12 VISTA AVE - BUILDING INSPECTION s The Commonwealth of Massachusetts
° Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 71h edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Nu Date Applied: en ` ez& e(a ZS
Signature: nA[vq` ` 2G -U U
Buildiii-grommuTAIjKnspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
/a UIs7H Z -- -
I.la 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 fn 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? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Recyyrd:
V11 c Pb4U.e"iIt40i4sKivwir� /,R V%STYI- AuC
Name I Print) Address for Service:
979--7YY-/dg 7
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Uni;s Other ❑ Specify:_
Brief Description of Proposed Work':
`/ .9�/Y fPd*, tui�urr%Hus7 =NT6rr/oc,e Rosf—,�.',rr� Hamra S'sn �
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Applicati n Fee
❑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:$ Z
�eck NoISYL Check Amount: FM Cash Amount:
6. Total Project Cost: $3a,carp &id in Full ❑Outstanding Balance Due:
sat t.Q !z Vtc r
r '
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) +
License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
Type Description
Address
U Unrestricted(up to 35,000 Cu. Ft.)
R _Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofiny,Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 ��Reggtstered Home Improvement Contractor(HIC)
�irfsi 1 sprier -TVt? /39 G
Number Regl;KtName Registration
7 a m e ulal +.G iYt4
Add•^" _--�',2��—.
PLtte�'�6:vLear-y�r Slib-S�FS-76(s3 Ezpi anon Da.e
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...I....... ❑
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 ofperjury)
NOTES:
I. 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 not 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 I IO.RS, 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
irk PUBLIC PROPRERTY
'�` DEPARTMENT
.I\ml Nf I Y Dlth(:wn 1
\I Yw ra 12^Wnilu.\(i ION S'1'XL1,r • SAI Efit,MAhh.u:In it.'1'I GI97�
978-17-6-9595 it 1'sx. 978.741^:)gi6
be
Workers' Compensation Insurance \fftdavit: Builders/Contractors/El Ptease Print m s A
-k t )licant Informal on
tAx Ti v( h cr Are
Nalnt: lBu<itwsv Organir:uirnvindrv)duuU: a+"t ts
A(idress: - f
s
City State,Zip: lU�eZ �26yt Phone
:tire you all euyiloycr'! Check the appropriate box:
'Pype of project(required): —
i 4. ❑ 1 uln a general contractor and ( G. ❑ New construction
o employer with -t-ar have hired the sub-contractors
employeee(full proprietor
r partner-
7. ❑ Remodeling
?.❑ I um a sole proprietor or partner- listed at the attached sheet.
ship and have no employees - These sub-contractors have 8. ❑ Demolition
workers' comp. Insumnce. q, Building addition
working Ibr me in any capacity. 5. ❑ We are a corporation and its
No workers' comp. insurance 10.E3 Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL I I.Q Plumbing repairs or additions
3.❑ I ymcuwner doing all work S [�] l oof repairs
myself.a hoelf. LNo wp�kers' comp. C. 152, S i 1(4),and we have no 12.
insurance required.] t clnployces. LNo workers 13.0 Other
comp. insurance required.]
-,1ny ,phcaul that checks box toI must also fill out the,-cliuu Wow showins their workui cumpemution policy inhumation.
' I tomcuwta:n who submit this ar7davir indicating they are doing all work arul then him outside cuntrxlon must vuhmil a new alfdavit indiwbng.uch. -
-f t 't (full Lhvck this box must 3 iwhcd an addilior,alAcci showigis tilt name of the sub-contractors and their workers'comp.policy information.
l ant all eeiip(oyer lhat is pruviditrg)vorAers'c•outpcotsalimt insurnuee fur oty eutpluyees. Below is the policy andlob site
inforulatiom
Insurance Company Name: A,4,RE !Qb-V�PA C--T-D
7/—o-2 a a3/ —D �. .. Expiration Date:
rulicv 4 or Scif-ins. Lic. t': UCI—/
) a 5
V)laS7Y)• /¢Ne City:Stateizip: o197G
Job Site Address: /
.
Attach it copy of the workers' compensation policy declaration page (showing; the policy nutuber and expiration date).
1mailurc to secure cocerdge as required under Section 25A ul'.NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 31.500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day ;rgainst the violator. lie advised that a copy of this stulcment may be forwarded to the Office of
Inc�angauults of the DIA for wituarce coverage %critic:mmn. -
!flu hen•hy ecru.1 umler the pain�s san�d penulnex of perjury that the utfurination provided above is true and correct
a�/�p:✓ '�Y Dat PkeL T'
O[Jiciul use only. Do not tsvite in this area, to be cwupleted by city or town o/Jiriul
(:itv or fawn: __ Permit/License d.- . _.
Issuingg .%uthority (circle one):
I. Board of llvallh 2. Building Deparuncot 3.Cityi rosin Clerk 4. Electrical luspector j. Plumbing inspector
b. Other _ --
Contact PC(Su1l: -- . .__. Phone H:
Information and Instructions
,Mavachusetts Gencral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant ro this statute,an ernploree 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
or the tbmgoing 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.rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
SIGL 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 puhlic work until acceptable evidence of compliance 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 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. ff 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 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 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 permiUlicense 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. it dug license or permit to bun leaves etc.)said person is NOT required tocomplete this affidavit.
Hic 0(lice tit Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do nut hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oftice of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
y ;;h CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
III 'Ji. 1L"S '17fl V= ' i J
Construction Debris Disposal Affidavit
(rcyuired l'or all demolition :Ind rcnoJ';uion `010
In accordance ill, the sixth edition of the State Building Code, 750 CMR section I 11 5
Dcbtis, and the provisions of MGL e 40, S 54;
Building Permit it - is issued with the condition that the debris resulting Born
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
II1. S 150A.
The debris will be transported by:
(IIan1C nt haUIVJ I
The debris will be disposed of in
(nap nr ul faulty)
?FCC DvytxA+5k I ri elm
i.i&lro,4,1 lacilim Q
.Icnatwc of lies 11101.111111 it ant
-
dale