,caw Thal hwks box PI must:dso,IIII Wa the wci.b a iwiuw.huwiny,her wurkui cumpensa/ion Iwllcy udiamatiun
' I lomeaworn who submit this affidavit%ndicadina they is doing all work and Then him uunide cuttrrxwm must submit a new atfdavil indiaama.,mh.
d-ontn:u,n that%heck this box mugs atrauhal.m adduiwul thane,huwmil tlw main of tho sub.ontroctorx and then workers'comp.policy mftutnart
/dun un employer that is prunidin,If workers'cuonpcnauimr insurnnee fur sty rnrpluyecs. Below ix the pufiry and Job.rite
infarumtiun.
Ir..,arancc Company
folic v 4 or Sclf-ins. Lic. rr: _-.. -. . .. ._ Expiration Date:
Job Site Address: _-_- City:State/Zip:
.Utuch of copy of the workers' cutnper tlon policy declaration pale (showing the policy number and expiration date).
failure to secure cuverage as required uodcr Section 25A ul'NIGL c. 152 can lead to the imposition of criminal penalties of a
rind op to il.5oo.00 and/or one-year imprisonment, as %cell as civil penalties in the lurm of STOP WORK ORDER and a fine
of op to 5250.00 a day against the violator. Re advised that a copy of Ihs st uicinew may be lot%arded to the 011tce ul
Im:.m,a sons ul the UTA io,,o irce aw ealyu t iiticaLon.
l do hereby t crfify under the painv door/penuftiev of perjury that the infunnstHon provided above is true and correct.
I'h Ord 'r
()/Jiciull use write uidy. Do not rite in this area. to he to..pleled by city or town yji,ial.( itv or down: _-_ __. PerinitiLiecnvc 0_
1„uing .tiuthurity (circle life): i
1. 114,ard of llc.dth Z. Molding ncpartolcut I. Cil).'fuwo Clerk 4. Electrical luspccror 5. Plumbing Invpeclor
6. 01her
Contact 1'cnuu: .. .. Phone tl:
Information and Instructions
%ljl,,a.liusetts General Laws chapter I52 requires all employers to provide workers' compensation for their cnlpr4ees.
Pur.u.ml to rois ,latwe, an employee is defined as " .emery pcison in the service of another under any contact of hire,
evprcbs or implied. oral Air ,vrnlen...
An :,npfuy.-r is defined as "an Individual, partnership, association, corporation Air other legal entity, or any two or more
.At the tor"jing engaged its a joint enterprise, and including the legal representatives of a deceased employer, or the
reeelaer of lrubtee of at individual, paamehhip, association or other legal cnnty,employing :nplo)ccs. However the
uwner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
Jwelluig house of another who employs persons to do maintenance,cunstruction or repair work on such dwelling house
or At,. the.rounds or building appurtenant thereto shall not because of such employment be Deemed to be an employer."
.%IGL chapter 152. $25C(6) also states that "every slate or local licensing agency shall withhold the issuance or
renewal of u license or permit to operate a business or to construct buildings in the cummonweulth for any
applicant wbo has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, NlGL chapter 152, a25C(7)stales"Neither the commonwealth nor any of is political subdivisions shall
enter into any contract for the performance of puhlic 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) namc(s),address(es)and phone number(s) along with their certificates)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
.%ccidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
be rcnmied 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
Plcasc he ,tire that the affidavit is complete and printed legibly. The Department has provided a space at the button
uF the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
1'la:lsc be sure to till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit 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 "ill locutions 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
applicants proof that a valid affidavit is on file for future priories or licenses. A new affidavit must be tilled 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 Jug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
1 ha ()(lice of Investigatiwn %kuuld line to diank gnu in advanA:c fur your cooperation and should you have :my questions,
please Jo not hesitate to give us a call
fhe D,parnncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Of Ce of Investigations
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.mass.gov/din