36 WARREN ST - BUILDING INSPECTION (2) OG /coa✓j
,, The Commonwealth of Massachusetts
i / I C119
Board ofBuilding Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'"edition OFSALEM
Revised lunnurI,
Building Permit Application To Construct. Repair, Renovate Or Demolish a l. .rRAY
One-or Two-Fomilly Dwelling
This Sjiction For Official Use Only
Building Permil Num Date Applied: O
Signature: \ O
Buildin issi d ns •torof Buildings t}rte
SECTION 1: SITE INFORMATION
1.1 Property Address: �_ 1.2 Assessors Map& Parcel Numbers
X1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
,:2 N,
Zoning District Proposed Use Lot Am(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Rcquired Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
/ P
Address for Service:9-/ t-,39? g,z/
2-1 Owasir'of Record*
Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units 2 Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfRclal Use Only
Labor and Materials
I. Building S 0 .,./ 1. Building Permit Fee:S Indicate how fee is determined:
cal S �04 ,/ ❑Standard Cityr town Application Fee
-1. Electri
- ❑Total Project Cost (Item 6)x multiplier x
X J. Plumbing S A00o / 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
b. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
i
SECTIONS: CONSTRUCTION SERVICES
5.1 Llcemed Construction Supervisor(CSL) 3�Q�7 � ��
../0, �4 AJb n l I.iccme Number I:xpi-maon Date
N:ue�o^f CS !II•�lolder'c . f C
O LeQ/A+'UC Z22! ✓C I.iat C'SL Type lsee below)
t Description
W resa P e4 4-6 D t�'• U I Inresirictcd(up to JS.OW Cu.Ft.
% /1-7 R Restricted 132 Family Owellinit
RC Residential Rwlin Coverin
I'clephOne INS Residential Window and Sidin
9 78-��'�=�6 9 7 SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
S.2 Registered Home Im vemeal Contractor(HIC) / ? 7 (�
To fro
� Registration Number
X I IIC Company N e ur HIC Registrant e �eA Q Al
\ Add
7 Expiration Dale
Si one 'telephone
1
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2. f 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 7s: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.
signatureofowner 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 We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
ISianed under the pains and penalties 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 rW 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 110.RS,respectively.
2 When substantial work is planned,provide the information below:
Total tloors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of are
Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed oPe^
J. "Total Project Square Foolage-may he substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
LI V It:KI.I:Y DR 15CUr.1.
>4art m 12C W AiHIN i I ON S raEer •SALEM,MASSACI a sl:'I't s 0197C
71a.:978-745-9595 • Pax: 978-74C-)846
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers
\nolicant Information Please Print Leeibiv
Vame (Business/OrBanizatinNlndividuull:� ` ' `� �`��J6�
/ h T
Address: 0�0 L P�f�i✓ c �R l ye
City/state;%ip: dD Phone i':
Are you an employer?Check the appropriate box: Type of project(required):
. ❑ I am a general contractor and I
LEI❑ 1 am a employer with 4 G. ❑ w construction
ol,lu ecs full and/ur at -time).' have hired the sub-contractors g
l Y ( P 7. Remudelin !J
2.I�'1 ;mt a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'cum insurance 5. ❑ We are a corporation and its
I P•
require].] of 10.❑ Electrical repairs or additions
officers have exercised their
a exemption
right of MCL I I.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work g P P
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
-Any ap plicaut that checks box al must also till out the union W-ow showing their workws'cumpenvlliun policy infurmmion.
'l lumcowners who submit this affidavit indicating they are doing all work and[hen hire outside contractors must suhnnit a new al'Gdavil indianing such.
�Contracrors that check this box mast attached a n additional sheet showing are name of thu sub-contrxrors and their w'urkers'comp.policy infurmariun.
1 am an employer that is providing workers'c•ompen.vadan insurance for ury employees. Below is the policy and job she
irrfutvnatiom
Insurance Company None:----._--. ..._. . . _..._.----.._---_'---
Policy 4 or Self-ins. Lic.#: __-___— Expiration Date:
Job Site Address: _ City/State/Zip:
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 of NIGL c. 152 can lead to the imposition of criminal penalties of a-
fne up to S1,500.00 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 against the violator. He advised that a copy of this statement may be forwarded to the Office of
Investigations ul'thu DIA for iosurarcc coverage vcritieatiun.
t do,hereby certify ender the pains and t ti v ujperjury that the infurrnutimt provided above is true and correct.
Si 'nan[re: __. Dar : re'0
Phu[:e 7:
Ojjiciul use only. Do not write in this area,to be completed by city or town ojjiciuL
City or'I'ow•n: _. _ . .. -... . Permit/I.iccnse # .-_-..- .. . .
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other --_--
Contact Person: .. _-- Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee 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 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 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 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 certificates)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 ,old 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.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Otlicc of Investigations would like to dmank you in advance fur your cooperation and should you have:my questions,
please du 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
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEI'ART�IENT
Construction Debris Disposal Affidavit
(required li)r all demolition and renovation work)
In accurdance o itlt the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
1 Dcbi is, and the provisions of NIGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name Lit hauler)
I lie debris will be disposed of in
(umnr ul laci ity)
Inddrcss ul facility)
.i ❑tore ul'prnnit applicant
,late