71 TREMONT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
11 Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Fancily Dwelling Ext 118
his S do b For Official Use Only
Building Permit Number: IV Date Applied:
Signature: _ a j % ' �
Building Com issioner/Inspe C f Buildi Date T
ON 1: SITE INFORMATION
1.1 Pro7rty Address: 1.2 Assessors Map& Parcel Numbers
YLI 1�Pss'+cwl S!•
I.I a 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(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:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owtt otr'Record• _
Name tnt) Address for Service:
�.�-
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
-
G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 3�O 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ 7—CO ❑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: $ �t 2�' 0G 0 Paid in Full 0 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)
T Description
Address U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature y r M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
- SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
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
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:
1. 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 toot 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 1 I O.R6 and 110.R5,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\Ilti N I Y.)alit I41
v l\•.�at 11�^ W,\s!a\I;I UD S l:l Cli l' r 5A I I\I,M A>lsl.l It i1 I IS J l ri7-
li'A. '/73. $54395 r 17 l.x 9711-74' J.446
Workers' Compensation Insurance flil'6davit: Builders/Contractors/Electricians/Plumbers
! )liednt Inform ttion (] 2 Please Print Leeihiv
V i11Tl:lllu�uwvsit)rpantlatinlVlndn iduall: �� � r'r" 00,
1Jtiress;
City,Stacc,%ip SQ �e�1 I'hune ;f: 4W- 7`0 - JY66
. priate box: 'type fir project(required):
tire you an employer? Check the appro
4. ElI a a n gen 0.eral contractor and l New construction
1:❑ 1 AM a cmpluycr with ❑
e liployces(full itnL'ur port-Bute),• have hired the sub-contractors 7. ❑ Remodeling
?❑ I am a sole proprietor or partner- listed on the attached sheet. g
ship and have prno etor or par These sub-contractors have if. ❑ Demolition
%.orking for me in any capacity. workers' comp. insurance. 9. ❑ pudding addition
IKn workers' comp. insurance 5. ❑ We are it corporation and its
officers have exercised their 10.C] Electrical repairs or additions
required.) officers
I. Ptumbin• repairs or additions
3�int a homeowner doing all work right of exemption per Iv c n ❑ b P'
myself. [No workers' comp. c. 152, ¢l(4),and we have no I2.❑ RWI Ie'palCx _
insurance reyuirkered.j s anployces. (No workers' 13.0 (Aher;20/ 1t �CJ'ICur4--
comp. insurance rcquired.J
•An<.yphcmu than checks box ttl must:dso till out the semm�Iwluw.huwiny their wurkui eumpuns:uiwt gwliry udirtmation.
' I lummrwncn who submit this of loavit indicminy they um dolny all work a,W Ihcn him outside ewurmlun must auhmil a new atr:davit indiatmy%och.
-c ontrwwn that check this box moat ,owhod an addflional 4xet showing the name of the
sub<onnacwn and their sorter'comp.policy mftxmanun.
l any an employer that is pro vidinr workers'c•umpeusntion insurance for ray ernpfu3'eee. Belrnv is the policy urW job site
irrfunnution.
Imorancc Cuntpauy Vane: --- ---- —
Ilnlicv 4 or Scif-ins. Lic. n: _--".". . .. ___ EApiralion Date:
�7 y Clty.SlataZlp: �eQsYl
Job Site -\tldress: T-) �TQ��i �L.__.
Attach it copy of the workers' cmnpensation policy declaration page (showing the policy number and expiration date).
haduic to secure coverage as required under Section 25A uI'JIGL c. 152 can lead to the imposition of criminal penalties of a
foe up eo S1.500.00 and/ur une-year intprisomncnt, as ucl1 as civil pcnalhcs in the form of a STOP WORK ORDER and a fine
of up to i250.00 it diy .igainst the violator. Ile advised that it copy of this siatranent may be forwarded to the Office of
llt\�.d D;allvni ul the DIA for Iomnarce c,.% ar gc wi iticallun. _
1 du hereby cwrifv wider the paiinnv turd penoGicy ofperjury that the utfurinutlon provided above is true rued correct.
Daly___
l.)f/iciaf nse urdy. Do not write its this areu, to be cusupleted by city,ur roovn o/Jiriul.
its, or Town: ---_ -- Permit/t.iecnse 4.
Issuing; Aulhuriiv (circle unc):
1. Iloard of Ileallh 2. 111111111114 Department .l. Ciq.'I'utto Clerk J. Electrical Inipector i, plumbingIniyeelor
6. Ol her
Contact Penton; .. _ Phone H:
f Information and Instructions
Nlassadm:etts General Laws chapter I i2 requires all employers to provide workers' compensation for their employees. -`
Punu:urt to this,tituie, an empluree is defined as "._every person in the service of another under any contract of hire,
evpress or implied, oral or %vritten."
An employer is defined as "an individual, partnership,association, corporation or other legal entity, or any two or more
,If the t„rcgoir,g engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the
receiver or trustee ol'.m individual, parmcnhip, association or other legal entity, employing employees. However the
owner of a dwelling house having not snore than three apartments and who resides therein, or the occupant of the
dwelling Iwuse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grountls or building appurtenant thereto shall not because of such employment be deemed to be an employer."
11GL chapter 152. §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal or license or permit to uperate a business or to construct buildings in the commonwealth for any
applicant it ho has not produced acceptable evidence of compliance with the insurance coverage required."
Addinunully, :NIGL chapter 152, a25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ufpuhlic work until acceptable eYidcnee ol'.cunlpliance 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 tile 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 purtners, 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 confimiation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he n>tunted 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 he 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 not in the event the Office of Investigations has to contact you regarding the applicant.
I'la;uc be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennio'license applications in any given year,need only submit one affidavit indicating current
policy intormation(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 affidavit must be.filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
ti.c. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he (Nticc 11 Investigations would It'a to thank )'ou in advance fur your cooperation and should you have ;city questions, -
please do nut hesitate to give us a call.
The Depar inent's address. telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofte of lnvesdgatlons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PRoPRERTY
1`s
'= DEPAR"I'MENT
III J'R.'a;. l:.l; I \\ !'.a V: • ;�„
constrtiction Debi-is Disposal .-affidavit
(re\luired li)r all demolition and renovation \wrk)
Ill accordance ill, the sixth edition of the State Building Code, 750 ChIR section I I I.5
Dcbris, and the provisions of ti1GL e 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 facility as defined by N4GL c
I 11. S 150A.
The debris \will be transported by:
4- 6�
(name tit hauler) -
I he debris will be disposed of in
T jn.r,Inr ,, fault ,
IudJre+� ut lacJuyl A
'lullaluic Alt pclnnt al\pllcanl
�i way 3 Zms
,late
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
Kl fd✓i'•L+Y tiw•ry.
NAVM 130 WASNINGMN MEET 9 Su.Fx%%SUCHUSE R 01970
TEL VS-715-MS 9 F.vc:978-740-9646
HOMEOWNER LICENSE EXEIMMON
Please Print
Date M0v 31&Or
Job Location L( �frezhmkT S7 S hem
Home Owner Address re
Home Owner Telephone -f8- Tat - t yti C
Present Mailing Address Z i ir evil e.c i S7
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwelling. attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code