6 WEST TER - BUILDING INSPECTION l,n^j The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
SALEM
L.
Massachusetts State Building Code, 780 CMR Revised:I far'011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- Tvru-Fatnily . welling
This ection Forj6fficial Use Only
Building Permit Number: at Applied: S•
2
Building OBicial(Print ame) Signature Date
ACTION 1:SITE INFORMATION
1.1 Pro .
�e s i lrrro e �
1.1 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 It) Frontage(It)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check ifycs❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'obf/Record: Q� le e
-21117
Name(Print) City.State,ZIP
No and treet Telephone Font Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition-0-
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-: • `/ A-,,�—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su Total All Fees:$
Check No. Check Amount: Cash Amount
6. Total Project Cost: S / i/ ❑ paid in Full ❑Outstanding Balance Due:
l3Gvtr/y ✓hA- d/9vJ'
SECTION 5: CONSTRUCTION SERVICES
r:N
n Supervisor License(CSL)
t1PLicense Number F:.cpirl ion Date
cr�h/ s% l_isl CSL'fype(sec below) Description
S-i�//�Srr�r r /✓1 Ass—U U Unrestricted 113uildin s u' w 35,000 cu, tlJ
Restricted 1R.2 raniny Dwellin
Cuy[fown.State,/_IP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tcic hone Email address D Demolition
5.2 Registered Home
Improvement Contractor(HIC) , /
124!ow`G �iOO�i�`� IIIC Registration Number Expiration Date
I11C aipal' ,Na�ro;�Registrant Name
No. andStreet
� Email address
Ci /Town Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDINGPERMIT
I,as Owner of the subject property,hereby authorize�,G,�
to act on my behalf,in all matters rela ' e t;wo authorized by this building permit application.
I mt Owner's Nmne(Electronic hi me, y Date
SECTI 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 application is true and accurate to the best of my knowledge and understanding. .
print Ounerr Ayhoc nt's Name(Electronic Signature) Date
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 can be found at
mvw �ry tux Information on the Construction Supervisor License can be found at w�ti w_nms. o�.IL
2. \Vhen substantial work is planned,provide the information below:
Total Floor area(sq. ft.) (including garage, finished basenment/attics,decks or porch)
Gross living area(sq. R.1 Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt%baths
Type of heating system Number of decks/porches
Type ofcooling system Enclosed Open
3. "Total Project Square Footage"may be substituted fbr"total Project Cost"
CITY OF S.�LE.�I, �&L-us ICHUSE-rrs
• St;ILDLNG DEPART.I&NT
120 W.tiHLNGTON STRErm.7'°FLOOR
T L (978) 745-959S
FAX(978) 740-9846
IQSBERIEY DRISCOLL
,MAYOR TH0.+as ST.PIERRB
DIRECTOR OF Pt;BLIC PROPERTY/BUREI NG CONWISSIOrER
Construction Debris Disposal Affidavit p T
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 11 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
S �3�039
(name of facility)
(address of facility)
si nature of pe mit applicant
Bate
dabn vlf 6a
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.snot.a:1 Y:la lKl-11
\I ti,aI
I�•�•\'rMftl.\Ulr)\)IYCL•T a)AIV%4, IN.\11.\1.111 V I lwl'/7Z
I'1'.1.: 'l7L�IS9i'15 as 1:.%.. 9711•74C•7x46
'iVorkers' Cumpensation Insurance I'Odavit: Builders/Contractors/Electricions/Plumbers
'•pnlicant Information Please Print le hlv
Villll�IUnM,wcsit)rgan,141mm Ind,*tduul): Nd ST4 7C AIX g G�;t2f�
Address:
Cily,Srare'Zip: Phunei/: &417
.1re)no • •"'Moyer?Check he approprldle box:
I I. wtl a cm to cr with 4. l•)M of protect(required):
p y ❑ I am a general contractor and I G. 0 New construction
entpluyeea(full and/or purt•lime).• have hire)the suh•tamauwrs
?•❑ I;fin a sole prnpricnx tar partner• listed on the attached.sheet t ?• ❑ Remodeling
ship and have no wnpluye no These sub-contractors have it. 0 Demolition
working Air me in any capacity, workers' comp, insurance.
9• 0 011dding addition
I No workers'comp, insurance 5. 0 We are u colporstio a and its
required.) oniccn have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per I►tCL II-0 Plumbing repuirx or ailditinna
myself. [No workers'comp, C. 152,31(4),an we have no 12.0 Ruul'repairs
insurance reyuired.1 t amployces. (Ko Markers'
comp, in.urance rcyuind.J 13.0 Odler
by.nplwwa th,a ehccks thu ell must also till out the wcuun Iwluw dwwnlg thmer wwkai cumpsnuuuat pulicy fntiamWiutn
't lumwrwmm who lubmil this umdavil indiulins Auto Ago doing all.vurk and then hue wniils erwtrnelela must.Mhrne a yaw al'Rdawit indiculinx Mich.
-C.m,rsclo"taw thcxk this beat mtrl aaached fin additionMI..hail.hawing Iho nanta orths lub•canitwta s and then Mohan'CO1°V,ptdwy mturmanma
/uln an ellaplayer that lr prot'/dlnp workers'cuinpealxnNon inrurvulre/br ally anp/uyerr. Be/uw lx rhos puy g/4od Jub site
hiforllliatian,
Insurance CompafiyNa,ne: �'S Clot
P bk .ANTcr^� •o a/Policy 4 ur Sclr•ins. LLiic.d:_ /'_'r•--`--ts?--.r . __ ._.Expiration Dare:
lob�iW Addrese: Vrf J✓LeSr T,o//p,N L'� C'lt lJlale/Lt {$
Attack it cupy of the workers'eumper satlon pulley deelurutlun page(showing rhos policy number and expiration date).
raituru to.secure coverage as required under SCcliun 25A ul'bIGL c. 152 eau lead to the imposition oreriminal yenaltie3 of a
line up u4 SLStlO.rN)anJ/ur one-year imprixnnmcnt, Js well as civil pcnalhcs in the form of a STOP WORK ORDER and a fine
of up to i250.00 is Jay.isuinal the violalnr. fie advi.4cd Choi a copy of Ihu autcmcnt may be lurwarded to the Office uC
III\'�.sIhJIUIIIa of the IIh\ Ior mrur:u:ee 0,vvrage %cl'tlicition.
l du hereby a erli/y seder the pit' nd penahirr perjury Char the in/brinetlon prurided above is true and corrrck
�tmaatare Gi-
F
Da nor n•rire in this arcm,to be culnylrled bycity fir/otvn a//IrruL'nwn:uthority(circle#)fill):
IV41111 1. IhItlJill Uvparnnent .1. Ckt,Torm Clerk 4. Llccirical Inspector 5. Plumbing luvpecror'cnuu:
I
s
Information and Instruction
\Ia.Ii.IClluscus U,:ncral Laws Chapter 1 JZ requircs all eulployc in the tcrvice of another tid wrkers' 1>,leronny contract tor their oy flhire,
11unuant to this.latule, an emplurre is dCrIlled as"...every person
e,tpress or implied. oral or written."
An elprpluper Is defined as"an individual,partnership•association,corporation or other legal Cntiry,or any two or snore
r the Ibregoing engaged In a Joint enterprise,and Including the legal representatives Of a decease tell.employer,However the
.It the eceiver re trustee ga ge individual,parmership,axsoctatioa or other legal naty,employing • p T
owner of a dwelling house having not more than IIIsons to�o nainromrnan ents and
C�nhvacti neotlrepair work aerein.or the nsuch dwelling house
J%Velling house of another who employs pt .
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an emplgyer.
�IGL Chapter 152, §35C(b) also states that "ever?$tare or local Itcensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business of to construct building,In the ce coverage
re for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required.
�dditionully, �IGL chapter 151. a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
corer into any VIGL contract for the pertomwnce of public work until acceptable evidence ulcgmPliastce with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please felt out the workers' compensation affidavit completely,by checking the boxes that apply to Your situation and,if
necessary, supply workers' ctor(s) name(s),uddress(cs)and Phone numbers)along with their certificate�a).4f.
insurance. Limited Liability Companies(LLC1voo or
Liability
ia ilia Partnerships
iruurship(if aa)LLC orth oLLP Jaoa have
employees er than the
members or panniers, are n wi
ot required to carry
employees.a policy is required Be advised that this affidavit besure
maybe 90 an d to the the aMdavIL of industrial
he rc�umeJ to the confirmation ry or town thainsurance
hecappli aeon for the pens eOf 1iceose is being requested,not heeChpar<ment should
industrialret nAccidents.city
Should you have any yuestioas regarding the law or if you are required to obtain a workers'
Compensation policy,Plea call the Department at the number listed below. Self•insrnrcd companies should enter thew
Pica"
self-insurance license number on the appropriate line.
City or'rown Official,
Please he sure that the affiduvit is complete and printed legibly. The Dep
leartment has provided u space at the buttons
of the affidavit 1'ur you to till out in the event he Oltice of Investigations has to contact you regarding the applicant.
I'I:use be sure to till in the permittlicense nwnbur which will be used as a reference number. In addition,an applicant
that must submit multiple Pennib'licetse applications in any given year,need only submit one afiidavit indicating current
policy intoi mati n(if necesslary)vihrt ll under-Job ha,been officially'tamped or marrkednbyi Ileac ty or town InaYptbe prSite Addss"the applicathold write"a luCiunovided to they
tar
town).",N copyill*
applicant as proof that a valid affidavit is on file for future permits or licenses. A new allidavit Ion c m tilled out each
venture
ye:u. ��'herc a home owner or citizen is obtaining a license or permit not related to any business or Commercial venturo
1 i.e. .I dug licence a permit to bum leaves etc.)said person is NOT required to complete this atftdavit.
I he I>ilix of luvesrigatiuns would like to thank you in advtulcc for your cooperation and shuulJ you have any yuesuons,
lease do nut hesitate to give us a Call.
p
fhe UCpartinent•s address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
oQ[ct of InvesdQadons
600 Washington Street
Boston, MA 02111
"ref. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.man.gov/dia