26 WEST AVE - BUILDING INSPECTION (2) fhe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR, 7"edition OF SALFM
Reviser/Juruarry
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 2MAY
One- -Fumiltl Dwelling
This Secti n For Official Use Only
Building Permit Number: D e Applied: A
Signature:
Building Commissioner/Inspector u u' n fAte
I SECTION N 1:SITE INFORMATION
1.1 Pro erty Addrca: 1.2 Assessors Map& Parcel Numbers
I.la Is this an acce ted street?yes ✓no Map Number Parcel Number
IJ Zoolog lulormatlon: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public O Private O Check if es0 Municipal O On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rteord:
�;lltK�ny., Qeaaden �� G✓�.rT /eve JO
Nome(Print) Address for Service:
�o9 s�7 - eao9Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied Repairs(s) ❑ Alteration(s) O Additio
Demolition O Accessory Bldg.l] Number of Units_ Other O Specify:
Brief Description of Proposed Work': / e gp S e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how tee is determined:
O Standard City/Town Application Fee
2. Electrical S O Total Project Cosl'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Su ressiom) Total All Fees:S
Check No. Check Amount: Cash Amount:
b. Total Project Cost: S 3d ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /0-0 "5-6.;z 942 /-
License Numbeber I:tpiraliun Uate
Nume of C S1 1lu�Vr. /P/fin I.ist CSL Type(see below) G �S
r Descri ion
Wdresl, - `n � J U I1nmtricl-1 u to IA fen Cu.Ft.
✓( R Restricted 132 Famil lhvellin
Sign i re ��5 M M (hd
RC Residential RootingCovering
cicphone WS I Reiidential Window and Sidin
.SF I Residential Solid Fuel Bunting A liana Installation
D I Residential Demolition
5.2 R er Home provemeot Contractor(HIC) /�� j 7
�� � �e Registration Number
111C Company N or�C Restsl! ume�
Address e9 Jg(� Expirat n Date
Signature Tclephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 ..........❑ 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. -
Siansture of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
rbehal
as Owner or Authorized Agent hereby declare
statements and information on the foregoing application are We and accurate,to the best of my knowledge and
e
Signature of owner or Authorized Agent Date
Fl.
i under the aim and penalties ofperjury)
NOTES:
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IO.RS,respectively.
Z 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%balhs
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may be substituted for'Tolal Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
♦I11 it;IT:I:>k lX:ol 1.
12.�.WASHING I ON 57x ELT SA L LA MASS%C I It if IIs0197:
Ti,i,; 778-71i9595 To 1°.Ix. 978.74C-9816
Yorkers' Compensation Insurance At'ftdavit: Builders/Contractors/Electricians/Plumbers
\Pnlicant Information /j Please Print LeeibIV
VARt0 11iucuksslOrganintintVlndivtdual): C--!"44 y/'e"W le
:Address: 64 t�
City,Statc;/.ip: S/TlleIitl Ld 11hunei': laze �` z106S
Are vnuan employer'.' Check the appropriate box: 'Typo of project(required):
4. ❑ I ant a general contractor and 1
I. I :un a employer with 6. ❑ New construction
�entployces(full and/or port-tint¢).• have hired the sub-contractors
.❑ 1 ;hn o sole proprietor or partner-
listed on the attached sheet. ? ❑ Remodeling
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
I p insurance comp.
No workers' i 5. ❑ We are it corporation and its required.) otTieerx have exercised their I0.❑ Electrical repairs or additions
3.❑ I ant a homeowner doing all work right of exemption per MGL I LE] Plumbing repairs or additions -
myself. [No workers' comp. c. 152,¢1(4),and we have no 12.❑ Ruof repairs
insurance required.j t - employees. [No workers' 13.0 Other
comp. insurance required.]
-.4ny:yphcunt tbm checks box it] most alt,a fill cut IIK wcuou wow,howLla their wor ws compensariwi policy inhumusium
'I IumauwmH whu wbmil this onWavil indicuing they are doing oil work anJ Oren hire outside cciTunw on must.utm+il a new al'ridavit indiuding atich.
-f i)mrtca,n that check this box moot altachcW an additional Acel,hawing Ibo mmnlo of the sub4ontraetors and their wurkun'comp.gxdicy infurmariun.
/run an employer tdat lr pruvidinp tvurkers'c•uarpcttsn!/nn intarmncc jar ury tarp/ayeer. Below is the policy and job site
information.
Insurance Company Name: rP ----.------__--
Policy is or Self-ins. Lie./n': __.. _ .._ Expiration Date: /
Job Site Address: 0f/ /it/r�S� /5��� C'itylstute/Zip:
Attach IT copy of the workers' compensation policy declaration page(showing;the policy nwuber and expiration date).
Failure w secure coverage as required under Section 25A of iIGL c. 152 can lead to the imposition of criminal penalties of a
rise 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 Tine
of up to S250.00 it day against Ilse violator. lie advised that a copy orthis statement may be lurwarded to the Office of
Invcxhgaums of the DIA for imuraitce .x.vcragu %ciilicatiun.
/du hereby cc wider the aux a tnd tt/l/�wGics of perjury that the information provided above its true and correct.
Sh_:runrc: T btit /7itiJ�-� Date: `� WOJ /�•
Official tuye only. Do nat ivrire in this area, to he completed by city or tmvn ojjicia/.
City or Town: PurmittLicense p._
Issuing;Aulhurily(circle one):
I. hoard orllealth 2. Ilutlding Department .i. Cityifowu Clerk 4. Llectrictl Inspector 5• Plumbing; Inspector I
6. 01 her
G 1111aet Tenon: __ Phone 4:
Information and Instructions
>lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation tin their employee .'
Pursuant to this statute, an empluree is defined as"...every person in the service of another under any contract of hire,
,•press or implied, oral or written."
.fin employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
,,r the lorceoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee ul an individual, paitnership,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."
`IGL 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 cumptlance with the insurance coverage required."
Additionally, (vIGL 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 till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) namc(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 sore 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 affiduvit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple penniUlicense applications in any given year,need only submit one affiduvit.indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write":ell 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 pertnits or licenses. A new affiduvit 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 bur leaves etc.)said person is NOT required to complete this affidavit.
Ito t)(licc of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
piease du not hesitate to give us it call.
The Deparunent'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
i-26-05
www.mass.gov/ells
R
i
�4r CITY OF S U EM, NIASSACHUSETTS
BuILDLNG DEPAR M&NT
J' 130 %V.NsHINGTON STREET, 3AO FLOOR
T EL (978) 745-9595
F.mx(978) 740-9846
KIStBFRr RY DRISCOLL
tiL;YOR THO�tAS ST.PtERAs
DIRECTOR OF PUBLIC PROPEATY/BL'ILDNG CONalISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 1 l 1.5
Debris, and the provisions of lMOL c 40, S 54;
Building Permit A 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
111, S 150A.
//Thhe' debris will
be transported by:
l -L� a / _
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of tacility)
signature of permit applicant
(late
d.bn..ilt bx