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37 WARREN ST - BUILDING INSPECTION
/f The Commonwealth of Massii L Board of Building Regulations aards Tom �� Massachusetts State Building Code, 78T"edition Building Dept Building Permit Application To Construct, Repavate Or Demolish a tli�► One- or Tivo-Funult Dwe This Section For OfficiaOnly Building Permit Num D Ie p Signature: //�Building Commissioner/I for of Building !SECTION 1 A1 INFON I Property Address: G1 r 1.2 Assessors Map& Parcel Numbers �1L 1.Is Is this an accepted strcel?yea � no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use lot Area(sq R) Frontage4Ymdd 1.5 Building Setbscks(fl) Front Yard Side Yards RRequired Provided Required Provided Required 1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.5 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal O On site disposal system O Public O Private O Check if vesO SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: •Mt-S4F•w — �• Nam(Print) Address for Service: 1644 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORKS(cheek all that apply) New Construction O Existing Building O Owner-Occupied O Repairs(s) Alteration(s) O Addition O Demolition O Accessory Bldg. Number of Units_ Other O Specify: Brief Description of Proposed Work': f SECTION I: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Budding f I. Building Permit Fee: f Indicate how fee is determined: ❑Standard City/Town Application Fee 2 Electrical f p Total Project Cost'(Item 6)x multiplier x J Plumbing f Z. Other Fees: f �n� 4. Mechanical (HVAC) f List: / t Mechanical (Fire f Total All Fees: f Su resston Ed Check No. _Check Amount: Cash Amount:_ 6 Total Project Cost: f ©f 110 0 Paid in Full 0 Outstanding Balance Due: r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Suptrvisor(CSL) 6 p• �2 D PI • e.,/5 � U '�-�o— Licerike Numm ber Ea uuu Dute tiyx of CSL- Hylder List CSL Type tare below) a R l ID�.(y`�A uUE`t` AJJres Type Description Unrestricted Jup to 35,000 Cu. Ft. �3 R Restricted 1&2 Family D%elfin Signature .N Mawnry Only 1' RC Residential Roofinst Covering Telephone CJ WS Residential Window and Siding Kti _ --, 300' f SF I Residential Solid Fuel Burning Appliance Installation I D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 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..........td No........... O 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:OWNEW OR AUTHORIZED AGENT DECLARATION 1, �o 1,-- tl'-S� \t ,as Owner or Authorized Agent hereby declare that the statem ts and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print N7k � Signature of Owner or•A`uthorized Agent Dee (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 ad have access to the arbitration program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IOA5.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 Ty pe of cooling system Enclosed Open 3 "Total Project Square Footage"may he suhsntuted for *Total Project Cost' CITY OF Sauxms NvLxssAcHusETTs BUIIDLNG DEPARTSLINNT 120'WASHINGTON STREET, l'a FLOOR TEL (978) 745-9595 F.%X(978) 74499" Kl.N(BEALZY DIUSCOLL MAYORTHOAIA3 ST.PffaRt DIRECTOR OF PL BLIC PROPERTY/SC[LDLVG CMMUSSIONER Workers' Compensation Insurance Affidavit: guilders/Contractors/ElectrlcianidPlum tiers annlleant Information Please Print Legibly Naine (Busirwvs.Organtranon lndevtduAl): \,n" F/ 1\-AC— "\— 1 bV Address- Q d 0,� Y_ /.A},- City/State/zip: Ell.= V/1 Q Phone M: 1`n 51 LN 7�cc7 ,%re you to employer'Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction sunployces(full and/or part-time).* have hired the sub-contractors I'd I an a sole proprietor or partner- listed an the attached shell : 7. 0 Remodeling ,hip and have no employees These sub-contractor;have V. ❑ Demolition workingfor me in an capacity. workers'comp.in;wance Y P tY• 9. C] Building addition iNo workers'comp. insurance S. 0 We ate a corporation and its required.) otYlce►s have exercised their 10.0 Electrical repairs or additions },0 1 am a homeowner doing all work right of exemption per MGL 11.❑ lumbing repairs a additions myself.[\o workers'comp. c. 152.41(4),and we have no 12.�f=repairs insurance required.)t employees. [No workers' comp- insurance required.] 13.❑Other . Any applicanl thin dsocsus beta al muss alai tin tier the mime,below showing their workm'cwnpnnfGm policy inrarrwloa. 'I I.vtevuweays who sub of this aflldsvk ini icuina they an doing all work one this him amide conreeken muss submit a now,affidavit itedieaing nocL :r.,mrabn the chak this has must attach"an ad linanal am"'hawing the mien of the VA-cwWarws and their wurkan,comp.policy inforenaam one an employer that lv pmvidinir workers'compemadom insurance for my employees 3elow is dbe panty andM slh information Inwrance Company Name: 11 tv� Policy 4 or Self-ins. Lic.p: fj� �tii' Expiration Date: 07 6 16) iub Site Address:—. ACC �Y CityiStatNZip: ,('Ai6)A, M 4 00Q �U ,tinack a copy of the workers'compensation policy declaration pap(showing the policy number and a;plradon date). Failure to secure coverage as required under Section 25A ot•MGL e. 152 can lead to the imposition of criminal penalties of fine up to S 1.500.00 andtor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fin Of up to S250.00 a day against the violator. Ile advi.+Al that a copy of this statement may be forwarded to the OMce of Inv c�ugationa ol'dte DIA for insurance coverage ventieatiun. ' I do hereby certify midi,the paints;aneed penaldes of perjury that the infonrradon provideeda above is true and tarred �i,•n.uu �re: . _ 1�a-"7`�" Dole, '1+ Yc �• �.�i Ofruial me only. Do not,vrife in his area, to be curnpleted by city or town offieial City or ruwn: Permit/l.Icense M__ Issuing.%uthunly (circle inc): — - -- - I I. Ituard of Ileallh 2. 9wlding Department 1. City/fawn Clerk J. Eltctriul lnspecto► 5. Plumbing Inspector 6. Other C-,;tact Person: - _ __ Phone_til: _. .._..__ .. CITY OF SALEM st =( ' PUBLIC PROPRERTY DEPARTMENT I20 W.,si IIXG'I ON S I-RUT • S.,i IA1, MASN'A,.III sr.rr, -I') TEI:978-74 9595 • p:,s:978.740-9846 Construction Debris Disposal Affidavit (required I'or all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit I _ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) sipatuiew permit applicant C)q date J�birafl uoc NOTICE __._ NOTICE TO TO EMPLOY EES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above m mentioned chapter by insuring with: 2 CI—T FIRE INSURANCE COMPANY N NAME OF INSURANCE COMPANY o ONE PARK PLACE, 300 S. STATE ST. , 7TH FLOOR N ` ADDRESS OF INSURANCE COMPANY 08 WEC AA8678 07/07/09 o POLICY NUMBER EFFECTlVff DATES HUB INTERNATIONAL NEW ENGLAND LLC PO BOX 9146 NORWELL MA 02061 NAME OF INSURANCE AGENT ADDRESS PHONE SALEM SHEET METAL INC 89 RUSSELL STREET PEABODY MA 01960 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment =to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the =Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the Egg NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Form WC 88 20 01 C Printed in U.S.A.