4 WEST CIR - BUILDING INSPECTION The Commonwealth of Massachusetts
t � Board of Building Regulations and Standards f()R
Massachusetts State Building Cute. 730 CMR, T"edition N1l'VIIiIP \l.l ll
i, l tif:
D Building Permit Application To Co,struct. Repair. Renovate Or Demolish a RcrncJ Jwmm r
One- or Ttru-Frtrnil v Duelling ) l t x)3
This Section For Official Use Only
\ Building Permit Numbe Date Applied:
Signature: 5 �r O �
\ Buildi g Commissioner/ Inspector o1'Buildings Date
SECTION 1: SITE INFORMATION
1.1 PSopert�ddrm: 1.2 assessors Map & Parcel Numbers
I.lads 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 It) Frontage(It)
1.5 Buildir
t)
Side Yards Rear Yard
Requirevided Required Provided Required Provided
1.6 Water c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public ❑ Check it es❑ P W" Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnerName(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work=: YYki-hr4-A"` 1 — coe. (-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Casts: Official Use Only
ILabo and Materials)
1. Building $ �z.Gl '� 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S 7a�' ❑Total Project Cost) (Item 6) x multiplier x
3. Plumbing S x1v), 2. Other Fees: 5 ��
4. Mechanical (HVAC) $ Llst'
5. Mechanical (Fire $ Total All Fees: S
Su ressiun)
Check No. Check Amuune Cash Amount:
6. Total Project Cost: S 461ar . 0 Paid in Full 0 Outstanding Balance Due
Y I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) � � � -3/2 4
License Number Eapirauun Dale
Name of CSL- Holder ! ° / List CSL Type(see hclow)
/2yi S if Yl St e�,l
Descn uun
Adylre-;b ��7 U Unrestricted(u to 35.000 Cu Ft.i
\� / L
ti Restricted Idk_' Family Dss ellin
Sigry�turr N %lasun Only
`5T,y J✓��L%ll / RC Residential Rooliu Cuvann
Telephone R'S Rasidelmal Wmdo,s and Sidra
5F Residential Sold Fuel Bummu \ s iliamc lu.(A J16 III
D Re>(denual Demol(uon
5.1_g�egLstered Morrie Improvement Contractor IHIC) (�J
,� �ct bl•N/ Cam[ .c i i'L n u/1/), �4 Zrc
t ) Rr utrarum Number
HIC Company Name or HIC Registrant Name
Addres G G_ [ 'L .
� _. C� �7�/=/�/ / /fj Ezp(rauun Date
Signature fie-= Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 9 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure it) prucide
this affidavit will result in the denial of the lssuancF of the building permit.
Signed Affidavit Attached? Yes .......... No ........... ❑
SECTION 7r: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i as Owner of the subje7inall
authorize to act on m
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1 . z -1 f/7, y , as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Pnnt Name ^ Uy
Signature of Own ur Authorized Agent Date
(Si ned under the 2ains and penalties of perjury)
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 base mendattics,decks or p )rch)
Gross living area (Sq. Ft.) Habitable rwm count
Number of fireplaces Number of bedrooms j
Number of bathrooms Number of half/ba(hs
-Type of healing system Number of decks/porches
Type of cowling system Enclosed Open j
3. 'Total Project Square Footage- may be substituted for "Total Project Cost"
r
CITY OF SALEM
PUBLIC PROPRERTY
r DEPARTMENT
M.\),IR 1_'� \t('.Ul i!Nl;1,1\]1RH I 0 $.\1!'\I,
I'! I: 978.I43-9;9 F.vx: T 8., ;-- 46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
> tliiant Information Please Print Legibly
ri ' �rt� ►� �r�.,,�cs�i C�rFracl�U, ._T;,ic
Name t Busutc:,.()rq.uuiauun ludtw tdu.d I:
Address: 2 c�5s ,z—xz>
City,State/Zip: �1 f
C d /W OV) Phone
��Si� �
.kre yo n employer' Check the appropriate box: Type of project(required):
1. ❑ 1 ant a general contractor and 1 6. New donsiructiun
I. ❑m a employer with ❑
employees(full and/or art-time).' have hired the sub-contractors
p listed on the attached sheet. 7 emodeling
?.❑ I :uu a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp insurance. q. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.0 Electrical repairs or additions
required.[
right of exemption per biGL I L❑ Plumbing repairs or additions
3.❑ [ am a homeowner doing all work S P
myself. [No workers' comp. C. 152, $I(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers 13.❑ Other
comp. insurance required.]
*Any applicant that checks bus HI must also till out the section below showing their workers'compensation policy information.
f I lonnowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:contracmrs that Check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
fain an erployer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Namr.��r'-«! —�?/fy✓l�'�
Policy #or Self-ins. Lic....#: 1)��l���t��� G sr' c'} { j-'- Expiration Date: C Zr B
Job Site Address: lJ�t� e't= Ciry'State/Zip:
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 N1GL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 andror one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a tine
of up to S_50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Ilncstigations of the MA for insurance coverage verification.
/Jo hereby cert:.•under t e pains and enul�s of perjury that the injorinutiou prrnided aby re and correct.
Phone
official use only. Do not write in this area, to be completed by city or town officiaL
Citv or Town: -- — ----—-- Permit/License -
Issuing Awhority (circle one):
I. Board of Health 2. Building Department 3. Cih'/'rown Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other —
Contact Person:------------ Phone
x
Information and Instructions
>lassachuseus General Laws chapter 1 52 requires all cnhplo\ct:s to provide workers' compensation for their employees.
Pui.uant ah this .talute. :uh emphpre is Joined as "...even person in the service of another under any contract of hire.
c\picss or implied. oral or hvritten."
All entph)i'er is defined as "an individual, partnership, association, corporation or other legal entity. or ally two or more
of the 6xcgoing engaged in a joint enterprise, and including the legal representames of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. llowever the
o•.vner 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 employ mcnt be deenied to be an employer."
\IGL chapter 152, §25C(F) 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."
:\dditionally, NIGL chapter 152, j2507)states"Neither the co runon wealth 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-cuntractor(s) 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
ntenhbers.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 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 permitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 tilled 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. 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 its a call.
the Departuhent's address, telephone and tax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
O(ilce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Ite�;set 5-'0-us Fax # 617-727-7749
www.mass.gov/dia
%L
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
M .)"Ik 120 W"ASHINGION S I RLET # SAI I M, MA iSACI It. I I
f m.:978-745-9;95 4 YAN:978-74-0,98-16
Construction Debris Disposal Affidavit
(reClUired fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # --- is issued with the condition that the debris resultin.v from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
ICE
(name of haqfer)
The debris will be disposed of in
(narne of facility)
(address of'flucilitv)
signatuie of pci-mitapplicant
(late