3 WEST TER - BUILDING INSPECTION (3) � �� y� �"3� y�3
;2ECEIYE{1
• � � 'Phe Commonwtalth of Massachusetts� 1 CITY OF
� ,� Board of DuilJing Regulations anJ Standa��$b �AR 29 A S9ALEM
(v 0�� Massachusetts State Building Code, 780 Cr�� RevisrJ.1%ur 1011
� Re air Renovate Or Demolish a
' n To Construct,
BuilJingPtrmitApplicaho P �
� One-or Tivo-Fnmily Lhvelling
rThis Section FocO�cial Use Onty
� F3uilding Permit Numbert` Data Ap ed: •
I �Uuilding Otliciul(Print Nwne)� . .Siguat�� � � Date .
SECTION 1:SITE INFORb1.+1T101�F.
1.1 Property.lddress: !.2 Assesnon��lap 3e Pnrcel Numben
we ut. ce
I.I a Is lhis an acce ted street?yes no M1��P Number ' Parcei NumM:r
1:3 'Loning Informntion: I.d Properry Dlmensions:
l�'�S,%X✓r"i') .
"Luning District : � �Pn+poseJ Use � Lot Arca(sy R) �- Fronmge(Il) � . . _ .
LS BuI1JIngSetbacks(R)
. Front Yord . . . .. � SiJe Vaiilv � - Renr�Ywr1� � ..
RayuiniJ . .�Provided �Requircd �- ProviJed. .. Requi�ed� ' � Providnl
1.6 Wate Supply:(M.G.L e.40,§Sd) 1.7 Flood Zone Information: 1.8 Sewag�e/Disposal System:
Zone: Ou�side Flood Zone7 MWIICIPOI dd.Of1911C II19P090I YYSIC(11 O
runr�� r��au o — cn���t eso
SEC'f[ONI: PROPERTYOWNERSHiP�' ` `
2.1 O ner�ofRcror ��tv���� /��A' 0/�`7a
�1.�<fM/ �. L��J�
.t�me Print . . . , Ciry State,ZIP � .
�3 �W�T �4/�a�3� ,S��C�/cr-,��r �t� 07��� �i
No.and Stn�et Telephone ' Em ' dJn:sg '
SECTION 3:DESCRIPTION OF PROPOSEU\VORK3(check nll thut npply)
New Conshuction O Ezisting Building Owner-Occupied� Repairs(s) ❑ Alteration(s)� AAdition O
Demolitiun AccessoryBldg.O NumberofUnits_ Other 0 Specify:
Orief Description of Proposed Work':
KjTr �, �
SECTION�:ESTIMATED CONSTRUCTION COST3
Itcm Estimared Costs: OU7ci•rl Use Only
Labur mid�lateri�ls)
I. �uilding g D I: Building Permit Fee:S Indicare how fee is detertnineJ:
O Standard City/Town Applicntion Feo
2. Electrical � � ❑Totai Project Cost�(Item 6)x multiplier s
3. Plumbing S ��� 2�?PtherFees: $ �
a.�Icchviical (HVAC) S List:
5. \fach�nical (Fire ,� T�tal All Fces:3 .
Su rcssiun) �
Check Yo. Check Amounh Cash Amount:
�.'I'utal Project Cust 3 `2�QD� ❑p;�iJ in Full O Outstanding Dal;mce Due:
M►����,� 3 l'�'
.,�
L.�t.s.;_.
r:ir>>n9�i � . .
�'� ���� � " SECTIONS: CONSTRUCP(ONSERVICES
5.1 Constru4tion Supervisur,Ucense(CSL)
: � Y �itli{� r,, ;
- Licensc Number Espimtion Date�
Name uf CSL tlulder
List CSL'fype(s�ro below)
. TYpc. - '- � ':- � . Descriplion .
Nu. ;mJ SInYt - � -
0 UnrcsUicted� Uuildin ii �ta 35,000 w. Il.
R - ResVicted 1&2 F:unil Dwellin
� City/iown,State,ZIP M b(aso �
RC Roolin Coverin �
WS Nindow anJ SiJin
� ' SF - Solid Fuel Buming Appiiances
I Insulation
Tcle hmie Email:ddrcss D Demolilion
51 Registered Nome Improvement Contructor(HIC)
� � H[C Registmtion Number Espimtian Date
� IIIC Comp:my Name or t11C Registmnt Name � �
Nu.m�d Street � Email address
Ci /1'own State ZIP Tele hone
SECTION 6:�VORKERS'.COhIPENSATION INSURANCE AFFIDAVIT(M:G,[i c.152.$ 25C(�},
Workers Compensallon[nsurance affidavit must be completed and submitted with this application. Fnilure to provide
this nRiduvit will result in the denial of the IsSuance of the building permit.
Signed AtTiduvit AtWched? Yes..........O No........... O
SECTION7acOWNERAUTHORI2AT[ON,TOBE.COMPLETEU.)YHEN '
O�YNER'S AGENT OR CONT[tAC7'ORAPPLIEB FOR BU[LDINC.PERl11IT
1,as Owner of the subject property,hereby authorize - .
t9 uct on my behalf,in all mntters relntive to work authorized by this building pertnit application.
Print O�mer's N�me(ElecUonic Signuture) � . Date
SECTION 7b:O�VNER�OR AUTHORIZED AGENT DECI.ARATION
Dy entering my name below,l herebp uttest under the pains and pennities of perjury that all of the information
cont�ined in this application is true und accurare to the best of my knowledge und understanding.
��'� G�cky� ����
� Print O�vner's ar AuthurizeJ r\genCs Nnme(Electrume Signature) Date
NOTES:
I. An O�mer who obmine a builJing parmit to do his/her o�vn work,or an o�vner who hires an unregistered contractor
_. _._.__.__.__ __(not registerzd in the Home.lmprovement Contractor(HIC)ProgmmJ;will nu have access to the urbi�mtion
- -- -- -- — -�
progFam or guaranty fund unSer M.G.L.c. 142A.Otlier imponan�inFormation on iha HICYrogram can 6e toim 3F- --"- """ "" -
�rw�v m:us.eo�;'ocsi Information un Ihe Construction Supervisor License can be l'ound at w���+.mass.aovldns .
� 2. When substantial w rI is p ined,provide the informotion below:
'fo�al tloor area(sq. ft.)� � � (including garnge, tinished basemenVattics,decks or porch)
Gross living area(sy. ftJ Habitable raom count
�umber uf tireplaces Number of beJrooms
Numbcrufbathroums Z Numberofhalf/bntlis
��YPz uf heating system Number of'deck�/porches ��
"fYpeuFcuuline�system — /�/D�U� — Lnclused� Open
7. "Twal Project Syuarc Foma��'may be,ubstih�ted 1'or"Tutal Project Cost" �� SF
. / ., .'
,i�� G�TY OF SALEM, MASSACHUSETTS
's �, ,. F� I BUILDINGDEPARIME�
�3 � 120 WASHIN TONS
�D, G 1REET 3 FLOOR
� ���,� �
\� TEL. (978)745-9595
FNc(978)740-9846
KIMBERLEY DRIS�LL
MAYOR TY�oMns Sr.PiE�
DIREGTOR OF PUBLICPROPERTY/BUILDING COMIvIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date > '�O '16 �
Job Location
Home Owner Address � U�eS� �`e1Q yC f�(� 6¢G G4. //�i y/ ���2a
Present Mailing Address G4(�0 d-P�
The current exemption of"Homeowners"was eMended to include owner-occupied dwellings of two
Units or iess and to allow such homeowners to engage an individual for hire that does not possess a
license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one=or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner'shall submit to the Building O�cial,on a form acceptable
to the Buiiding Official,that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State euilding Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem euilding Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE ��`��
APPROVAL OF BUILDING INSPECTOR ��- zS �'
C�TY OF SALEIV� NIASSAC�iUSETlS
E[�.nu.rc DEra�xr
� � 120 WASFmJG7YJ9VS7REET,3BDFi.oGtR
�Y?L(978)7459595. �
FAx(978)7449B46
BIMBERLEYDRIS�II.
MAYOR 7�fasST.P�utE
D�crcvt a�r[�ucrxaa�xTr/si.m�nuca�ssto�rt
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Sedion 111.5 Debris,
� and the provisions of MGL cAO, 5 54; Building Permit� is issued with the
condition that the debris resulting from this work shail be disposed of in a properly licensed
waste deposit facility as de�ned by MGL c 111, S 150A.
The debris wiA be transported 6y: �
l`b(� (C(< 1�IcS�2S� � �
(name of hauler)
The debris will be disposed of in:
��Nl�3�1G WA-Srl��
(name of facility)
3�o t�re� sfi- F��}��,
(address of facility)
Signature of applicant
Date � �
� The Commonwealth ofMassachusetts
- Department oflndustrialAccidents
� 1 Congress Street,Suite I00
Boston,MA 0211 4-2 01 7
x www mass.gov/dia
Fi'orkers'Compensation Insurance�davit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNIITTING AUTHORITY.
Aoplicant Information Please Print LeQiblv
Name(sus;ness�o�ganizationitnaiv;dua�): SI.�sA'J�/ /Y� �('�(��
Address:��
City/State/Zip: ��}'� �}- D�Gj7/� Phone#: OS
Are you an employer?Check t6¢appropriate box: . �
Type of projeM(required):
I.�I arn a employer with employees(fiil]and/or part-time}� 7. �New conshvction
2❑1 am a sole propnemr or parNership and have no employees working for me in $. �Relnode�in
any capacity.[No workers'�comp.inswance required.] g
3.�am a homeowner doin all work m self. 9. Demolition
8 y [No workers'comp.ins�uance required.]1
4.�I am a homeowner and will be hinng coniracrors to conduct all work on m 10 Q Bui]ding additiOn
Y Prope�y. I will
ensure that a11 contraaors either have workers'compenaation insurance or are sole 1 I.Q Electrica]repairs or additions
proprie[ors with no ertryloyees.
12.Q Plumbing repairs or additions
5.❑I am a general conLactor and I have 1'ired the subcontracrors listed on the attached sheet.
7hese subcontractors have emp]oyees and have workas'comp.insurance.7 13.❑ROOf iepairs
6.Q We aze a corporation and its officers have exercised the'v nght of racemption per MGL u �4'���
152,§](4),and we have no employees.[No workus'comp.ins�vance reguired.j
•My applicant that checks box#1 must also fill out the section below showing theu workers'comprnsation policy information. �
t Homeowners who submit rhis affidavit indicatlng thry are domg all work and then hire outside contractors mus�submit a new andavit indicating such.
iContractors that check thu box must attached an additional sheet showing ihe name of the subco�maaors and state whether or not Nose entitiu have
employeu. Ifihe suh<ontractors have cmployees,[hey must provide the'u workus'comp.policy number.
I am an employer,that is providing warkers'compensation insurance for my employees. Be[ow is the policy and jab site
information. � �
Insurance Company Nazne:
� Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
AttacL a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a crimina]violation punishable by a fine up to$1,500.00
and/or one-yeaz imprisonment,as well as civil penalties in the fo:m of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi under the pains and penafties ojperjury thal the injormalion provided above is true und correct
Si ature: � Date: 3 � ��.
Phone#:
O�cial use only. Do not write in this area,to be completed by city or town o�ciaL
City or Town: - �� Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Piumbing Inspector
6.Other
Contact Person: ` Phone#:
Information and Instructions
Massachuset[s General Laws chapter 152 requ'ves all employers to provide workers'compensation for their employees.
Pursuant to this statute,an emp[oyee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other]egal 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 an individual,pazfiership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more then three apartrnen[s and who resides therein,or the ocwpant of the
dwelling house of another who employs persons to do maintenance, construc[ion or repa'v 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 with6old the issuauce.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 compliaoce wit6 the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any conhact for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contrac[ing authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with thevi certi5cate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or parmers,aze not required to carry workers'compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised tha[this affidavit may be submitted to the Department of Industriai �
Accidents for�confirmation of insurance coverage. Also be sure to sign and date the afiidavit. The affidavit should
be retumed to the city or town that the application for the pertnit or license is being requested,not the Depariment of
Industrial Accidents. Should you have any questions regarding the law or if you aze requved to obtain a workers'
� compensation policy,please call the Departrnent at the number lis[ed 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]egibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Inves[igations has to contact you regazding the applicant.
Please be sure to fill in the pemilUlicense number which witl be used as a reference number. In addition,an applicant
that must submit multiple pernrit/license applications in any given year,need only submit one affidavit indicating current
, policy inforatarion(if necessazy)and under"]ob Site Address"the applicant should write"al]]ocadons in (city or
town)."A copy of the affidavit that has been officially stamped or mazked by[he ciTy or[own may be provided to the
applicant as proof that a valid affidavi[is on file for future permits or]icenses. A new affidavit must be filled out each
yeaz.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 pemut to bum leaves etc.)said person is NOT required to complete lhis affidavit.
The Deparhnent's address,te]ephone and fax number:
The Commonwealth of Massachusetts
Depariment of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE j�
Fax#617-727-7749 �
� Revised 02-23-15 www.mass.gov/dia
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