8 VISTA AVE - BUILDING INSPECTION The Conunonwealth of iblassachuselts Lt)It
M t` Board of Building Regulations and Standards \II Vlt'll' \I Il 1
T4 MassaJhusetts State Building Code. 780 CNIR. 7 ' edition
Building Permit Application To Construct. Repair. Renos ate Or Demoli.h a Rr
One- nr Tlco-h(unih lhrcllin,ti - If'S
his Section For Official Use Only
Budding Permit Nun er: _ Date Applied: -- ----_---- .
o
Signature:
Bill]dItg C'ununi .ion ospe it of Buildings Date
SECTION 1: SITE INFOR..NI:\'fION _
1.1 Property Address: 1.2 Assessors Map S Parcel Numbers - —--
I. Ia Is this ,in aCCepteJ +iced' vti.,__ no Map 1lumher Panel ,Nnlnher
1.3 Zoning Information: lA Properly Dimensions:
I
zoning Ji.iticl
1.5 Building Setbacks(ft)
j From Yard Side Yards Rear Yard
Required Provided Reyuued PnrviJeJ Required.__.� Pni,iJcd
j
1.6 Water Supply: (M.G.L c 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone:' ;\Iunici al ❑ On site dis Nrsal sy>tcm ❑
Public ❑ Private ❑ Check if yes❑ P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
{�ti1Ds� �2�ti1B44y _ 8 UrST�
N.une t Print) Address for Service:
979 -7VV - G ?60
Signeture Telephone
SECTION 3: DESCRIPT19 OF PROPOSED 6RK'(check a that apply)
pBrfef
Constructiun ❑ Existing Building Owner-Occupied Rep:ars(s) .Alterauonls) U \JJitim t]
lition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:_
Description of Proposed W,)rk':JS7-AIF �t LJ N u- C OAJ h-1(DE12SOAJ Cfe3d SEr t t=S cJ t Nd10cJ3
o F� rOG-C rnua-G- r=tu9Su�N t y7�u�<Mt [ ?_ cr , _
�Si iZ7l� �I Rc/e FC'p L,� h!ays� 3o y� �it� ,7 v : . 5 s t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Rk
Estimated Costs: Official Use Only
(Labor and Materials)
$ I. Building Permit Fee: $ Indicate how fee a determu)eJ j
Standard City/Town Application Fee
$
❑ Total Project Cost (Item G) x muhiplier x _
'. Other Fees:
l IHVAC) $ List:
i. Mechanical (Fire ,� __----�--
Suppression) �_� Total AI] Fees: S (P
Ch Ck No. Check Amount: _ C.i,h Afnf)uni:_. _ -
0b Total Project Cost: 5 aid in Full 0 Outaandinv Balance Due:----
� - —� — —
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (C'Sl.)
Licrnw Number F\1111awnl U,u: ,r
Ndme or ('St. Milder
LuI CSL 1)lie ia'c hrlow) __ -
�.
1JJres> Type Desch rlio❑
t. [ In Cso'I,led n]r to ti.(9)0( u. FI B
R Reslncled L@_' Fainik Ds[:Ilene
Sipnauua \I \farms Unls
RC RcvJcnnal RUU tine ( 01ii ale
fclopluone
SF RCsidcnn.11 Solid Fucl Ilw nuu \IgrL.0 lc; lusnil l,n iai
D RcaJcntrJ Ucmohnr,n
5.2'Registered Home Improvement Contractor(HIC) �C 2 3
Ii IC'Cm rp:my Name or HIC Reautrmu Nalnc Regisnauon Number
LrrGer �J �l _7CIO O�OI F.xpuatio❑ Date
Signature r� Telrphonc
G�
SECTION 6: WORKERS' COMPE ATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure nr prof ide
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. u[ :JI (natters
relative ur wolk authorized by this building permit application.
I
I
Siera"ne of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby declare
that the statements Lind information on the foregoing application are true and accurate, to the best of my knowledge and
.behalf.
Print.Name -
Slerianue or Owner or Au[honzad:Agent Date
(Si re
under the auu and penalties of edu ')
NOTES:
I. An Owner w'ho obtains a building permit to do his/her own work, or an owner who hires an unreL1l,tercJ contra,im
(not registered in the Hume Improvement Contractor (HIC) Program), will nut have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other imporGmt inhumation on the [I IC Program and
Construction Supervisor Licensing WSL)can be tlrnnd in 780 ChIR Regulations 110R6and 110.R5, respecus cly
' When subs(anual work is planned, provide the information below:
Total floors area(Sq. Ft.)
(including garage. finished basemen Uatucs. decks or porchi
Gross living area ISq. Ft.) Habitable room count _
Number of treplaces Number of hedrnoms — --- ----- .
Number of hathroonu Number of ImIlih.uhs
hype of heating system __ Numher ut decks/ pr�nhcs
Type of cooking system _ Ln:I, ed __ upon --
1. "Total Project Square Footage- may be stlbstutned for Goal Project Cost- J
CITY OF SALEM
".. *t r
PUBLIC PROPRERTY
Vp
DEPARTMENT
-L
,MIS;K:1'.1-Ug KC V Lt.
Nt\sua 12C WASHING ION S'I'IIEGT • SAI E\4,MASSA0n sfl Is0197.
11a:978-745-9595 9 1'ax: 978.74^'1846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Please Pr lit Le ibly
A i tlicant Information t
V 81mC lnusiocss/Organi�atinNlndwulual): �//---
A(Idress: Q
�61 J
cay;stat,.;zip:4e'3G�G`r
Phone 0-
A an employer? Check the appropriate box: "T)pe or project(required):
4. ❑ 1 am a general contractor and 1 6 New construction
l; I am a employer with ❑
entpioyccs(full antLbr part-time).• have hire)the subcontractors 7. ❑ Remodeling
2.❑ 1 ant a sole proprietor or partner- listed on the tachcd sheet.
ship and have no employees These sub-contractors have S. ❑ Demolition
workers' comp. insurance. 9, ❑ Building addition
working for me in any capacity. 5. El We are a corporation and its
INo workers' comp. insurance officers have exercised their 10.❑ Electrical repairs or additions
required.] 11. Plumbing repairs or additions
3.❑ 1 alnl a homeowner doing all work right of exemption per MGL ❑ b P'
myself. LNo%Yorkers* comp. C. 152, §1(4), and we have no 12.❑ Roof repairs
t employees. (Ko workers' 13. Other
insurance required.] comp. insurance required,] ❑
-.4nv'.q>plic-nt that checks box hl must also till out the vxtim,Wow showing their workers cumpensulion policy information.
'l lomeowners who stnnnil this affidavit indicating they are doing all work and then hilt outside contractors must aubmil a new aff davit indicuong.such.
•(' t t r that check this box must attwhcd nn additional it-et showing the name of the sub<ontraclors and their workers'comp.policy information.
f atrl an employer that i.a providing rvorkers'c-ompen.catiaii ut-currutce for oty earployees. Below is the policy and lob site
information. 4 Y e,j
Insuranct:Company Name: /9/-J�-L- - ------I---/--
I'olicv S ur ScIC-ins. ic. ---
/ 2 Expiration Date: D 2r/ 08
�Ly *': -
Job Site Address:
t% //l S'TA 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 of 1IGL c. 152 can lead to the imposition ofcriminal penalties of a
tine up to 51.500AO and/or one-year imprisonment,as well as civil penaltics in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. llc advised that a copy of this statement may be furwardcd to the Oft-tee of
tat esli,-attOos ul Lite DIA for iosurar.ce alvcragc vcrilicttiun.
t do hereby certif I ar •r the pains and penalties afperjury that the information provided above is true(slid correct.
gf� Date:
7
Ff)flicial wrly. Do not write in this area,, to bacampleted by city or town official,wn: ___--- Permit/License#_--lliority (circle one):
f Ilvalth 2. Building Department 3.Cilylfossn Clerk 4. Electrical luspector 5. Plumbing Inspector
-----r Sant. Phone it:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pnr5n311t to this statute,an empluree 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,ernployntent 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, ,NIGL 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 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 confirmation 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 pennit 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 till in the pennit/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
policy 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 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. a (log license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Of I icc of Investigations wVuld like to thank you in advance fur your cooperation and Should you have any questions,
please do not hesitate to give us a call.
'rhe 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
a.%;.ed i-26-05.
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
:j PUBLIC PROPRERTY
!J.
�.KI•. DEPARTMENT
III '!'S ';i I; A I \\. 'i'8.-4- '6 Jb
Construction Debris Disposal affidavit
(required li)r all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 C'NlR section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the dchris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The dchris will be hansported by:
r
69 g AAA;: �N� CouiTizoieTirciG Cd
r
(name of hauler)
The debris will be disposed ofin
(namr o1 Iaci)ity)
A/D st y F` V'10_-5_ x�, e
7;t 1fxlls
I❑Jtlrca. ur racdtiv)
agualwc cif I nnrt applicant
z/ 08
date