11 THOMAS CIR - BUILDING INSPECTION (2) .. Thr (�u�nui��m+r:�llh uf �laxsarhus�tts --- '
� . �` i„ Ii�iarJ ��� 13wl�ing Rrgul�tiuns :inJ Sian�arJs I U12
I � '� ; htass��husetts St�tr l3uilJing ('ude. 7SI) ('!�1R. 7°i �Jiiiun V l �'Ie IP �1 fl 1 '
I '�I.
I + i
., , � Kri n��J huuen� '
l3uildin � 1 crmit A i licaliun Tu (�unslrurt. Rr �II'. R�n�i�:ur Or Drm��li,h a
� � f � �
� Unr- nr T�ru-F��u�iilr D�rrllin,�� l. '��n.ti' �
� �.� Secliun Fur Offirial l,�se Only -i
� l3wlJing Parmi� Numbar: _ D;ue ,lpplird: _ G �_ �
—
--�
� Sienaturc: . --��(-0� ---- � - � -- -- -- !
13iiilJiiiE ������i»��,�������/ li»pi � ur n�HwlJmes U.ur ... ._i
� SECI'ION 1: SI"PE INFOR�L�"I'IUN _ ------- - --
i LI Pro �rn��.�ddre�s: I 11 �»essu�5 �I�p :F Pa�cel \�u �hr�s ,
� -��� GILLGL� '
� _ I Sta \.�inher _____. . 1':�r. I nmhrr._ .—.__. _ '
- � I.I:i I� Ihi� '.n a� _pfCd ,rr[rt ' tie� __ nu __ � P ___— '_'�
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��.�_� ; : � �:nF;u-*:.s:�.x�s��:::::n: -. ' I.d s'r.�.u.�r:_ :iim�<::siaa,: !
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j -- - ' ----- ----- _-_ _ � --- '
•.:ni��g Ci�l.irl Pru��•rJ l,'se � Lut Arcu Isy Iti F�unw<< t:t� .'-__ ��
._. � .
__ '_._ _—
�__...___.____.— �
I LS Building Srtbacks (ft)
I�, F----- - — ---
j Frum Yard tiiJr YarJs Rear 1':irU _ _l
' ! Reywred Pruvidrd Rcywred PruviJed Reywred Pru�idrJ ��
._.�_—.__—..
�I ' —' . � --__�
� 1.6 1Va[er Supply: t:�1.G.L c. 10. §S�l) IJ Flood Zone Infornsa.ion: L8 Sewage Dispos�i System:
Zune: Outsiue Flaid 2one? ,titunici �I ❑ On sile dis�osal s s�rin ❑ I
� Public ❑ Privale❑ C'heck il yes❑ � � } �
' ^ SEC'iION ?: PROPERTY OWNERSHIP�
� ?.l Ownee'�nf Record: I
A���,a.�.� -� ,� _ �l C�; Ati�.4 D2 Sr�..�..s nM oiRob i
� N,ur.c�Pri AJdrese (or Service,
� �—� Co �1 - a��- so8� _ I
�I Sien:turc Tcltphunr _ ____-�
SECTIOM1`3r L`L�'tiCRIPTiON OF PP.OPOSF..0 iVORK=(check all th•rt spplyl I
� �fewCunstruetiui� Esistin� Hwiding��O� reny Oiiupiad O � R- a�) ❑ Aleer❑t�unls) ❑ :\JJiti��n ❑ �
Demuliliun ❑ Ar�es iry 61d�. ❑ � Number uf Uni�s_ Other ❑ Spcuiy:_ �
---.I
��II �ricf Dest�ripunn ��f Pr��p��sed 1\�. .!:':_,._ . _ .—l2LN-GG-6��� <<' - �----.
�
- --- -_ _-- - -----�oU�NP���-�= � --- `�'-"-'��- ------- - i
� ---------- - ------------___- ...—-- I
I - ---- ------_--
_ . _ _ - - -- _.._- —----- a
- -- — �ci:'f10N r: E�Tf�7ATF.D CONSTRUCT[G�N t'05TS — -- ---- '
� Imm E�nrnatzd Cu,cs: --��(�ffi:ia0 Use O�;ly — � i
1 �( abur und Mmerials�
I. liuilJing S L Duildfng�Permit F�ee: S _ InJiraie h��w� f« i. �ricrinincil: '
❑ Standard Ciry/T�>wn :\ppliratiun Fee
'. F.lectricul 5 � ,
- __, ❑ Tulal Project Cu�f (ftzm GI s multiplier s
1. PlumbinE 'S �. Other f�ets: $___ i
l. hlerhanical �HVACI 'S Li,�: __ .
5. Mechuniral IFire —� - ---��-�----- �
5 � T�,tal :\II Fer.: S
Su� rcti�iunl � -- .
C'heek No.�U(.'htrA :�muunt:/��('.i,h .\m�,um:_.. _ . �
j o �fulal P�ujec[ Cotit � � � O o O I Paid in Full ❑ (�u�scin�ing [3:il:mre Uue:.-_. .
' -----
tiECT10N 5: CONSTRUC'1'ION tiERVICES _ _ _�
5,� �.�i�ensed Cmistruclion tiupen�isor ICSI.1 1
� CS 06_q_oo3_ �L ��Sl�ao^� �
I _��h��.-+'� I • rJ _ Li.an.a .Vumh.r I`.�pu�.ili��n l).u:
\'aulr��I(�SI.� I IuWCr �
I.ui CSL T�pc I.cr h�lu��1 ._ _'_
� - "I'v c Dr.:ri �uun
' \.Idrr.> -
� l� l�nrr.IricliJ �uitoli.lN1U(�u. l'li —�
_ �'1 �' n�n pR. S�M� O�f�b H � R�•slncicd I.�:' Fdinil� D��:Iliuc �
lipumua �1 \I:u�mn Unh i
f_.� � ��� _A00� - RC Rcoi�:nUal R�niline (�u�:rin`_ —' -1
filiphunv \\'S I<r.i�iulial N1pJu�� .u:� ]iiLii_ __ _
. SF R:.iJrnii.il SuliJ Pu:l I3uiniuc \�i.in_lu.i.ill.iii��u�y
D K:.i�enU.il l)rmuli�iun — 1
�.? Rrgisterrd Ilome Imprurrmen[ Cun[ructur IIIICI — I
HIC C��mpany Vamc or FIIC Nceutnnt Name Rcgi,trauun \'uwbrr
�Jdrei.
IFl�lll]�IUI: UJ�I'
Signature Telephunc
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C16))
Wurkers Cumpem�tiun Insurance affidavit musi be cumpleted und �ubmitted with this ;ipplic:uiva F:ulurc tn pru�iJe
�his affid�vit will result in the denial uf ihe Issuance u(the builJing permit.
Signed Aftid:rvit ,attachedP Yes ......._. ❑ No . __.. .. ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
� _ , as Owner uf ihe wbject pruperty hercby I
Iau[hurite tu act un my behalf. in all m:uters �
re!�tive tu w��ik :wthurized by ihis building permit applic�tiun. . j
I I
Sienulure uf Owner D�le __�
SECTION 7b: OWNER� OR AUTHORIZED AGENT DECLARATION
� , as Owner or Authurized Agent herchy Jecl:irc
that the statements and infixmatiun un the furegoing application are true and ac�urate. tu ihe best �if my knu�vl�dge :ind
hehalf.
II pnnt Name
Sienatum ol Owner or AuthonteJ Agent ���� I
�.1i� nrd unJtr d1c ams�nJ cnallies ol rfu �1 �
NOTES: �
I. An Owner «�ho ubiains � building permit «i du his/her uwn ����>rk,ur an ��u�ner whu hire� an unrcgi,�eraJ r,n;tr:i..�,�r
(nut regismred in the H��me Impruvement Cnntracinr IHICJ Prugraml, will �ro[ ha��e access tn ine ;irhivau��n I
program ur �uaramy fund under M.G.L. c. la'_A. Oiher impurtant int��rmatiun ��n the HI<' Prngr:mi anJ
Construciiun Supervisur Licensing (CSLI r:�n be liiund in 730 C:�1R Regulati�ros I IO.RG :ind I IO.RS, i�,p«ii��l�.
' W'hen ,ub.�anual �vnrk is pl�nneJ, prucide the inlbrmntiun beluw� ,
� � Tuial flourti area ISy. F'LI �incluJing e�rage, fini.heJ b�,cmenU;unc., deeka ur p��rrhi ;
� Gni�s livin� area i5y. FL1. H:ibitable ruum cuuni
� � Numbar��Y iirrpluce� Vumber uf hr�n�nm. — — ---_ �
� I Numbar,�i h:nhruunu Vumbar��l h.ilUbaih. . _
� �f vpe uf htanne �v+tam _ Vumber uf�I�rk./ p��rrhe� .-- -----._------. i
T�peuf.��uling ���,tem L:n.L�.aJ -- Upcn ____
�'� 7. �T��ial Pr�,ject Syuarc fuucige" may be ,ub>ti�wed t��r "��,cil Prn�crt C��.i.. —�
{��:'" *�> CITY OF SALLM
y � `f'.
' : , A�r PUBLIC PROPRERTY
;,•; � .. , _
'- ` ` "�f"�' DEPr�IZ'I'?�1ENT
.,,�,��,,:,,
.� . ��� , ,.,::., � .:� --
� �.� .�„�r. „cU�.,;in.�,.;��:,i�i.ri . S.�ii��i. �,.�.;�� ... .� i , =i" �_
�IY�: 'c3-Tf;-•1;95 � 1���: 77S�N:�'�9�6
Construction Uebris Uisposal At�tidavit
(r�yuir�� Ibr all dcmulition .ui� rcnovatiun �wrk)
In accurdancc ��itli thc sixtl� rdition of dic Statc Buil�ling Code, 7S0 Ch1R scction I 1 1.�
Dcbris, and the provisions uf MGL c �0, S 54;
Quilding Permit i� is issued wi[h the conditiun tha[ the debris resultin� front
this �vork shali bc disposed of in a properly licu�sed wa,te disposal Pacility as defincd by MGL c
l l l. S I SOA.
The dehris N�ill be transported by:
�1 a- � �`�'2 ��^Fi r .
�.. ... �uame o[haulcr) � �
fhe dcbris will be disposed of in :
�1a -�,"� �"`-`�^ e �v .�:ti�
---- _ -
(name ul Iacility)
Sw 1...Qbco"� ' 1"'� SF1\CN\
� I��ddressuf�l�rilitV)
(�� �
;
tii�iW�urc of pr� n�i�yaj>lican[
� ( � S ���J
�latc
,.b��.�if�.,,.
,:>���� CITY UF SALEM
�; �x,�: ��,�� PUBLIC I'ROPRERTY
�'�';;;��;: DEPARTMENT
.„��:,K:�,-:�K„�:,,��.
��t�i��,n 1?�W a�ru�c�ro�Srx ee�' � Snu:�a.b1.�is.�c�u-sr:r i s G 197�
'17:L:978-'ii9i9j � P:�s:978-?a�9H4G
Workers' Cumpensation Lisurunce :�f'tidavit: L3uilders/Contracturs/Electricians/Plumbers
\ � il�csnt Infonnation Please Print Leeiblv
V817'td ll3u<incs5�nt,�,ani�uinNindivuluull:
A✓-�^aN� �� ��
:'�i�(1l�titi:
\ v:r1.�aJR �2 Sn� S, /� OaSOc�
SH—k"S ��ElURC i': b t1 ' ��'J - 80 9�l
(.IIYi SCiCCi�1�: -
� :\re you •rn employer? Check the:�ppropriate bux: 'Pype uf prnject(required):
I 1.❑ I am o cmploycr wi�h 4. ❑ I am a gcncral coWracwr and! (�. ❑ ��w ����,truction
havc hircd thc sub-u>ntractors � Remodelin
tmployces(full umL'uc part-tima).' lis�zd on rhe anached shect. � ❑ 8
?.�. I ;mi a sole propriceor or partner- .
ship anJ havc no empluyces 7hese sub-connac[ors have 8. ❑ Demolicion
working for mc in any c�pacity.
workers' coinp. insurance. 9, � puilding�ddition
5. ❑ We are a corporation �nd its
(Ko workers' comp. iiuuranca 10.� Electrical repairs ur addidons
rcc�uired.] oftiecrs havc cserciscd thcir
right of txemption per MGL I I.Q Plumbing ropairs or additinns
3.❑ I am a homcuwncr duing�ll work c. 152, �l(3),and we havc no 12.0 Rouf'npair�
mysclf. [Ko workers1 umip. cmployec.. �No workzrs' .
insur.mca rcyuired.j 13.❑ Ol6er
comp. insurancc rcquircJ.J
-.quy�.,,plicunt�but chccks bos HI mus�alsu lill um�hc xcliun lwlow showin�{thcir wurkur cumpcnmliw�pulicy inlirtrtutiun. .
�I lomcuwnen whu submil lhis affidavi�indicating Ihcy�m doing ull work and ihen hin outside cunimc�ors mmt suhmii a new alf:clavit indiubng vmh.
=�. .i �ii I ch•�k�his box muct atlxh�d on audi�ional.aheer.h iwing�Iw nainc of ttu�sub<ontmaurs and ihcir wurkers'cump.policy intormariun.
!�uir un ruiployer tha!is pruvidinx rvo�6crs'cw�apensnuna uisurnnre jov nry emplo)�eea. BeGnv�� the pohay und/ob.�ite
iuju�u�urion.
Insuraucc Company Vame: . . _ . . .__ .__...--_..__—.----
Policv �i ur SelGins. Lic. r: -----..- -. ..
. __ __ Expira�iun Date:
Ci�y�S�a�ei`Lip:
lob Site Addre.s: .—
,�ttnch a cnpy of 16e�rorkers' cumpcns•rtiun policy declaralion page (showin�; the policy numbcr•rnd ezpira[iun drte).
I�ailure w securc covtrage as required under Seciion 25r\ol'�[GL a 152 ean Iwd to tlie imposition of eriminal penalties of a
tinr up u>51.500.00 anJ�'or une-year impri.onmcn�,as wcll�,ci.•il pcnaltiu in the 1'orm uf a STOP \tiORK 02DER and a fine
;,fiy� ��� j�jp.qp a Juy ;�gai�u� �he �iolaenr. I3e advi.c:d thut a copy uf this,iutcmunt may be forwarJud �o �he Oltice of
In��c�tiga�ions�I'thc DIA ('or irouraix� an�cr:�gc ccriticaiion.
1 do hrrehy ceriiJV����ilur die pnin.r�n�d pr, /'f,lr;`'�,'�IPr�l��4'lhut die injonnulian pruvided aGose is vue uud correct.
� ��� (o �S �O 9
I)�tc'
bii_ i uni� / C�-o--
Ph��r.c:;: Ca c'l - � u - ao �i
Q(Jiciu!r�se anly. Do nn� wrire iu�hi.c ureu.fo be cuu�ylered by city or rorvn nJjicrul.
Ciry or'1'o��•n: ---._ . "
Pcrmit/I.iccnse�---._. .__. _ . � - - - -
Itisuin�:\u�hori�y (circicunc): �
I. ISuarJ uf Ilc:�ith 2. 13uildin� Dcpartmcul .i.Cily/fo��n Cicrk J. L•'Icctrical lnsputor 5. Plumbing Inspcctor
G. Olhcr _ ---- -
Coulucl Pcnon: -_. . --- Phonc N:
Information and Instructions . �
� \�I;15J:11'IIUSCIIS GCOCfBI L8\V5 l'I78�)[CC UZ fl'(�WICS:III Clll�)IOy'CfS[O PfOVI(�0 WJlICCCS� GOIIIp0fi.18[t00 �Of[I7CIf t`I11NIOyC05.
Punu;u�t to this�iatwe,an rmplq�•re is defined as "...evzry pe�son in�he service uf anothar undzr any contract uf hire,
etpress or implicd. oral or writttn." �
\n einpin���v is dctincd�s"an individual,partnership,associatiuu, corpuration or other legal entity,or any two or more
oi thc Fomwing en�,aged in u joint cnterprise, and including thc legal representaeives of a deceased employcr,or the
rccaiver or crusiee of:m individual,paimership,�ssociation or other legal en4ty,cmploying zmployees. However the . .
owner of a dwelling house having not more than three apartrnents and who resides therein, or the occupant of the
dwel�ing irou,e of anorher who employs persons w do main[rnance,cunsVuction or repair work on >uch Jwelling house
or on the arounds or 6uilding appucten:uit thereto shatl no[becaust of such zmploymcnt be deemed tu be an empluyer."
J1GL chapter 152, �25C(6) also sta[es thu["every state or local licensing uRency shall w•ithhold [he issuance or
rene�val uf a liccnse nr permit tu uperete a business or to coostruct buildings in the communwe�lth for any �
;�pplican[ wLo has not produced acceptable evidence uf compliunce wi[h tl�e insurance coverage requfred:'
.�dditionally, �1GL ch.�pter 1�2, 525C(7)states"Neither the commonwesl[h nor any of its polilical�subelivisions shall
�nmr into any contr�et for the perfonnance uFpubliz work�witil acceprnble evidence otcomptiance wich the insurance
requiremrnts of�his chapter havt l�een presented to the contracting authoriry."
Applicants
Please fill out the workers' compensation a�davit completely,by checking die boxes tha[apply to ywr situaiion and,if
❑ecessary, supply,ub-conerac�or(s) name(s), address(es):u�d phone nwnbar(s)along with their certificate(s)of
insurmice. Limited Liability Companies (LLC)or Limiced Liability Partnerships(LLI')with no entployces uther than the
meinbers or purtners, are no[required to carry workzrs' compensa[ion iiuurance. if an LLC or LLP does havc
cmployees, a policy is rzquired. Be advised that this affidavit may be submitwd to the Department of [ndustrial
:�ccidents f'or contimiation of insurance coverage. Also be sure tu sign anJ dute Ihe ul'tidavit. The aftidavit should
lie returned �u die ciry or town that the applicxuon for the permit or licznse is bcing roquesred, not the Uzpartment of
. f nJustri�l Accidcnts. Should you have any yuostions rtgarding the ]aw or if you are reyuirzd tu obtain a workers'
cumpensation policy,please call the Department a[the number listed below. Self-insumd companies should enter their -
sclf-insurance license number on the appropriate line. �
City or Town Ofticials �
Picasc hc sure tha�the affidavit is complete and printed Iegibly. The Deparhnent has provided a spaca a[the bo[tom �
nf dit attida4it for you to till oue in the event the Oftice uf Investigations has to con�act you regarding the applicant.
Pka�e be surz to till in�he permiVlicense number which will be used as s referenec number. In adJition,an applicant
Ui:u must submit mWtiple pCrmit7ice�vse applications in any given ye�r,need only submit one affidavit indicating current
pulicy information (iY necessary) ;u�d under`7ob Jite Address" [hz applicant should writc"all locatiuns in (ciry ur
eown)."A cupy of ehc aftiduvit that has beeii officially s[ampcJ or marked by che ciry or[own may be provided to�hz
applicant as proof[hat a valid�fFidavit is on file f'or future pe��nitti or licenses. A new atfiduvit mu,t be tilled out each
. yzar. Where s home owner or citizen is obtuining a license or permit not relared to any business ur commzrcial venture �
(ix. n dog licznse or permit to burn laavzs ztcJ said person is VOT reyuired to complete this affidavit.
�I�hc OI't ix uC luvestigations �.�ould like io diank you in�dv:mce fur your tooperatioii and should yvu have :�ny yuestions, .
plaase cfu not hesicate to 5ive us a calL � �
Thc Dep;irnnent's addtess, telcphone and faz numbtr.
The Commonwealth of Massachusetts
Department of Indusuial Accidenu
011ice of InvesUgallons
600 Washinston Street
Boston, MA 021 l 1
Tel, tl 617-727-4900 ext 406 or 1-877-MASSAFE
r<,��.�d �-�r�-us
Fax # 617-727-7749
www.mass.gov/dia
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i P.O. Box 1081
�I C� Accredi e Evaluation andetts � c3 -��" -- --f---
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