7 UPHAM ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
t� Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T"edition Building Dept
`J Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numb Date Applied:
Signature:
Building Commissioner/I pector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Proppp��rty Address• 1.2 Assessors Map& Parcel Numbers
rl Ur�NiRW�
Ma Number Parcel Number
x 1.Is Is this an accepted street'?yes_ no. p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L C.40,§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private ❑ Check if XesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: .S 1 �� �� �
j3V_VL,� (1 {� Address for Service:
X Cf
Name(Print)
q 7g-578-'Y698
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building,:) Owner-Occupied Repairs(s) O Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
BriefDescriptionofProposedWork':- r,O,EX/S77/d� tK Cf 5 �9kT S6A�
n`ss3o�t iti i%�E�t✓rtle'�si/ist/l !-�B{CM7"&# 4&O t, sUn✓6rLS-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building $ I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List: ,7
5. Mechanical (Fire S Total All Fees: 5
Su ression
.Check No. Check Amount: Cash Amount:
6. Total Project Cost: S (�G ❑ Paid in Full O Outstanding Balance Due:
z
SECTION 5: CONSTRUCTION SERVICES
5.1 L'censed Construction Supervisor(CSL) �6/O
r L'/'l�/1rL(� Licrnsc Number Expvaton Date
Ngme of CSL- Hpldrr List CSL Type(see below) C GJS
Address T Description
�� � U Unrestricted u to 35,000 Cu. Ft.)
R Restricted 1&2 Fame Dwellin
Signature �Q M Masonry Only
RC Residential Roofing Coverin
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
�Tfrt WZ;6Y Co�r.Pi2.3Gncs /6677K
HIC Comp y Name or HIC R istra Name Regis iratio Number
eCO S ,I'- q qq ��II
A drc d / O'G[b
1 ^ Exp ation Date
Signa a Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 .......... No........... ❑
SECTION 7s: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, Z!(i , 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 Na
y b
Signature Owner or Authori ed ent DatiV
(Signed u der the pains and nalt of du
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 no 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 110.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenbattics,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
it I \ .nil( I q i
\I •,qt 13� Rt\Hu\.J.+� 17LL 1' 5.\lt\I, M.\».\I III NI I I.J197J
Ib.I. YtL'li'li'+3 • 1 Ix 979J1,: )146
Workers' Compensation Insurance %ffiduijit: Builders/Cuntracturs/Electricians/Plumbers
t )ILLant Information Please Print LeCihly
V It ind II1n.0 K.fr(')rgan IlatinNI ndni dui ll.
VItltti.i.:
Ctty.Stac State. � 4- U/9Go Phone 0: el' -J31-16'Flo
Are \. an employer:' Check the appropriate box: '1')Pe orproject (required):
I. I am a employer with Jl 4. ❑ I :un a general contractor and 1 fi. ❑ new cunstrueuun
c ngrlo)ccs(full onlL'ur part-time).• hajc hired the sub-contractors 7. ❑ Remodeling
�.❑ 1 sun a soh: prnprieux or partner- lifted on the:coached sheet.
ship and have pretnpluycar These sub-contractors have it. ❑ Demolition
working tier me in :any capacity. \jorke a corpo Insurance 9. ❑ Building addition
No workers'cum . insurance 5. Cl We are a corporation and its
I p officers have exercised their 10.❑ Electrical repairs or additions
1 required.) . ie airs or addlttnris
J.❑ 1 :u»it homeowner doing all work right of excntption per h1GL 1 I ❑ PI bin b P
myself. LKo workers' comp. c. 152. 41(4),and we have no 12. Ruuf repairs
insurance required.) 1 employees. LKo worker' 13.0 Ulher
comp. insurance required.]
-\... ....III,one rh.te checks box nl mean 460 II II Wt Its,wCOJII JKlaw Yho,wisill dWa wurkus'cumpon,oaiwt Iwhcy nnl.rnudura
' I IJmv'nwKn who...billet Iris af/ldavil indicating IIK)are doing dl work mW then him uuNtde cutorneton null.ohnil a new al G.Iavi1 indiuW ma....h.
d,.ntrxu.n Thal..heck out box moat nlxhevl.nl add.lional-hL%l.lowing IIW natW of fw t te,'emlrxion,and(heir wurkon'cunt rloicy odtamanon
/and all employer tlrut Lv pro riding tvurktrs'a•urnprncntion in.taraaca•jar my rasp/uytrr. Br/nry ix the pis/iay wld Jub soil
IlrjurnlutlrrM1 )-l u�
lr.,oranee Cumpauy -Name:
1'oliev a or Sclr-ins. Lic. r:q ,St,., 7S3FO�Iy7b. -- Enpirauun Date:. l!T�
loU jne -ltldress: �Ul`H/1r't Kl 5,L1t,4- City:SlataZlp.
Altach it copy of tire workers' cumpcnxatlon pulic) declaration page (showing{ the policy number and cxpirattun date).
failure tea secure cu\erdge as required under Section 25:\ul'>IOL c. 152 can lead to the imposition of criminal penalties of a
tine up to iI.511o.tto unJ.'ur one-year impris.nuncnt, av .jell as vi%il penalties in the: furm of a STOP WORK ORDER and a fine
of up m 5250.00 a day •Igainst the violator lie adjt.vcd That a copy of this amcmcnl may be lurwarded to the 011icc of
I n.;.n•pmnn ul :he DIA :or in..0.axe an.r.Iyc \eI Ilieat:on.
/do hereby r:rQfV Ir+race t/rt poir c gad penultir, ofperjory that the injurrnatlon provided above+s true and a'orrect.
1 U
IJ�/iriu!use way. /)u nnr writer in thly urea• to he cwuplrted by..ivy ur 0' a//iriu/.
( iiv or ft.c n: _-_ _—. Per miul.iecnjc st
Issuing Authority (circle tire):
I. 14.urJ of 1 .11111 !. 1111 a" 14 11rt onvlt 1. cif Cfo.ut Clerk 4. L••lec l rical lu\pcc ror ?. Plwn bin Ilnpecfor
b. Other _
Phone is:I'cnull: ..
Information and Instructions
�Lu+.tchu.ew Gcncral Laws chapter 1 52 wqures all einplo)cis to provide workers' compensation 1i)( their employees.
I'ur.d,.uit to r:tn statute, in emplu ter is &find as " ed cry pcison inthe service of another under.ury contract of hire.
c.press or mphcd, oral or dvruten."
%n :,nployer is defined as"an individual, partnership, .tssoci.mou, corporation or tither legal cnmry, or any two or more
.,r the torcaomg engaged in a point cnicrprsc, and including the :coal represeutamves of a deceased cmplu)cr, or the
rccetvcr or(rusice of individual,pnuniershnp, association or other legal entity,employing emplo)ees. However the
owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelluig huuoe of another who employs persons to do maintenance,Cun%truction or repair work on such dwelling house
or on the grountl-s or budding appurtenant thereto shall not because of such employment be deemed to be an employer."
\IGL chapter 152. �%25C(6) also states that "every state or local licensing agency shall withhold the Issuance or
renewal of a license air permit to uperate a business or to construct buildings in the cuintmonweallh for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
\dditiunally, NIGL ebapter 152, §25C(7) states"Neiihei the commonwealth nor any of its political subdivisions shall
enter into any wnaract for the perfomtance ul public work until accepetble ev idence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants 11
Please fill out the workers' compensation atfdavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contraclor(s) motels),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 confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The afldavit should
he renmicd w the city or town that the application for the permit or license is being requested, not the Mpartment 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 Ofllclals
please he sure that the affidavit is complete:md 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.
Phase be sure to fill in the fermi✓license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit,license applications in any given year, need only submit one affidavit indicating current
ptilicy 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 die city or town inay be provided to the
applicant as proof that a valid affidavit is on lie for future permits or licenses. A new affidavit must be filled out each
vear. 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.
1 h; i)i iice of Investigatiuns would in�e to thank you in aJvancc fur your cooperation and should you have -my queslons,
please do not hesitate to give us a call
fhc Ucparunciil'.a address, telephone and fax number-
The Commonwealth of Massachusetts
Department of Industrial Accidents
0171ce of Investigadons
600 Washington Street
Boston, MA 021 1 1
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mass.gov/dia
'l
CITY OF SALEM
ry „ PUBLIC PRc)PRERTY
DEPAR"I'MENT
IJ. \\ \,111\i..,'I:1:311 r # 1.\I I \1, \(.\. b '. .. I •.I'1
II I- '/'$.'Ji.7S•li I \\'.
Construction Debris Disposal .affidavit
(required fix all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Code, 780 Ch1R section 11 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
l 11. S 150A.
The debris will be transported by:
:L4 la al-It
(name of hauler)
I he debris will be disposed of in
(name of lacilrty)
n(llfC5<u1 lac IIIIV)
\1 LIIa1Wc of perm It Ipphc
a
Ilalr