22 VALLEY ST - BUILDING INSPECTION •I � The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code. 780 C'MR, 7'edition OF SALEM
Revised Junuurr
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. '(RAY
One-or Two-Funrdy Dwelling
/TVis Section For Official Use Only
Building Permit Number: Jbate Applied:
Signature:
Building Cumm' oned Inspec ildings Date
ACTION 1:SITE INFORMATION
I.1 Pro a Address: 1.2 Assessors Map dl Parcel Numbers
�" o Q.s, . sir-
I.la Is this an accepted st ?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Am(sq 11) Frontage(11)
I.S Bullding Setbaclts(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 O Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2./ wrier'of Recor
Name int) Address for Service:
�S62 .SC3�i 'l L422
Signature Telephone
SECTION 3: DESCRI ION OF PROPOSE WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) III Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descrip�tio of Proposed Work-:
S'l1NK YVL�1rJ Ls01
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building S 00 I. 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 /�\ x
4. Mechanical (HVAC) S List: ` f
5. Mechanical (Fire S
Suppression) Total AI)Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S C& ❑Paid in Full ❑Outstanding Balance Due:
c
r e
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 0
I.icem Numbs li. inl n Unto
Name of l'.l'L-1 hrlJer f� ' .,t{� List CSL Type(see below)
f Dirscriplion
_L �JJ R Restricted 142 Familylhvellin
SttplalUR M M Only
SDa .ribq 1�+50 RC It.c I nlial RoutingCoverin
fdcphrme WS Residential Window and Sidin
SF ReiJentid Solid Fuel Bumin A fiance Installation
D Residrmlal Demolition
5.2 Rr!,tered Ho IgsploYeer�ent Contractor(HIC)
I IIC Com_pCannyy-N. nor HIC Re sst frank .one Registration ber
spira on Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.I.,e. 152.1 2SC(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 ..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Sistrusturc of Owner Dale
SECCTIOONNp7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, T o \_ as Owner or Authorized Agent hereby declare
that the stand information on the foregoing application are true and accurate,to the bat of my knowledge and
behalf�c�
Print Nome
Signature of Own uthorized Agent Date
(Signed under the pains andpenalties of 'u
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who him 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. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS,respectively.
? When substantial work is planned,provide the information below:
Total floor area(Sq. Ft.) (including garage, finished basement/attics.decks or porch)
Grose living area(Sq.Ft.) Habitable room count
Number of fireplace Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Typ
e of cooling system Enclosed Open n7. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
!,IWI RI FY t)nliCul.L
\I XY<In 12^�WASHING ION S'fn EL•T • SALEM,M.sssAO IEIE'I ISOIM
TI-A.:978-745-9595 • PAx:978-740-9840 -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
nlicant Information Please Print Leeibly_
Name tnusim:ss/Or8ani7atinNlndivicluull: a X - ` y�It
Address: C(r� l>��w N�� `t-
CityrSrarci%ip: ��� ,1 1U1 h►° Phone ilk �a� r ,k;-fN
Are%ou an employer'.'Check the appropriote box: 'Type of project(required):
1.I,J 1 am a employer with!_ 4. El am a general contractor and t fit. ❑ new construction
employees(full and/or part-time).• have hired the sub-contractors 7. gReinodeling
2.❑ 1 inn a sole proprietor or partner- listed on the attached sheet. r�
ship and have no employees These sub-contractors have S. ,G Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
No workers' coin insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of 11.❑ Plumbing repairs or additions
3.❑ exemption I toll a homeowner doing all work g P P'a MOL
myself. (No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t cmployccs. LNo workers' 13.❑ Other
comp. insurance required.]
'Ally a,plicant that chucks box bl must also till out the suction below showing their workers'cumpens action policy infinnectiun.
'I lumcuwners who submit this affidavit indicating they are doing all work and then him outside con melon,must.uhmil a new arfidavit indicating such.
�C,ntcaeuo%that check this box mull attached on additional shcel showing the cattle of the sub4ontractors and their workers'carp.policy information.
/run un enydoyrr shut is proridinK Ivorkers'conrpen.cnlion fncurnnre fur my employees. Below is the po/icy and job sire
information.
Policy 4 or Self-ins. Lic, t:: ___--_._._ Expiration Date:
Job Site Address: �'� 7R1���� '� �' CityiStatei'Lip:
Attach it 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:vlGL c. 152 can lead to the imposition of criminal penalties of a
tine up h1 S1.500.00 and/or one-year in,prisonmcn[, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against file violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ul the DIA for insurance coverage verification.
l do hereby certify under the pains curd penalties ojperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be comrpleted by city or fawn ojfic•ial.
City or Town: -- . . Permit/License x__----
issuing Authority(circle onc):
I. Board of llealth 2. Building Department 3.Cilyffossn Clerk 4. Electrical Inspector 5. Plumbing inspector
6.O(her
Contact Person: _.... ..- _---- Phone#:
Information and Instructions
,%%Issachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, in employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
,\n 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 is political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill 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 confirniation of insurance coverage. Also be sure to sign and date the affidavit. 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 till out in the event the Office of Investigations has io contact you regarding the applicant.
Please be sure to till in the permitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/licetse 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 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
(i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Olf ice of lnvestigations would like to thank you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The Department's address, telephone and fax number;
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ounce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax #61.7-727-7749
www.mass.gov/dia
CITY OF SALEM
ti S. ",
PUBLIC PROPRERTY
DEPARTMENT
\I `.i::l; 12^1 \\.KI II INS SCR I:I T ♦ S.\i I\I, \t.\ii.\i I'. :I I
1),474 i.9;95 • I'.\\: 9'8.'4 9546
Construction Debris Disposal Affidavit
(Iv(Iui ed litr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CN1R section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will bef transported by:
Icier ( rtlix
(name of ler)
I he debris will be disposed of in
(name of facility)
AFr
X�-� tnddress of IacilitV) < � _���
.iglr rc of permit applicant
� aOla
date