103 WASHINGTON ST - BUILDING INSPECTION >> The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 CMR SALEAI
Building Permit Application To Construct, Repair. Renovate Or Denwlis
One-or Two-Fonull Dmellhnq
This Section For 0 I Use Onl
Building Permit Number: - to Applied:
Fhold,rg official(Print Nfunc) Signature Date
SECTION I:SITE INFORMATION
I Pro arty Ad ress
a W 57(-
1.2 Assessor blap& Parcel Number
1 c�
I.la Is this an accepted slree . yes Y no_ Map Numhcr Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) —mmage ttl)
1.5 Building Setbacks(it)
From Yard Side Yards Rcar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:( - I.c. 40.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal ❑ Dn site disposal system ❑
SECTION2: PROPERTY0 ERSHIPt
2.1 Owf RRc rd:
i
Naute(Print) Ciq•.Stalc,ZIP
No.and Street Telephone Entail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) K AIterationts) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Spccily:
Brief Descri tion of Proposed Work:
M d�� ti M I l l i'0 2
� (r c +F, i -f- Yz�i i�
c� o H
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S C) O I. Building Permit Fee: E Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
). Munihing S ❑Total Project Cost(Item 6)x multiplier
S oU ?. Other Fees: 5
1. Mechanical tli\'.1('1 S List:___
5. \lecltanical (Fire
Su„ressionl S Total :\II Pees: S --__ ----- ----------
t,. Total Project Cost: S .2 OU Check No. ----('heck Amount: _ ('ash 4mount:.
r ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTIOCN'SFRVICFS
5.1 Cons ruction Sup•rvisor License/(C'SL) �y G 'I ''II y
So, 1� License Number I cpimtion Dale
N:nnc ul l'.SI. I(older
�y List C'SI.1)Pe(see belt\s1 —
__a ------- .I.y Description
No. aid Str•et
I Inrestrictcd I Duildin�s li to 35,000 cu. 11.1
d G', R Re.tricted l&2 Tamil Ih\cllin
Cilei roon.Sltc,LIP _—... . - M Masonry
rn _,� O 9 R Window
Covering
F)5
-/ o 5 W'S W W'indu\e and'siding
SF Solid Fuel Burning Appliances
I Insulation
l'ek hone F.mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ( L l G t7 7 S y _1 7_3
(-r tsd�� ( � S�- IIIC RegistrationNtnnler IfspiralionData
IIIC Company Name or I IIC Registrant Name
No. mid Street Email address
City/Town,State,ZIP 'relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.t. 152.1 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..........�E;f
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.
Print o\vncr's Nwme(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this)I application is true and accurate to the best of my knowledge and understanding.
Fal—It o\\ncr's or:\uthorired Agent's Name I lilectrunic Signature) Date
NOTES:
i. :\n Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program).will ref 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
\\\\\\ MIA" . \ 'k,l Information on the Construction Supervisor License can be found at
2 \?'hen substantial work is planned, pro\ide the information below:
Total floor area(sq. ft.) _ (including garage, finished basement'attics,decks or porch)
Gross licingarea(sy. it.) Habitable room count _
Number of fireplaces ._ _.._ Number of bedrooms
Nunl her ofbathrooms .. — .Numberofhalfhaths - -
- - .- .. . ._- - Number of decks: porches
� I\pc ofhcating ;ystam -- ... . _. _ � - - -
I\lie of eoollllg sy item _ - I,Ilcloied _. - --01'en
1. 'Total Project Square Footage"may he substituted for"Total Project Cost"
J
CITY OF S,Vi &Ni, 21vLASSACHUSETCS
BctLDLYG DEPAIMMNT
120 W%iHLYGTON STRM, 346 FtOOR
TIEL (978) 745.9595
KI\IBERL.EY DRLSCOLL F.Vc(978) 740-9846
MAYOR THou,U ST.Pzzxxn
DIRECTOR OF PL BLIC PROPERTY/BCII.DNG CO\LV tSSION ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit M 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
t 11, S 150A.
The debris will be transported by:
S/d p
(name of hauler)
The debris will be disposed of in :
Lz�
(name of rac lity)
�d
(address or facility)
fi rule Mmitapplicant
L r
JJrC
;,hn vl(.6w
" :% CITY OF SALEM
' ' 11 PUBLIC PROPRERTY
DEPARTMENT
.i�u::nfl Y:,aNI'nl
sl tts at
ISC WA,1i11.\GIU\j18CL•1' 6 $dll!.N, M.u�.u.iu u I It,;lv7�
I'IA; 77/.715.95'fS a 1i�tx '77N•71C•9344
Workers' Compensation Insurunce :kft(davit: Builders/Cuntracturs/Electr(cians/Plumbers
li 1 )llcant Infurinut(on
Please Print le 'AI
N:IInC I11uau'e,sif7raanv.lfinry Ind'aduul l:
Address: F 6
Ciry,Sr:ua%ipr_ �� (Q /Al Phone0: L 709S
\ry sou an gift lloyer:'Check the appropriule box:
I I 1 :un a cal lu ur with 4. 1. of w construction
ruction ):
P Y _L ❑ I am a ticncral contractor and 1
L3.0
yeus(cull antYur part-time).• have hired the+uh•cunlraclurs f• New Cunsulrcuun
a sole propricux or partner• listed on the anachcd sheet : y ❑ Remodeling
nd have no clnpluyesl These subcontractors have tl 0Demolition
ng fur me in any Capacity, workers'comp, insurance.
orkers'wlnp. insurance 5. ❑ We aro n crnperotion and itsq ❑ OuiWing addition
ed.) )tytccrs have exunisud their 10.0 Electrical repairs oradditions
holvlcuwner doing all work right orexentption per h1 IL 11. Plumbin ro.(Ko workers'comp, c. 152.¢I(4),and we have no ❑ g pairs ur atWitinns
cu rcquired.J r employees.(No workers' 12•❑Ruul'tepain
comp. inwranat requinshl 15.0 UOter
•s n>.yrphcys'hW chcYa eea of mop alw fill uw the Wcuon hvluw dwwine'twir.awhlse cum
it lv'mn'wnero whe%uhome this affidavit indiu'ins thin "a dome di work and them hire Wilide cumrnctan m1'aIvA'1.u'hw Ianew alndavil indla .,it,ine v .
T.mtnwhe,;hN ahech'his box mop allaehgl an addifiutel..hap aluwine t enY
he na1W of 1he sub�comranora and life ourkns'eOni,ptotcy'nfbrmafue,
/tun un eulployrr shut IT previdlnX rvorllers'runi'venratioa hlwrr/ere/ar'my e/np/r/yees, Be/r/Iv is/hepu/8y and/ub ai(e
iII�YfIIIY/IIIn.
Inauranw C'unlpany Nnme:��Ihllicy a ur ScIGins. Lic.H: W c c Cj U 6 r;0 C Cn
J J012 61 T
Espirutfon Date:
)ub Site AtItI sr: t U
Cltyrslute/ZIp:_
.\oath a co w
copy or life orkari cumpunsallon p0110 duclarallun page(showing the policy number and expiration date).
Panora lu.secure cosenage as required under Section_25A ul'IGL c. 152 eau lead to the imposition of criminal penalties of a
line up('1.5I.500.00,1nd/urune•year imprisonment, us well of civil penaltius in the-turn ora STOP WORK ORDER and a fine
Drop rn i?10.00 a Jay .itlainat the viohuor. ne advi.4ed thus a copy of this,Imcmunf may be lurwarded to the 011ice wr
Inre,l'�aunro of the 1)L\ :or in,uruxa tovaragc terificanun,
/du herrby I cwily under/he paint uI a/t //Iry/bin the in/brrnul/on pfuvidrd u`bure is true and correct
0`7 �
1I�/!c'iul II1e only. O n u or Wriu in Udr urea, w he rulnpleted by city of town a//lriul
City urrnsrn: Permit/I.Ieensc tl
Issuing ,\ulhurit
y (circle noel;
I 1.G. ')lift
1h „f Ilcahh 1. Iluddiu� Ilagsaruncnl 1. (:it):'1'ona Clerk J. Electrical lospcctur 5. Plumbinll Inspector
I'hune .Y: .
i
information and instructions
rson in fie service of another unJar any contract of hire.
\LU j.lel,aaella lrenefal LJWY chapter I JI i'egLLIfCY all :111111O)drs 10 provide wvrkers' col",
n tor their employees
I•unu:uu w this afatwa,an implored is JetineJ as"...every pa
c,Lpreas or unplied, oral of written."
to empluper s dclined as"an individual,purtnenhip..fYsoeiuwn,corporation of ,that a de eased or any two r t more
oyer,
ar enterprise
, rssoewtiaa or other 1e11a1 entity,empWying employees. However he
a the loregamg engaged m a Iwm emcrynxe,and including the legal representatives la adecease)ces. How or the
iecerver ar trustee of cur iudivving p
ant of the
owner of a dwelling house having not more than three to o nainroiretnan ents and
urt"ru tsan aides r repuit wurk uherein.Of the n>�h dwelling haLLte
,lwclhng huusd of anoihar who employ. persons
or oti the grounds or building appurtenant thereto shall not because of such employment be deemed to tx an employer.
�IGL chapter 132. �3SC(6)also states that ''sorry slats or local licensing agency shad withhold the Issuance or
renewal of r license or permit to operate a huslness or to construct buildings In(ha Ith the ce coverage
re for any
11pplicanr Nl,a has not produ lad Acceptable i states Neither he coce of mmonwealth not any Of its poli calgiubtkvisions shall
AJJiliunully.SIGL cllupter 1 S_. �- ( I
enter into any contract tar the performance nrcdbo the contracting 1 acceptable of onlpliarlce with he insurance
requirements of his chapter have been p' •'
a'
Applica°ts
Please Iil1 out the workers' cumpertsation Affidavit completely,by checking the boxes that apply to Your situation and,if
necessary,try.supply sub-contractors)nme(.$),aJJtess(es)and phone numbers)along with thek cartificute(s)of
insurance. Limited Liability Companies(LLQ of tens, compensation Limited Liability insurance-f ships(If an)LLC or LLP does have
with no employees er than the
nelnbat$or partners, are not required to carrybe submitted to the Department of Industrial
employees,a policy is requited Be advised that his affidavit may
Accidents for confirmation of insurance coverage. Also be sure to sign a is nd Jute the Affidavit.n Tie Department
should
he returned to the city or town that the upplicAd cfos rep rdrng the low or Cho permit or or if you are ng requiredto obtain a workers'
of
I ndustriul Accidents. Should you have any q tent at the number listed below. Self-insumd companies should enter their
compensation policy.please call the Dcpwm
self-insurance license number on the a)oro riot°line.
City o►Town Omelets
please he sure that the affidavit is complete ;uid printed legibly. The Department has provided u space h rho bottom
„i tilt aiFJavit for you to fill nut in the event the office of Investigations her to contact you regarding the applicantan
1'l:axc be sure to till in the permit license nuru ' rin anch y
ba n tee s teed only csubmitoner. laffidavit nd ea JO ting current
yg y Y
but moat submit muif nee necic essary)
uldtinter"Job site applicationsprovided ro hd
policy i11t'armati,it ha utTldavitylhut has been offit ially xumcped Or marked lbyi tile city or town ,nayebe p o (city or
tuwn)•..,\ copy
applicant as proof that a valid affidavit is on rile for Future permits or licenses. A now aITlJavit morn m filled out each
t not
to any business or
a`r.;1,�Krc ensa or permit w butm leaves zcri is etc.)`id pct.+un is NOT a license or lrequired o related complete thisat'fidavia mercial venture
I would Iced w think you in advtulcc Cut your cooperation and should you hose:uty quexllons,
he 0111ce of Investigatiuex
please du not hesitate to give us a call.
fhe Ueparunent s address, telephone aThrail
Commonwealth of Massachusetts
Department of Industrial Accidents
OMCO of IsvaUgradons
600 Washington Street
Boston, MA 02111
'rel. # 417-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727.7749
,,,d "'("s www.mus.gov/dig
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