8 WARNER AVE - BUILDING INSPECTION fl The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
4 Massachusetts State Building Code. 780 CMR, 7ih edition MUNICIP:\LITI'
1, USE
Building Permit Application To Construct. Repair, Renovate Or Demolish a Revised Junmu r
t� One- orT[co-FamilyDxelling / INIS
v This Section For Official Use Only
�1 Building Permit Number: /Date Applied:
\" Signature: 11tI y/g
/O/5'
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro ert Address: 1.2 Assessors Map & Parcel Numbers
I.1a Is this an accepted street? yes ono_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tl) Frontage 111)
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 ❑
Public ❑ Private❑ Check if es❑ p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 OwFlerl o[Record: .6 JH
Name (Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief,Description of Proposed Wurk : v G - G L
elf_ e
SECTION 4: ESTWAATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
E
g $ `/ .p 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Ibwn Application Fee
al $
❑Total Project Cost (Item 6) x multiplier x
ng $ 2. Other Fees: $
ical (HVAC) $ List:
ical (Fire $
on) Total All Fees: $
Check No. Check Amount: Cash Amount:
Project Cost: ❑ Paid in Full ❑ Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 'n �- 9��ic /
f�L f /n [7� �i' License Number Expiration D `t5
—6 �T
Nume of CSL- Holler
�f-/ �!>� Liu CSL Type(see heluw)
T e Description
„l lid/���yt7 U Unrestricted lu to 35.000 Cu. Ft.)
2::!:, � R Restricted Idt_' Family Dwellin
Signature 7 M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidm
SF Residential Solid Fuel Burning Appliance hia.tllauun
D Residential Demolition
5.2 R7 V4110nee Im roMt� fJio�rgctyr 2 C)
G t
HIC Co piny Name or HIC Registrant Name ^� f Registration Number
Add F . S�/O
�i T b-3...` irrg ton Date
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 ..........
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.
Si nature of Owner Date
SECTION 7b: OWNER' 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 do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will CoL have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115. respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementfaitics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half1baths
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
3 PUBLIC PROPRERTY
G ` DEPARTMENT
njNmi%RIJIF ItRI.NCIA L
M.UUR 12C WAsHINITI'oNS'I R LFI • SAt II\I, MASSACMI 1t'1IS 51973
TLI_: 978-74n-9595 ♦ FAX: 978-74G9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A > >licant Information �/ Please Print Le ie blv
Name I Husuress,Urganizatiotti htJiviilvaU: Zf7/ G�r
�^
Address: g � T ���c� t/ 7t us F/2lJ
City/State,Zip: 7Z .t,, e5a�� hone #: 7 `� 75
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
eu Io ees full and/or art-time)." have hired the sub-contractors
Y ( P 7. ❑ Remodeling
2. ❑m a sole proprietor or partner- listed on the attached sheet. I
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers' comp. insurance 5. ❑ We are a corporation and its
( p to. Electrical repairs or additions
required.] officers have exercised their
1❑ I am a homeowner doing all work g P
right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. a 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] r employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box M l must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/ain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy #or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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 MGL c. 152 can lead to the imposition of criminal penalties of a
f tine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
I Investigations of the DIA for insurance coverage verification.
l do hereby certify under the pain, ad aloes of Wjury that nation provided above is trite
and correct
51 ncure
Phone »:
Official use only. Do not write in this area, to he completed by city or town official
Citv or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Ciy/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
%1n55aChUSefts General Laws chapter 152 requires all employers to provide workers' compensation for their employe,n...;, /
Pursuant to this statute, an eetplgree 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, Pa uiership, 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 conitruet buildings in[he 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'anjof 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 till 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 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pen-nit/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 dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
3 �. I
PU
IC PROPRERTY
l
-.. r
DEPARTMENT
0 S.uU ff, Sf.\\inc :,I
Ii' 9i95 F.+x: 978J4G/846
CFI:`i7& Y
it
Construction Debris Disposal Affidavit
�I (required for all demolition and renovation work)
i
1n accordance with the sixth edition of the State Building Code, 730 ChIR section 111.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit # __ is issued with the condition that the debris resulting from
facility as define b v1GL c
• 11 he di, used of in a properly licensed waste disposal y y
this work shall p
I 11. S 150A.
The debris will be transported by:
�.hauler)
(name of ltr)
'• will be disposed of in
Hie u�bfu 1
name of facdlt• )
I �
♦ _L;.IWJ �R.ti ..I:j1.iC1d[_._ .___