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TINKERS ISLAND - BUILDING INSPECTION (4) 1 The Commonwealth of Massachusetts CITY L Board of Building Regulations and Standards I f Massachusetts State Building Code, 780 CMR, 7"'edition OF SALEM Revisrd Junnurr / Building Permit Appli 'on To Construct, Repai , Renovate Or Demolish a O On -or Twu-Family Dw ling is Section For Offt at Use Only Building Permit N m r: 1 Da Applied: Signature: HuiliJ4 Commissioner/Inspit&pf Bu Id ngs Date S CTI N I:SITE INFORMATION 1.1 Pro a Addrcu:�s/!�� n 1.2 Assessors Map& Parcel Numbers I.IaTTIs this/an accepted street?yes X no X Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(11) 1.5 Building Setbacks(R) 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: Zone: !� Outside Flood Zone? Public❑ Private 0— Check if es❑ Municipal❑ On site disposal system ®— SECTION 2: PROPERTY OWNERSHIP' 2.1 wiser[of R jord r Name(P 'nt) Address for Service: U7 G: r�cs S�D�5 ?-z8?? Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials L3. Building S ' Jr de" 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee Electrical S ❑Total Project Cost(Item 6)x multiplier x Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire Total All Fees:S Suppression) S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due: �"q eT SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expimlion Date Name olY'SI--I lulder List CSL Type We below) NDZResi11dcmi;d Dewri ion Address uicteJ u w JS,000 Cu.Ft. cted IRI Famil Uwellin Signature Onl ential Raotin Coverin Telephone entil Solid Ful Bumin A fiance Installation Demolition 5.2 Registered Home Improvement Contractor(HIC) I IIC Company Name or HIC Registrant Nume Registration Number Address Expiration Date Signature _ Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 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 ..........0 No...........0 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. Sianature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 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 eh gnature of Owner or Authorized Agent Date Si ed under the aims mid penalties of 'u 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_W have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.145. respectively. 2. When substantial work is planned,provide the information below: Total Moors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) Gross living area(Sq.Ff.) ffabiiable 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" N CITYOF eAEM ; ,. i� l PUBLIC PROPRERTY ' D� DEPARTMENT '..I.\t l'dat.CY DKISCOLL \f.�)oft l2�^WASNING10NS MEET • SALE.M.M.tssncaa:sE'I'IsG1979 Tl:i.:978-745-9595 • P:\x:978-74C-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anplitant Information `//� / 'n/ { Please Print Leeiblv %lalne (13usincssior8aniratioNlndivi,lua4: / v © ntleP Z— dl,• e,4r :�dclfcss: TNT r �T�w Cityi'starcilip: J:;/e pY4. Phonel:: Are you an employer?Check the appropriate box: 'Type of project(required): 4. ❑ I am a general contractor and I I.El I ❑m a employer with 6. ❑ New construction a Flu ces(full and/or art-time).` have hired the sub-contractors l Y P 7. (a R modeling -20 1 :un a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub-contractors have 8. [�'ITemolirion 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• 10.❑ Electrical repairs or additions required] officers have exercised their right of exemption per MGL i 1.❑ Plumbing repairs or additions 3.��am a homeowner doing all work S P P' myself. LNG workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.j t employees. [No workers' 13.0 Other comp. insurance required.] 'nay.�pplicunl dint chccks box nl must:dso till out the section W-uw showing Choir workuni cumpenvuion policy intiumuliun. 'l lomcuwnen who submit this affidavit indiuming they are doing ull work cowl then hire outside coomuton must submil a new afLda.it indi"ing such. -Contracmts Ihui chuck this box niml attachul an additional.,heel.,hawing the name of the subcontractors and their workers'cemtp.policy information. l con an employer that is providing workers'compensation insurance for toy employees. Below is the policy and job site inforulution. Insurance Company Name:---... Policv 4 or Self-ins. Laic. Expiration Date: Job Site Andress: //z-/2�� r �Jr/2 - p City/Stateizip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). failure to secure coverage as required under Section 25A uf.1IGL c. 152 can lead to the imposition of criminal penalties of a tiny up to S1,500.00 and/or one-year imprisonment,as 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. lie advised that a copy of this statement may be forwarded to the Ofitce of Invcstigatirnu ul'the DIA for I0Snt'n1 CC coverage ecritication. l do hereby tertif der tl a pains uit tetralties of perjury that the information provider/above is true and correcr. Si I um Dattr lh t .i OJJiciul use only. Do not prire in this area,to be completed by city or tmvn official City or'fow•n: Permit/license .....__.-...__ ..__._ .. _ . Issuing Authority (circle one): I. Board of Health 2. 1uilding Department 3. Citi7fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Olher _ Coulacl Person: _--- Phone it: Information and Instructions Massachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an einploree 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,partnership, 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." 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, MGL 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 ofcompliance 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 confimhation of insurance coverage. Also be sure to sign and dale the rffidavit. 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 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 pennio'licetse applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and tinder"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 tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. 'I'hc 01)ice of Investigations would like to drank you in advance for your cooperation and should you have any questions, please du nut 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 Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia ., r�At CITY OF SALEM al PUBLIC PROPRERTY DEPARTMENT Construction Debris Disposal Affidavit (required lur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CN1R section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit i _ is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal I3cility as defined by MGL c 111. S 150A. The debriswill be transported by: (came of hauler) I he debris will be disposed of in (name ul facility) tndJress u(Ihcilityl %//�/////�/// �ignuturc of pdnnit applicant O ,late --