9 TAFT RD - BUILDING INSPECTION (3) r
�� 07 The Commonwealth of Massachusetts --- -
f Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Reri.,rd.Vur=011
L,W
Building Permit Application To Construct, Repair, Renovate Or Denw ' a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D Applied:
Building Otlicial(Print Nmne) Signature Date
SECTION I:SITE INFORNIATION
LI 1.2 Assessors Nlap& Parcel Numbers
Q
1.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 II) Fronlage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provide)
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 ycs❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' Record:
cat �L /�JJity.State.ZIP
Nu.and Street elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': et 61i llon4r
d C
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only 6 Labor and Materials)
I. Building s �21 7 S I. Building Permit Fee: S Indicate how fee is determined:
2.. ElectricalSv ❑Standard City/Town Application Fee
S ❑Total Project Cost'l Item 6)x multiplier x
3. Plumbing s 2. Other Fees: s
q. .\Icchanical 01VAC) s List:
s. Alechanical (Fire
Su'I re on) Total :}II Fees: s
ZSSO Check No. Check Amount: __Cash Amount_ ___
G.Total Project Cost: s 7 ❑ Paid in Full ❑Outstanding Balance Due:
X00
SECTION 5: CONS'rRUC'fION SERVICES
5.1 Construction SupervisorrLLicen��seii(CSL)
License Number Lc ir. C—
N;unc of C'Sl. I[older
List CSL 1, pe(sce below) /C
Na. ;mJ Strcel '1}pe Description
D UnreRestricted
l (Buildings2 Fa ni toiag cis. R.)
R Restricted IX2 P�unil Dwellin
Cliy rown.Slate.ZIP M Mson
ry
RC Roolin Covering
WS Window and Siding
SF Solid Lion Burning Appliances
1 Insulation
`rcic hone ('.mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
II C' Registration Number Kplr un Date
I IIC'Coil N:uyn• x I IC Registrant m tc
Nu. ; 'eo Email address
Ci /Town, State,Z[V relc hone
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 ..........NEI 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print ON%ner's or Authorized Agent's Name(Electronic Signature) Date
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 riot have access to the arbitration
program or guaranty fund under %I.G.L. c. 142A.Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at
2. When substantial work is planned, provide the information below:
Total fluor area(sq, ft.)_ (including garage, finished basement attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces_ _ Number of bedrooms
----------------—
Number of bathrooms _ _ _ _ Nwnber of halfbuths
l)pe of heating system ---- .----- -- Number of decks,porches.. ---
T)peofcoolings)stenl___ Enclosed _ Open _........ ...
i. "rolal Project Square Footage"may be substituted for"rol:d Project Cost'
CITY OF sm.&Nfli A-1SSACHCSETI'S
BL U.DLYG DEPARMLE.�:T
110 W.LiHLYGTON STREET, Y°FtOOR
T EL (978) 745-9595
FAX(978) 740-9846
Kl�®E U.EY DRISCOLL
MAYOR T omU ST.PMUR
DIRECTOR OF PL:HLLC PROPERTY/HLAML-IG CONWISSLONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section it 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will bebetrtransported by:
(name of hauler)
The debris
will be disposed of in
(name of facility)
�f 1�3 t>z®oryc�vcv�r /�LCui�,�d/�c,
(address of facility) �—
signature of permit) plic
If
date
�+ CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.liar:m:l Y:inl4 Of
\INlyl
\VA\ffl.\t;IU,\i I xEL•I,• idl l'.4, ALus.\t.111 V got Jl'/7:
1'1•d: 77j.713-9395 a 1:Ix 97s•74C.•I•yµ
Wurkurs' Cumpensation Insurance AI'ndaviC 11uilders/Contrac torsi Electricians/Plumbers
\ I Illcjnt Inftlrmation
PI3ic Print Le 'AI
V:11T1E:tIlotlrlesyf)r�anlruioNlntll�„luu♦��/_iy�fil ������. _ .
City.Starc.%ip: Phoned:
Are If Liu an employer?Check the all roprlate bur:
I h)M a/prn)ect (required):
1. 1 am a emP lu ur with 4. ❑ I a general contractor and I
. cnlpluyecs(roll unLyur part-lime).a have hired the subcontractors f• 0 New construction
e I.1111 a tale pmpricnrr or partner. listed on the aeached sheet. t f'] RttpotlelinS
gold have no cmpluyving These sub-contractors have It. fkmolirian
working liar me in any capacity, workers•comp, insurance.
I No workers'cum . insumoct S. 9• ❑Oudding addition
P ❑ We are a mlporstion and its
).0required.) otRcen love examiscd their 10.0 Electrical repairs or additions
I con a horm:uwncr Joins all work right of exemption par NIM 11.0 Plumbing repairs or additinnt myself.(No workers'comp, C. 152,¢1(4).and we have no 12.0 Ruut'rupuirs
insurance required.)r cmployeaa.(No worker'
enlnp ittsurancv•pry.,phew nyu l ntatiwr 1 J.0 Uglier
its built Mufti fillwthe 4elun hcluw dwwins iAnr wwtws'clmperhW chid.J
pulley mridmlwias
'I Iunwllwtwn witty tldlmil this amdevis indicting I"Lie Joins at wurk any Them hire outride eanrnchrs mwt.�h�y a new alRdavil indicatingmwh.
f,mlruetun film ekeh this spa aal opuhed an wallketel..Ibell eluwins tha naml**fill*tuthcoolarerWts and their murkM'ramp,ptdtey Inlbrrmanas/Lira Lill edrplayer thug/r pruWJ/ng IvtrAert'ewnpenradon hErdrnnee/w my emp/ogees Be/alv/r the pu//ay unr//ob sift
In.urancu Company Nnln, G_
Irolicy As or Salf•ins. Lic.fis SIT ^.��� �7 /
/ '�. .. (7%jExpirauan Data:
Job Skit -ltldrusto: 2a ��
C'uy9ratelLlp:_ ��0197p
.littach it copy of the workers'cumpensJtl°n p*llcy decleraNun page(showing the policy number and expiration date).
Puiluru lu secure coverage as required uudur Sccliun 25A ut'.%IUL c. 152 can lead to rite imposition of criminal penalties of s
fine op nit 31.5110.00 Jnd/ur uoe-year iotprixlnoncnf, a4 aell as civil penalties in Ihy form of a STOP WORK URGER and a fine
Of toil on i230.00 it day.Iguinsg fife violator. Ile advi.4cJ thut a copy of lhil malcmeln may be lorwdrded to the Ullice of
III1'i al1�a11Ulle JI IIW l)IA Ior IthllGlnee GliYera�e %o iliealllln.
film hereby terrify under r/re point Irarr/ary fh n da iu/LrmW/en provided above is boo and aorrerR
I'll• ; .,
U/j/rlfil ase ufdy. Do nor write in thin area. tube runry7eted by city of town n//7ridL
t
('iry or 1'01lrn: YenniuLfeenee>r_ I
Issuing Aulhurily (circle nnc):
I I. I of Ilealtb 2.
L. I)IIlvr Ihuldinq Ilcpanmcul I, l:it)r'1'ulln Clerk J. Llcctric•1) Inspector 4. Plumbing Inspector
)lher
lluu.tel I't nun: .
i
Wformation and Instructions
\Llsi.lti11u9ells(;,:neral Laws ihJptef I J2 w4uIres JII entplo)ei o sCry Je of anotherenUler/r111y cuntrl,ct of hire.
1'ur%uAnl to this >litutd, an empluree is detined as"...every fiction In
:tpre»or unplied, oral or written."
�n etnpluper Is detined as"an Individual,partnership,association,corporation or other legal entity,or Lilly two or Inure
to in vm to eee. However the
\ the turegumg engaged m a goat entarpnsa, and including the legal representatives of a deceased employer,ur t e
ecmver or uustea of.m iudivlJual,prrmershlp,asaoewtioo or other legal entity,a resides therein.
h e g ' D Y
owner of a dwelling house having not more sthan ons to ee li3mmian nts anconstruction w Of repair work ua such dwelling(house
dwelling house of another who employs persons
ur ,III the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.'
s.IGL chapter 132. 425C(6) also states that"every stay or local IicenslaI A owaulth for any
easy shall withhold the issuance or
renewal of it license or permit to operate■ buslmass of to coostruet buildings In the commo
applied me utto has not produced acceptable evidence of cumpnroce wlth not any the Insurance coverage required."
kid itionally, ion �ufcr the sartom performance of sufililotwork the
until ceenWble�eviJance olteu nolliarlce wuh the linsur nee
enter into ny D
D 1 V
requirements of this shaper have been presented to the contracting awhoriry.'
.applicants
Please fill out the workers' compensation affidavit completely,by checking die boxes that apply rt your( )Situation geed i
necessary, supply sub-contractors)name(s).addrees(es)and phone numbet(a)along with their certiAcate(s)of
insurance. Limited Liability Companies(LLCw Or Limited Liability orkers' compensation insurance-(f an)with LLC oro employees LLP does have
than the
members or partners, are not required to carry
employees,a policy is required. Be advised that this alRdavit may be sign
an d to the Deportment of Industrial
enlploents for confirmation of insuranco coverage Also be sun go slga end Jute fbo u[tldavl4 Tx aniJavit should
questions regarding the low ur if you ors required to obtain a workers'
.% cidoretu ttad to the city or town thus the application for the permit or license is being requested,not the Department o
Industrial Accidents. Should you have any y
t else number listed below. Se n
Self-insured companies should enter the
compensation policy,please call the Department a
selr•insurance license number on the a ro rime line.
City or Town Officials
applicant.
Please be sure that the affidavit Is complete :mJ printed legibly. The Department has provided u space at the ,bottom
Of the affidavit for you to rill out in the event the Otlico of investigations has to contact you reg addition,
the app
I'Irase be sure to till in Ihu permitllicelise nuinbar hie will been de s ace reference
ere csulumbenor. l;ntliduvit�Idicunng content
any given Y Y
that must submit multiple pannioceltse appthe lications i u provided to the
policy information ha uflidavirtYlhat has been offleiully stad under-Job Site mped or marked tbys tile city or town may be pin (coy ur
town).",N copy
applicant Js proof that a valid affidavit is an file for future permits or not
let. t now Affidavit must m tilled out each
year. Where a home owner or citizen is obtaining a license or permit roe related to any a this Af d commercial venture
t ice, J Jug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. questions,
tit he I)tiicc t Investigatiuns would like to thank you in advance for your cooperation and should you halm;mY 4
plcabe du not hesitate to give us a call.
the U.:p:uumnt's address. tetephuna and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Otflee of[ovesidjadons
600 Washington Street
Boston, MA 02111
(el. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617.727.7749
<.1n.u3 www.mus.gov/dia
n�'
Latulippe Construction 35 Sunset Drive
Carpenter Beverly, Ma 01915
Lic#088378 978-836-9973
Hlc.#131457 Licensed — Insured
Proposal Page No. of Pages
PROPOSAL SUBMITTED TO PHONE DATE
cl7b' 77/ 2 7/
STREEf JOB NAME
CITY,STATE AND ZIP CODE JOB LOCATION
! lizo
ARCHITECT DATE OF PLANS JOB PHONE
We.her
eby propose in furnish materials and lebor necassar,for the completion of: - -
I Lcc--L 0 e'+ (/j 10 C(4'W
1 Su�pf it cur Ins!'XX(/ 0) Ill ca,3 a 141 t- rn l
cloolo(e v� c:Ilec( cjoolole hu., f W) ndQw 0 J714-
t to d o t l o , !- /-o inn e..e oL !l u 'ye" f- s"A Cl--a I,, coi✓�c'
( ot,n efe ; oL, 4o IkC- jve& in , zn !-eviin ;1Z rvvf
v
Qod E'1 &jr16. - GS we-(L &A II I nl SA--5 n i/7
�,rfevto✓ 1-o Let M4ytif yree -Pr +- 41 % t)
L3 �a �� CiGlirJ4 ,n
�vclr�InaPi Su> lied ot, 'I-
P - I
A e.-- ill c a I v 37
IJ zl {t -r Cr ,lax Ao(e -cCr IkIS&II O1 b
FWEPROPOSE hereby to furnish material antl labor-complete in'accordance with above specifications,for the sum of:
ade as follows: dollars is )
All material is guaranteed to be as specified. All work to be completed in a substantial
workmanlike manner according to specifications submitted,per standard practices. Any Authorized -
alterationordeviationfrom above specifications involvingextra costswill be executed only Signature
upon written orders,and will become an extra charge over and above the estimate. All
agreements contingent upon strikes,accidents or delays beyond our control. Our workers Note:This proposal may be
are fully covered by Workman'a Compensation Insurance.
withdrawn by us If not accepted within days.
ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions /
are satisfactory and are hereby accepted. You are authorized to do the work as specified. /t�
Paymentwllibemadeasoutlineabove. Signatur- l.l. V
/ t
Dale of Arreptance.: % / �� -Signatur t i b