264 WASHINGTON ST - BUILDING INSPECTION (2) �' r I The Commonwealth of Massachusetts
�yJ Board of Building Regulations and Standards Town of
kj Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a !
One- n-Family Dwelling
This Secti n For Official Use Only
Building Permit Number: Date Applied: / '
Signature:
h b`o
Buildin ommissio er/Inspe uildings Date
% SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
�G y Lu iAS.d/NGTsN s i
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: _
Zoning District Proposed Use Lot Area(sq fl) Frontage(fl)
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❑ I Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner[of Record: ii
57--eue SAr�,,,, t L y G[,AS HidGTcl/ S`T
Name(Print) Address for Service:
97P- 75iy- ya-7o
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition Ell Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
1AI-W l L-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Casts: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
' Check No. Check Amount: Cash Amount:
6. Total Protect Cost: S 0 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES r ,
5.1 Licensed Construction Supervisor(CSL) GGG 2
Cj�, �3��.v!-� License NumberExpiration Date
0 4 r k .B
Npme of CSL- Helder f List CSL Type(see below)
t^�Q;Z S� T Description
Address `7/ /n/I,,yt/� U Unrestricted(u to 35,000 Cu. Ft.)
��I` (�'�^'� - R Restricted 1&2 FamilyDwelling
Signature M asonry Only
A 7k- fat- -/o e Z RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential solid Fuel Burning Appliance Installation
s D Residential Demolition
5 2 Rp��rp�fli `)�rSoNJContractor(HIC) /�/yr
HIC,Cj_ ompan Name or HI Registrant Name Registration on Number
C�/ ;!X ST SALeo, ,
Ad rg /}'/ •`' w/�� .A'-� 0 ,�„-7y,�_,Q� Expiration Date
S' ature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 .......... ET-' No........... 13
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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I. 96/.3L�2r t�• �/l't�NA?//� ,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
Sign Lure of Owner or Authorized Agent Date
(Signed under the 2ains and penalties ofperjury)
NOTES:
I. 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 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 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
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
a +iri PUBLIC PROPRERTY
DEPARTMENT
f11%W R:LY URIsC, I.1.
�1at oft 12C WASHING IONS I RELT • SALEM,MASSA(a it SE I I s 0197C
Tt,i,978-745-9595 • Pax:978-74.0.7846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
\nolicant Information Please Print Legibly
Name tnusiucss/OrganizatioNlndividuul): �/[IG 'r�7 rr " lg� SANS
Address: yr 06949 s T
City/Starer/.ip: c5el&o% I31/l Phone /':
Are vouan employer'.'Check the appropriate box: 'Type of project(required):
1. i ;un a employer with 'L 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(fill antl/ur part-tinge).' have hired the sub-contractors
listed on the anached sheet. 7- ❑ Remodeling
_
�.❑ I ❑m a sole proprietor or parinur-
ship and have no employees These sub-contractors have 8. RT`5emolirion
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its required.] of 10.❑ Electrical repairs or additions
officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption p(:r MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Ruof'repairs
insurance required.] r employees. [No workers' 13.❑ Other
comp. insurance n:quired.]
'.Ally Bl)plicaw that checks box Of niust:lw till cot the section tNaOw Slowing their worl,co'cUmpen adion policy information-
7 I lomeowm;rs who subminhis ntTidavit indicating they are doing all work and dten hire outside contractors mot submit a new affidavit indicting snch.
�CoNrncturs that check this box cunt attached:m additional sheet showing the name of tho sub-contractors and their w'urklin'comp.policy information.
ts+
I l any air employer that is providing workers'compensation insurance for uty employees. BeNiv is the policy and job.cite
information.
Insurance Company ?lame:
Policy is or Self-ins. Lic. It:. gk&13 '0�8�C (i._ —G.". _ Expiration Date: /a.3/Q 9 Q
Job Site Address: �y�7 /.!//lsjf�/�/�SI✓ S� City/State/Zip: cSA� /#;f
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�1GL c. 152 can lead to the imposition of criminal penalties of a
tins 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 violamr. Be advised that a copy of this stutcment may be forwarded to the Office of
lavcstigatiuus ol'the DIA for insurancc eovcrage verification.
l do hereby certify trader the pains at odd ppertaftiiee�s:crfpperjury that the information provided above is true and correct.
Datct lalge 6�
Phrn e:; 9 7t7
Official use uody. no not irrite is this area, to be cuutpleled by city or town official.
Cilv or Town: ---- Permit/License#._ _--- _-
Issuing Aulhorily (circle one):
I. nuard of licalth 2. lAlildin' Departuicut 3.City/fotcn Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Pt:nou: __.. - _-_-- one
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplt,.ree is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An einplayer 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 .m 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, y25C(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 nuluber(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 continnation 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 till in the pennittlicense 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. 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
lbc Office of Investigations would like to thank you in advance for your cooperation and should you have any 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 0211
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Rcviscd -26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
TMENT DEPAR
0 12,, A N,i III,,, �N_S I U I T * SAI I M, Nhli N' ii 'i I
Construction Debi-is Disposal Affidavit
(ICLILliNd for all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CNlR section 111.5
Dcbris, and the provisions ofMGL c 40, S 54;
Building Permit 9 is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(name of hauler)
'I he debris will be disposed of in
(name-of Fa- I I ity)
(address of Cucilo.v)
signature of permit applicant
'law