0047 WASHINGTON SQUARE NORTH - BPA-16-1334 ILI The Commonwealth ofMassachuset f=d1Yi"+
Board of Building Regulations and Stan6r1' t4 C 5x�i�°?ir t a FOR
Massachusetts State Building Code, 78Q MR MUNICIP 4I ITY
[��b NOyy � DD ���� USE
M Building Permit Application To Construct,Repair,Renovate Or I7embliX7F 2 Revised Mar 2011
One-or Two-Family J)v Tllfng
Itts S�lionForbcial Ilse Oily -
Ir1.1 Prop�rly Addy h,n l
1.1 a Is 1.2 Assessors Map&Parcel Numbers
e this an accepted stree yes_ no Map Number Parcel Number
13 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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?Check if yes[] Municipal❑ On site disposal system ❑
2.1 O uertofRecord: f
"&&4ytA- _StAcm 019- 7
Name(Print) City,State,ZIP
`lam- was 9JK'5�00'57 P 0'0-0- PA- Q/��, •cht
No.and Street V Telephone I Email Address
-__ ._ SGR_ TTCF / iIflPE SE 1 C?Zt3fi ill ba yy
New Construction❑Existing Building❑ Owner-Occupied ❑ 1 Rep ' Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposeq Wo
�IGCP ry � c,� e yf n roP ':zr OP492ii7 Sk- ec) e2
--f
Estimated Costs — � > �=�
1.But7ding $ / U� 0 1 Btutdmp Patrm�F-ea� �div�te llosee��I3etemr�'�
1:]&t6u .C>fawa��ilteatr �e � - ,
2.Electrical $ °� =
Q`i'Ata]Pr�eTt��st (F#crrL6)arrullip}te� x -
4.Mechanical (HVAC)
'5.Mechanical (Fire _
Suppression) $ Tiftal A11 Foes $ _
��7 De' tbzek�In � Chec�-Amount �-C�sh i�mount
6.Total Project Cost: $ �O(f/� O 1'a�3mFu]I t?y3siandui tea] eDue
P �"
9 _ _ _ --
5.1 Construction Supervisor
�License(CSL) 6 7�OZ /_ 1-7
K,V( J C(27 � J
- License Number "Piration Da e
Name of CS Holder - -
I List CSL Type(see below)
No.and StreetoII =
Unrestricted(IMIdings up to 35,000 cu.ftq 2
R . I Restricted 1&2 Family Dwelling
City/rown,State,ZIP M I- Masonry - .
. ItC Rooling Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
�TYiVC�`-? �✓1" ' /�e9tSY✓u I Insulation
e Email address CuJ D Demolition
5.2 Registered Home Im rovement C tractor(HIC) 3��� ./
1 5
r S G9'1 HIC Registration Number irati Date
HIC Co y Name or C Registrant N
I(rlo S A RA4 �y 7
No.and S et
Y"7�'����' Email address
City/Town,State,ZIP Telephone
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...........0
MUMMOM
I,as Owner of the subject property,hereby authorize S-Vf,eL1 S�t C1L2/—
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
L? �SWNER��I��cYJ�rr�rtt�FII��EI�'LIiT�T�_�
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this app 'cation is and�ac; ate In thebest of my knowledge and understanding.
tL✓l_
Print Owner's or Aulhorized Agent's Name(Electronic Signature) - ate
ME TWO
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,:decks or porch)
Gross living area(sq.8.) Habitable room count
Number of fireplaces Number of bedrooms
Plumber of bath cows Number ofhalftbaths
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 Cosy'
The Commonwealth efMassmhuseits
Department ofdndastrid Accidents
®,fj"ree oflnvesi igadons
VU
600 Washington Street
Boston,MA 02111
www.massgw/dra
Workers' Compensation fnsltrance Affidavit.- 1BniDders/Contractors/Etectrieians/Plembers.
A Picant Information Please Print lahly
Name(13eskms/Organintion/Individual /): /�►
-Address:. f i 4O
City/State/ rip: <_�sA7,j ( Phone#: k/7�Zl(e
Are ypu an employer?Check appropriate bus: Type of project(required):
I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hived the sub-contractors 6. []New construction
2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9 Buildm addition
[No workers' comp. insurance comp.insurance.: ❑ g
required,] 5. ❑ We are a corporation and its ME]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L[I Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
'Any applicant That checks box#1 must"fill outthe section below showing theirworkm'compensation policy information.
t Ho ncowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such.
'Lontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they mast provide their workers'cough.policynurnber.
I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy andjob site
Information. /�
Insurance Company Name: f') W__4/(CCr>7 z,,Cam"/
Policy#or Self-ins.Lie.#: 4o-IR06— -M(Vu_3--y—/ (f Expiration Date: /o ZZ /
Job Site Address: 2`�_-rt/J- cST City/State/Zip: M
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
fine up to$1,500.00 and/or one-year imprisonment,as well as civil,penalties in the form of STOP WORK ORDER and a fine
of up to$250.00 a d against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of tbqplA for insurance coverage verification.
I do hereby nder paint and pena&ies of peduiy that the information provided e' true and correct
Sip-nature: Date:
Phone#:
FOther
only. Do not write in this area,to be completed by o ty or town of dial
n: PermitUceuse#
&oraty(tie de one):
gealtfi 2.-Building Department 3.City/Town Cleric. 4.Electrical inspector 5 PlumEwtor
rson:' Phone#c
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 dltpfpyer is defined as"an Individual,.partnership,association,Corporation or other legal entity,or any two or more
ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a.deceased employers 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-contractors)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 ifyou are required to obtain a workers'
compensation policy,please call the Department at the number listed below. SeIf-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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitAicense 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. Anew 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
(Le.a dog license or permit to burn 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
®trice of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4 24 07 Fax# 617-727-7749
www.mass.gov/dia
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TOWN OF WINTHROP BUILDING DEPARTMENT
OFFICE OF THE BUILDING COMMISSIONER/INSPECTOR
Was SOPW COMMISSIONER
100 Kennedy Dr,Wmthmp,MA 02152
Tel(617)8464341,Fax(617)534-1545,Emalisopm@toamAnthmp.ma us
DEBRIS REMOVAL FORM
Section 111.5 780 CMR, State Building Code states: "Asa condition of issuing a permit for the
demolition,renovation,rehabilitation,or other alteration of a building or structure,M.G.L. c.40,
subsection 54,requires that the debris resulting there from shall be disposed of in a properly
licensed solid waste disposal facility as defined by M.G.L.I11,subsection 150A."
Job Location:
Location of Facility r ster Company's Name and Address
Signature of A lkaK Print N e
Building Permit Number:
Date:
Revised.July 8,2010
i
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
✓ Reconstruction ❑ Alteration
❑ Demolition ✓ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: Washin gt on Square
a
Address of Property: 42 Washington Couare
Name of Record Owner:Sara Swartz
Description of Work Proposed:
Replace rotted clapboards with new wood clapboards to match existing and paint with matching color.
There will be no changes to the color, material, design, location or outward appearance of the house.
Non-applicable due to being in-kind repainting.
Dated: November 9 2016 SALEM HISTORICAL COMMISSION
By: �Q ca �eeti/1 (
The homeowner has the option not to commence the work(unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
Once completed,please submit a photographs) of the final result(maximum of four-i.e. one photograph of
each affected fagade).
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals)prior to commencing work.