8 TAFT RD - BUILDING INSPECTION (2) t
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
nn Massachusetts State Building Code 780 CMR, 7 h edition OF SALEM
(y/ Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Famil Dwelling
This Section Kr Official Use Only
Building Permit Numb I Date Applied: v
Signature: t-)
BuifdMg Commission r/1hreV4kPBuildings Date
TJ SECTION 1: SITE INFORMATION
1.1 Property Address: / 1.2 Assessors Map&Parcel Numbers
L 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 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of ecord:
zr
Name(P int) Address for Service:
2'h - 71V--�
q � s�
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : 1,r)MzIl
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ — I. 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 (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $
❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder
List CSL Type(see below)
Address e?J= /! Type Description
t j U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burnin Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Vr2� AJT' 4:CA-b
Address
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
authorize Kobe to act on my behalf, in all matters
relative to work authorized by this building pe it application.
Signaturelof Owner Date
� -- SECTION/7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I, J"'!e� 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
Signal e of OwnefiWr Au riz d ent Date
(Signed under the pains and penalties ofperjury)
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(MC)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 I O.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"
1
Nlasseclimett% - Department of Public sa1'cts
1 Board of Buildin_ Regulations and Stan&I •d.c
Construction Supervisor License
License: CS 66002
Restricted to: 00
ROBERT M MONTMINY
11 CLEVELAND RD
SALEM, MA 01970
Expiration: Sf7/2012 _
('nnmi.ai^nrr Tr#: 25839
office of✓Co At7ai�rtn&�6lfsines len'oe I
qHOME IMPROVEMENT CONTRACTOR Type:
Registratlon 116266
Expiration 12/62012 DBA
TMINY
ROBERT MONTMINY
11 CLEVELAND Rf7;�
Undersecretary
SALEM,MA 01970
�5
CITY OF SALEM
y� PUBLIC PROPRERTY
0��rw DEPARTMENT
'.I s 1'CA.\;f11m.:,�N"rsmr r ♦ 5.si r'%t. Nh"�;
'I'pj: 974-74i.7;95 I'.\S: 9,8.'4-,9841,
Construction Debris Disposal Affidavit
(required Ibr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section I 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ik _ is issued with the condition that the debris resulting from
this work shall be disposed Win a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
' (flame of hauler) T—
I lie debris will be disposed of in
a✓ sldi rj -_
(name ut facility)
(address u(laciliry)
signature of permit allplicliTf
date --
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
--,1%W:'RI.LY DRISCu1.L
LC WASHiNG'IONSTRELT • SALEM,M.\yACl it st:'I'iN01970
978-745-9595 a F:\x:978-74C-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
militant Information Please Print Leeibly
V itlTtt: t8usincss/Or�aniratioNlndividuap:
t
Address: l
CityiStarei"Lip:� Ci/i^ / "/ 1 Phone i.'-:
Are you an employer:'Check the appropriate box: 'Type of project(required):
1.❑ 1 ;can a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
in lu ces full and/or art-time).• have hired the sub-contractors
P Y ( P 7. ❑ Remodeling
2 ,can a sole proprietor or partner- listed on the attached sheet. :
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
I P•
required.] of 10.❑ Electrical repairs or additions
officers have exercised their
3.❑ 1 unt a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,j 1(4),and we have no 12.❑ Ruofrepairs
insurance required.] r employees. (No workers' 13.0 Other
comp. insurance required.]
'Any applicant that chucks box#1 must also till out the action W,ow showing their workers'cumpemation policy information.
t I lumeuwm m who submit this affidavit indicating they am doing all work and then hire uuiside conimetors must euhmit a new affidavit indicating such.
�C.'ommcwn dust check this box most anachcd an additional shut showing the name of the sub-contractors and their workers'comp.policy information.
I ani can employer tliat is.providing workers'c•ompcn.cntion inrurattee fur sty employees. Below is the policy and job site
infortnutiom
Insurance Company Nmne:�_ _. .. . ..._ __—_—_---
Policy 4 or Self-ins. Lic. P: __......_ _.._____ Expiration Date: -
Job Site Address: Cityistawizip:
.kttach it copy of the workers' compensation policy declaration page(showing;the policy number and expiration date).
Failure to secure coverage as required under Scction 25A uf:vlGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment, is, well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
htacsligatioms ul the DIA for insurance coverage verilicalion.
!do hereby certijV r e pain.v d tenaltics afperjury that the information provided above is true and correct.
Si �n;uurel Dar � l0
Official use only. Do not write in this area,to be completed by city or town ojjiciaL
City or Town: _. _. __ ... ._ Permit/Liccnsc x---- —
Issuing.tuihurily(circle out):
I. Board of llcaldl 2. Building Bcparnnent 3. City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other _....
Contact Person: --- " -- --- Phone n:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee 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 foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,ptumership,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 louse 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."
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 in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, Iv1GL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance w ith 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 nanber(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 contimration 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 at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please 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 pennit/Ilcetse 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 atfdavit 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. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Off ice of Investigations would like to thank you in advance fur your cooperation and should you have any 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
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia