158 WHALERS LN - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:•14aru�rv�t r.
1L►nrr 12;'7ala.Va7trs SMUT a Uum WMman a'1.1s 01we
ThL Mft&•M a P.sx:WW40.gtN
Workwa' Cotrapouatloa Imorraer AMdavir BdlQer%fCmltrachWL Eloetrldslu/Phmbtn
Applicant Informrftor please Prise Lotift
Nametuuwe.rOrp.irarierhrs.rA.11:
AJd
Ciry/SttcdZip: 7$f - 6-SS -Q)q0
Are yea an e0player?Cheek the Appropriate boat
hPe of proJesk(►M•wdl
1 1 ern a eatpby with 4. [31 a a gtataal txtotracmr u ( 6. �New coruaetr-O.
ernp4,yam1(fuII ll salvor pin-tints).• have hired the wb.eutrruwes
2.0 1 am a sole proprleax or Partner. listed on the attached dso•t. t 7. ❑ Remodeliaa
ship and have no o aployam Than tads-conomads It a. M Demolition
working for ma in Any capacity. workers.•nntp inWt•ttoL y
O ins
addhiar
(ne wrtAters'damµ innrrsnee S. ❑ Wears.corporation And its
Nquired) oAleers have exercised their 10.0 Et«a+cal repairs c r additions
3.0 1 am A homeowner doing all work right of marapdan per h1CL 11.0 Plumbing repairs or addidom
myself.(No workers'comp. a 152.}1(4).and we have no 12.0 Ruorm
insurance required J t .mPIPYWA.(Wo workers' Ce.�
comp insuesn 13us mquirod.j 0 Other
•Asa 4,ph"ad wr etroA.gas As .a.aim as w a...aide Wow shewly nadir wk a'n•4s•t"k.P•tler k ..,:n,
'tL...+srts wag na.At 1ai errawk�racy are mwy at walks"Arta W earrt4 ea,.ns ar.a wd.h a ae.amd♦eil taiaolirq rai
{uerq ewe tb rkerk lase rag ear ar.derl r sddnlaal.pert.howi,y tY ne.e dots rsMsaarrera aa/dtdr..rk..•ta,atp.awk h ocadin aka
/uaa uw eiaployrr rhos b proWatYng worAor•'eosrpentedew Lueraacrfo?as ear o et Bi/•w b n!i awd
Insurance Company Varna. SScx
Policy•at Salt-ins. Lie.o: 11� �o d h St E t a-0c) (o_ t
rp ._ .. ..._ �_ Expiration Date: (
Juo Site Address: 15-Y tj" l
I"l CitysSWw2tp: Va.lewl r'�4
\rtach a copy of the workers,compensation pulley dselAratloa pay(showing the Polley number and aspiration dodo
Vailura to xxurs coverage as required under Section 25A ur.%IGL c. 153 can lead to dw imposition of criminal penalties of s
tin.up 10 51.5110.00 and/or orw-yex imprisomnent,as wc11 as civil penalties is the farm ors STOP WORK ORDER and a fins
of up m$250.00 a Jay against the violator. Ile advised that a copy of this statement may be iurwarded to tha O(Yce of
:a%*:,naawnss of iho DIA Cot ia.utarca an:raas:%aifu:attun.
/Jar heresy tern/ I side? pains and iwooliks olper/s,ry that the Information"did aloes is pate and comeA
;?-,1 vt—�3 D
rah n:r a_
d;1jWaf are oa1A Ao oat WAN/n/h/r Area.to be Crrwpkrd IAr dP N Arre r alJli/aL
Ciry or 'rows: PerlsitAJscas•p
1»uing authority (circle also): — —
1. ouord of Itraltb 2. nuildint IhParttncnt ). awronn Clerk 4. Electrical luspccror S. Plumbing Inspector
4 Other
C"olacr Person: _ Phone a:
Information and Instructions
132 requires all employees to provide workers' eanpensatiea for than anpb MVM
huaetta General Laws claapat
�tassac a dafithed a_...vwy person in the service of anaMr nger
t under any co of!ti ro
purstsaar to this awassR as#AT/fa7e'e . : ,,s
raper"es impbo4 oral or waterer .
a other kph daft.or any mew more
Ate dsl/byar,is dslind a"stt indhtidte"pnroasbig.a a 'vat of a deeeiutod employer.or the
of clad foregotag anpged m,e�catep►iss.and inches td the gal representatives ilotsavar the
cewive at commove of s udtvidmak vwme slow&Nag&""at other kph Meow.employing cmpmyes
baw 1rWI08 not agate then duo WwwAatn and who red"threes-or the socupeat of tb
dwoutsig house of mother wow employs Parmat a an mau meeeco,cdm+irucdaa of repair work on such dwelling house
� �of buer aa
ild apPeaat tOtlaa the net beastttl of sum►ootpheyraanh ha diasnad a a tm employe.".
of Ott the Y`^"�,h�
blaold the legitimate
wis
MGL chapter 152-42=6)aeave err do trams•that"w�seer"as bed Moandng speey Nov e•aae�wcaMk am
renewed of a l peealt me opar es a landmass se a commove behWp sppotrr"wbo bed met peadstaod acceptable widows of compose"wYk the lesarae"eovengs"Matd..
e
Additioaalb•MdL chopter 1 S2.i2W47)stags-P eNter the eoamnoeweabb gar any of its political atbdividaaa AW
entat eta any coamaat fee the poffoe•eace of public walk until aeeepnble evidesw of oanpliasce w ith the irmtna"
fequiry earso of this chapter bevo bra presented to the contracting au*ArW--•
Appotaatf
)kill out the workers• eaatp resae °a
affidavit completely.by checking de bona that apply to your alaanao gad.if
PteaPleasePl necessary.raPPly OO�s m nhs(s).address on
es)and phe sumber(s)along with their cwtiAcata(z)at
Limited Liability COMP
Ks) a(LLC)of Limited Liability partnerships(LLP)with so employees Odw that the
i""` an gat regttf red to carry works'coatpeaotiaa insurance. If an LLC or LLP does haw
�1�"a acUuMa mquiead 8o advised that this affidavit may be submitted a the Deparanmm of Isduse ial
Accideas for caaAaasdm of hwurawA eoveep. Mambo sun to sign and date the alodaviL The affidavit should
be resumed to the city or awn that the application far the permit at Hcmm is being requested.ash the DaPartmaat of
Induaaial Aa:idsaut. Should you have any questions retarding the kw or if you am required a obtain s workers'
call the Depaftttsat td ousabor listed below- Self-iasused companies Should enter the
compensation Polly.plea" ir
self inwrahee license number on,theappraprom
Clry w Taw-Oflklads
to The Deportment has provided a space at du batlorn .
ptd�ce be sure that the affidavit is complete and peened g't by.'
of the affidavit for you to fill out in the event the Office of Invwtitations has to contact you regarding the applic"
lat.aad be sure to till in the pdrmitlticenss number which will be used as a reference number.m n addition,
an applicant
cant
nt
that must submit multiple money) ind tan er"Jo Sift A any liven year,need should write"oil locations is__iciry or
policy information kif necessary)and under"Job Sea Adampe or app
town►."A copy of the affidavit that ban been oRieleUy stamped or!narked by the airy or town easy be provided a the
apPlieant as proof diet a valid affidavit is on file for kbtum permits or licenses. A new affidavit must be filled out tack
Year. wham a hone owner or citizen is obtaining a license of Penult not related to any business or commercial venture
(i.e.a dog license or parade a barn leaves ate.)-aid Parma is NOT required to eomplate this atlldaviL
Vho 01111,a of!3ves9iVtiunS would life to thank you in advance foe your cooperation and should you have any questions.
,ileaae du not hesitate to Yive lit a call.
The Dcpatrment's address. telephone and fat number
The Comamwealtlt of Maswhusettll
DCPMMM of Wusaid Aeoidwts
ON"of[ovo dphMr
600 Warhio8ow Suva
Ba o MA 02111
Tel. 0 617-7274900 cal 406 or 1-877-MASWE
Fax 0 617-727-7749
acviacd 5-26-03 www.num.giv/dia
CITY OF SALE W
PUBLIC PROPRERTY
DEPARTMENT
>LMS lie W.%mew.ams" *ns::9
h:90t 4&o)lM SW40 ant
Construcdos Debris Dbposst< Affidavit
(requimd lbr all dattosidon aad sumatim wont)
Is mordsncs w itb the six&edidm of dw Stets Ruildiot Code,7W MIR soclian 1 t t.!
oaxi&and dw provisions of M- CL a 44 S Sk
Suildia4 FWudl 0 _ is issued with tits coodidm dw dw debris maddns dom
ibis wet shall bs disposed*tin a propwty Remised waste disposal &cility as dented by.%tGL a
111.s 15"
The debris will bs transported by:
—� �aoar�tio�
rho Qcbds will be disposal of in :
MmuYfaciGty)
— f Ya.a.tyl
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) GS a�I C7 7 v`7-OC
:1 �L��� License Number E.cpualiun Date
Name_ott cSI- l—folder C_ List CSL Type (see helow)
it S�- G� T T e Desc'ri non
Addr•ss U Unrestricted(lip to 35.000 Cu. Ft.)
R Restricted Ide2 Famil y Dsvcllin
nature M Masonry Onl
-�y3C7 RC Residential Ruotinc Covenne
Telephone WS Residential Window and Sidin_
SF Residential Solid Fuel 13unnrte A )>liance luuallatum
p Residenual Demolition
5.2 Regli teere Home Impr cut Contractor (HIC) 1 Z<iO0 "7
//��L J RegistrationNumhcr
HIC flCJ Name
�iL-,MgistFUHL11m � (�L�t �_�—
,s 75s1 Expir tiun Date
gnat 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 per
Signed Affidavit Attached'? Yes ..........IM No -
SECTION 7a: OWNER AUT HORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
I, to act on my behalf, in all matters
authorize
relative to work authorized by this building permit application.
Date
Signature of Owner
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
I.
lication are true and accurate,to the best of my knowledge and
that the statements and information on the foregoing app
behalf.
Print Name V-141-.e 1
Signature of Owner or Authorized Agent
Date
(Signed under the pains and penalties of er'u ) NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires ss to the arbitration
unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access
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 I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
(including garage, finished base ment/attics, decks or porch)
Total floors area(Sq. Ft.)
Habitable room count
Gross living area(Sq. Ft.) Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms
Number of decks/ porches
Type of heating system Enclosed Open
Type of cooling system
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
XJ o
The Commonwealth of Massachusetts
r Board of Building Regulations and Standards FOR
Massachusetts State Building Cade, 780 CMR, 7"'edition MUNIc'IP:1Lfl'1'
<y`r List-
Building Permit Application To Construct. Repair, Renovate Or Demolish a Rr;^;s�-,ll<uuiarr
ne- or n•o-Fancily Duelling
This ection For Official Use Only
Building Permit Num Date Applied:
Signature: t
Biting Cummins r it p or o(Buildiugs Dale
SECTION L SITE INFORMATION
1.1i Property :1dd(ess 1.2 Assessors Map & Parcel Numbers
u L"-S I�
1.1a Is this an accepted street? yes no_ Map Number Parcel Numher
1.3 Zoning Information: (�J 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq to 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:
Public ❑ Private ❑ Zone: _ Outside Flood Zone'?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownes o Rec rd: c , J J�Z_ '6a OL, _
-X�l f7 _ "cPytit
Name(Print) Address for Service:
Signature telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction I Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units_ Other ❑ Specity:
Brief Description of Proposed Work':
OtJ. F✓� ow . cuti 9
SECTI N 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Offic'al Use Only
I. Building $ f[�Q o L Building Permit Fee: ndicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑ Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ I. Other Fees: .$
4. Mechanical (HVAC) 56F, �
S List: 0 �Mn —
5. Mechanical (Fire
Sir) ressi(m) $ Total All Fees: S
Check No. Check Amount: Cash Amount:
ull ❑ Outstanding
6. Total Project Cost: $ j LOd O , d ❑ Paid in F Q Balance Due: `�`