1 VALLEY ST WAY - BPA 11 668 ROOF I� rile Commonwealth of Massachusetts CITY
Boar
d of'Building Regulations and Standards OF SALEM
WMassachusetts State Building Code, 730 CMR. 7 1 edition Revised donnorl•
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• =nn'v
One-or Tu•o-Family Duelling
This Section F �Otiicial Use Only
Building Permit N mbe Dale Applied:
Signature:
-3,22
Buildi Commissi ner/Ins Aoro luildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
X ( k/,O(2 v Z. (.00. Parcel Number
1.[a Is this an accepted street?yes_ no
Map Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq t3) Frontage(it)
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-'
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rfcord:
Nome(Print) Address For Service:
Signature 'relephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: ,� I A-D J:� b o'r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1. Building 5 I. Building Permit Fee: S Indicate how foe 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 (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No. Check Amount: Cash Amount:_
X 6.Total Project Cost: S Lif 60/0 ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 5( �� 0
J �-1 LiccnseNwnheUr Iixpimlion Date [ /
Nance W GSI I.-I lulder
1. � List CSL I'1 pe(see below) �6
J •ss A f% Description
�— H I!nrestricted a to 35.000 Cu. Ft.)
Si t toe R Restricted Ittt:Family Dwellin
ib r 1 --1 _ ( p M M:uun Only
RCResidential RootingCovering
telephone WS RcsiJential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
5.2 Regis r d Home Improvers ontractor(HIC)t /a ai 7651
o rl - L� 7 Lo �
MC Cum y NameName o�istr�me Registration Number
Ws �
Expiration Date
tii nut a V 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 Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIE)Program),will mor have access to the arbitration
program or guaranty fund under M.G.L. c. 1.12A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations I I O.R6 and 1 IO.R5,respectively.
?. When substantial work is planned,provide the information below:
Total Iloors arca(Sq. Fl.) (including garage, finished basement/allics, decks or porch)
Gross living area(Sq. Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number ol-bathrooms Number of half7baths
Type of heating system Number of decks/porches
Type of cooling system Finclosed Open
3. "Total Project Square Foulage" may he substituted fir"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
11^�WA\ttl.\ki ION S7x Ela' • SALEM, M.UTACIII afro X197:
lhf.:978.743-9595 • fAx. 979-7Q-'J346
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
konlicant Information Please Print Legibly
NainCIno.iocsslOrganirafinNlnJrotduufl: cl go Rr ` ,0Qt— f— �\
Addre,is: 15-t
City,Sla1Ci/.ip: f0_ X L : ep . Iia. Phone i': � ' rdQJ
Are you an employer? Check the appropriate box: 'Type of project(required):
1.PT I ant a employer with 2 4. ❑ I am a general contractor and 1 6• ❑ new construction
eat to ce%(full and/or art-Lime).' have hired the sub-contractors 2.F-1I ;un a sole proprietor or partner- listed on the anachcd 7. E] Remodeling sheet. � .
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q. ❑ Building addition
No workers'cont insurance 5. ❑ We are a corporation and its
I P• ME] Electrical repairs or additions
required.] officers have exercise) their
3.❑ I ant it hontwcwter doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. loo workers'comp. c. 152,§1(4),and we have no 12.ff Ruufrepairs
insurance required.) r employees. loo workers' 13.E1Other
comp. insurance required.]
-Any:yphcant ilial chceka box dl must also Jill uut rhe woiun twluw,Lowing their wurkai eumpenvaiust pulicy i ifnnutiu
'1I41RpIOW MM who udtmit this affidavit indicating they ate doing all work into then hill:uutslde cuiu,,wi n must submit a new affidavit indi"ing vwh.
f.,mrhUtr•t that check this box mwu attwh xl an addinional sleet showing the Hallie of the suh4onlractom and their aurkon'comp.policy infurmatiun.
/am wr employer that is providhr g workers'c•urnpensetion insurance for`ray employees. Behnv is the pulicy and fob site
inforinatiols.
I nNurauce Company Vmne: ___..
Policy is Lir Self-ins. Lic.0: _-_... ..__.._ Expiration Date:
Job Site Address: cityrstate/Zip:
— .\ouch,t copy of the workers' cwnpen.cation policy declaration pale (showing the policy number and expiration date).
Iailurc to secure coverage as required under Section 25A ul':vlGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.5110.00 and/ur sue-year imprisomncnt, as well as civil penalties in the furm of a STOP WORK ORDER and a fine
of up to 5250.00 it day against the violator. Ile advised that a copy of this smtcment may be turwarded to the Office of
In,'cangatnnts of the DIA for insurarce covcragc varificauon.
7/i/a herchy ce in, r hepain•mrdpeon/tics offierfn that the information provided above is true aut correct.
rurc — Dar•: — 6 —
O(/icial use aoly. Do not write in this arca,to be rwruplefed by city Lir toren official - 1
i
City or l'ownt Permit/License 8.__
lssuing Authority(circle enc):
I. Board nr iivaith 2. nuildinu Ucpartmcnl 3. Cifyi fonu Clerk 4. Electrical Inspector 5• Plumbing Inspector
6. Other
l''mLtct I'cnuu; _ ._ Phone 4:
Information and Instructions
>Iassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employed is defined as"...every person in the service of another under any contract of hire,
oppress or implied, oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more
,a the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of.m individual,paimership,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."
`IGL chapter 152, ¢25C(6) also states that "every state or local licensing agency shall withhold the Issuance or
renewal of it 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."
AdditWnally. 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 ol'cumpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) namc(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 docs 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 date the affidavit. The affidavit should
he retuned 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'rown Officials
Please he sure that the affidavit is complete ;rad 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.
11Idase be..Sure to till in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicentse applications in any given year,need only submit one affidavit indicating current
policy information of necessary)and under"Job Site Address"the applicant should write "all lucatiuns 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
1 i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he 0I Iice of Investigations would like to drank you in advance fur your cooperation and shuuld you have;uhy questions,
Please do nut hesitate to give us a call.
The Dcparuncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OIHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. N 617-7274900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
R:vi>cd 5-26-05 www.mass.gov/dia
CITY OF S.ULE.NI, NL-1SSACHUSETTS
BUUMLYG DEPARTIENT
130 WA.SHLNGTON STREET, JiD FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJtHERLEY DRISCOLL
MAYOR THo.+us ST.PrEitan
DIAECTOa OP Pt:BLic PROPERTY/BUMI)LNG COMMISSIONER
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 111.5
Debris,and the-provisions-of MGL-c-40 $54; -- - --
Building Permit # 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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility) — — — - — — - — -
(address of facility)
Qj)
sonrurlof permit applicant
!late
dannvl(d•A