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160 WHALERS LN - BUILDING INSPECTION (2) CffY OF Spa,[ }� a 1 u BLIC PROPRERTY DEPARTMENT �:t0'f7�1lM �f.Ve'�y�'rtM r Construction Debris Disposat Affidavit (reyuinal Rx all danolidim aid tomovad"wash) In=ordancs with the sixth adidam olths Stan Building Coo 7110 0612.soctial I111.S Debris,and the provisions ot�tGL a 40.S 54 awkin4 Parton p _ is issuad will dw eoodtdao that the debris resttldng Oats ,his wort shall be disposed or in a property dca mod waste disposal &dHty as darted by% L a 111.Sis" The debris will be transported by: rho Jcbris will be disposed of in : 44 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT >.rv.rattr aartana.. >tLtnta 12ti rlasra nMtMWT a SataaL bf,►zwa l7-jjGIW3 AL 97►7e&OM •Fax:OW4&vse6 Wwkwae Compsuadoa fasurnaea Afbkvir BdldwSfCoatrsecsn/Flft daoa/phmban 40011enot Informado■ Please Met *tiwti VarttetauwatarOry.ilLedallrWavult.11: �`�'� �^�'�'^••r�b� Add Cityl t zip: �� U l�'� C?C�`� %re yam an emplayer?Cheep the appropriate!lost F13.103= rolL� I .a a etrtpkeyot with a. 1 ant.g tarraetarnod templ'syum(run somw putt-W e).• have hired the aa&eudnctora2.❑ )am s aola propAeaer ar partner• livad a tba aeeeelted aleeat sedetisg ship and haw no employees Tees haw ttalitioaWarring for ma in my capacity. workan'eootp.insutarAML FNe works,.•estop. inwraam s. Q We an a corporation amd its lai�,.anionOfficm hat,.exercised their trical repairs or additions 7.Q I am a homeowtaer doing aU work right ofexamplloa per MGL bing repairs ar addition. myself(No workcn'comp. c. 152.f 1(aL add we haw no f rein.Yt.ce required•) t employer,.L*'o work". r comp. incauvwx required.) •A.q.pphaW era etrasiu sea in meal atae nit ale Y.War hafaw saowiy+hed e.r.r mer.paeI dos policy iaarersaiaa llwraWrra s wb somwe"wedwk wasaviaa d"sae loofa 0 Warr and den W.aeeit aarra.era oar wlawh a came.amdwk IcaJtaria$cak& c rAraowa ddl rb"tnis b.suer..odor r adeaar.we ao.„MONSOONy ae aa.e rta.wk eeaaae.a aid dew ogre. mac 0� atrraarlaa /ua.Yw rmployer/liar!b proWding worAps'eO..prnsaafea In+Yroncijar nay r/ap/oydss Bi/ory le the pulley tmrl foI rill In urarue Company Nomr Ali S&v` Policy a w SYlf--ins. Lie.0 W (<�d��5� � d i ?C0 G—�_ Expiration Oato: tt d Job Site .Aloha,.: /6 c) City'Sww2,p: .tttack a copy of lbo workers'compensation pulley declaratlos page(showing the policy number and expiration dsts) I'ailurr u)wxun coverage as required under Section 25A of.MGL c. 152 can lead to dw imposition orcriminsl penalties Ora ri ne up[is SI.500.00 unaYor one-yea imprisamncnt,.a well is civil penahias in the form of a STOP WORK ORDER and arms ,If up to$250.00 a Jay og:aimt the viuiatur. Ile adviacd that a copy of this stawaaem may be turwarded to the Office of I,,a..nS•ourn Jf LI1e DIA .."or incwarce aner��as vcrifieuuun. + /JY hereaj Certify It tltY iqa Y/II iJfnYl- tlrf y pd/�Y/�/AY/fie I/Ije//Y/fd/OryrJr/I�YIIy�Ix t/YY Ynrl CO/ICCL ii.rror..rx _ _ It-7�Vli`.`C•—, Dote �� 0 O/Jiaief user wale Ise YAt trr/re/A/his Oren./Y ee rvaephfellY c&Y a V wr 0A./4d City of rows - PensittrUeeaee d Issaing .%alhurity (circle one): — — I. lloard of Ilcalth 1. Ruilding Department I. Citylfova Clerk J. Electrical Los75- Pluinbind Inspector G. Other Cuntict Person: — Phone a• Information and Instructions I32 requis"all employers to provide worker' canpenrtion for their employees. 1tassa to this, General Laws chapter is the service of another under any contract ofhite. A.nsuasx to this atatuu,sea s�Ittl7'��e is dalinad as"...ewes Person e�nos or ;ropliod.�or wnttK ataseiattias.ooepatudes a odor legal bout ,err any two err mora Ace �apn is ddMod to"as Wd'W dttaL�MWO k r sattadves of a deceased employer.Of the Of the foregoing engasad in&joist enterprise,and including th! gal egae may"& Novever the reviver err tturtto d s iodvidttal.parmssb+p.&aaasuaoa at other legal aaagr,employing bane havia f red men t�rhtaa apartmeta sd sobs teaido t rep iir err the 6 Vjab d e(ift owlet are dwelling s do semen eaaece.cuostracon►of repair wont on streh dwsiieg bean or on t e hoar of soother who pwuo a Personabe ddnrd to be as employer." or on the g►eans or Wilding apgttrssttss thuea shti net basso dsroh entplayeswr t 52-i2SC(6)also sates that"~"etett or Meal tlanbt aga•ay shag wkhMY the ton o names K rMGLose chapter a operate a bmb e K to construct bW~Ice the syva"'"t"fir say .tamest d a e aea err producrreaft evidence of gsPianet with the leantfntt coverage rsgslrs&" appYeaot ty. CI sot for I s2, sues 'TNider the caeruanWG"star OW d its poNsieal subdivuiota sbai Arldisirtnalb,M(N.chapter iS2,i2SC( ) Is evidence ofcaoplience wish the instranas must bon-my nxeeace fee the performance of putb8c work anal aoeepwb Milainmeos of thin cbepsor bow bens pnum ed r the contracting atnbaft.- AppNesas Please lilt out the workma' compensation affidavit completely.by checking the boxes that apply to your situation and if r(s)man o(ab ss addr (es)ad pboos number(*)&Ions with thisir cartillcan(s)of necaaary.supply ette.ewteraem_ the Limited an not required eo e�arey�or Litrded Llobt7by Painsurance.Iif an LC r LP der h other than memo members w��. ioaunnca tt w LLC a[LP dos has members or policy i uirrad Be advised that this of ldsvit may be submitted to tbo DePutmmu d htduatial empioyea,•policy nq Aloe be sun to sign sad duce the amdevlL The alfldevit should Accident&fa contlttrtatloa of insuranea coveraga at license is being r uested. sot tba Dapaeamsat of be returned to the city a toarn that the application for the parfait a erg leuluswial A"idsnta. Sbould you have any quaaoos regarding the low or if you ace required to obtain s worker' compenrt call dw at do number lisped below. Self insured eompauies should eater their nceuttaPolies.piston lit number on the lint. Woman IMMEM City air Town OQlelds lei The Dspw m m has provided a spats at for bottom... ptclx be sure that the tofill o is complete and gar fflosnted legibly. the lions. of nits at-fidavit for you to fill out in the ever the OtTke of lnvseiguioas has to contact you regarding an of th s be sure w till is the purmw1kense number which will be used as a reference number. In addition,an applicant is[uhat must submit multiple Pumiulieenas application lo any given year,need only submit one affidavit indicating laity toot policy information(if neeeaury)and under"�Site Address"the applicant should wrim"all locations in_lcity or town)."A copy of tM affidavit that boa been officially statttptttJ or muked by the city or town may be provided to the applicant as proof duct a valid affidavit is on file for Iluur'e permits or licensee. A new affidavit roust be filled out cub year. Where a hate owner or citizen is obtaining a license a pannit tux related to any business or commercial venture (i.e.a dog license or PaInit to bun leaves se.)rid person is NOT required to complete this affidavit. t l'hc Odii.c ul lnvesnigatiun wwuW !us to thank y.w:n :,Jvance for your cooperation and should you have sty questions. ,,:cube Ju rwt hesitate to give us a call. The Department's address. telephone and&a number: Ths Commonwealth of Massachusetts Department of lndustrid Accidents of @ of lavatlpdeme 600 Was11ia6tsa Street 9oston.MA 02111 TeL 0 617-7274900 cut 406 Of 1-977-MASSAFE Fax 0 617-727-7749 i;via;J 3-26-05 wwwmas.6ov/dia _ x The Commonwealth of Massachusetts ,� Board of Building Regulations and Standards I'OR ;( Massachusetts State Building Code. 780 CMR, 7°i edition NIUNIt'll':\Ll ll" Util Building Permit Application To Construct, Repair. Renovate Or Demolish a Reiv:rrd Juneau c One- or Tiro-Fame.v Duelling 008 -,,This-Section For Official Use Only Building Permit tuber: .,11 Date Applied:,�yy Signature: �`'I'• Building Commissioi s eec(e Buildings Date SECTION l: SITE INFORMATION 1.1 Property Ad ress: 1.2 Assessors iblap & Parcel Numbers /�U I.to Is this an accepted street'?yes_ no M❑p Number Parcel Nuinhei 1.3 Zoning Information: 1.4 Property Dimensions: v Zoning District Proposed Use Lot Area(sq to Frontage (li) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L a 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public ❑ Private❑ Zone: _ Outside Flood Zone'? Check ifyes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 O nex ci(Record: Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction �if I Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ i Demolition Accessory Bldg. ❑ Number of Units_ Other Specif Brief Dtescription of Proposed Work': e` 4 tJ 4-el ✓; SECTION 4: ESTIMATED CONSTRUCTION COSTS ' Estimated Costs:item (Labor and Materials) Of tcial Use Only ,[\J I. Building $ ((.Q0 d I. Building Permit Fee: —indicate how fee is determined: r\� 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost' (Item 6) x multiplier x 3. Plumbing $ 1. Other Fees: 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Su ression) $ Total All Fees: Check No. Check Amount: C:uh Amount 6. 'Cotal Project Cost: $ ICE d 0. © a ❑ Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) �J -,z, �C' '7 �,n D O Cl License Number Expiratioale Name ot'C,SL_Balder SJ. (/1/�.uz����.P� List CSL Type(see below) L r6- Jam- > T e Descrinion Odd ss (,(ti _ , , U Unrestricted 1 u to ii.000 CU Pt.l "v`— R Restricted Itic'_ Famil Dwellin_ tgnatury p-.) rt C� _ ��t� M "ALISMResidential O en l RC Residential Ruufin I Coverme Tclepluxte \VS Residential Wind( w and Sidon" SF Residential Suhd Fuel Eunune A)thtmie In1tull;aum D Residential Deutulition 5.2 Re 's ered Home Improvgment Cp�ttractor (11IC) j c Lei ( `, ^ ^��n Registration Number jd � m `Jame or HIC �t rant Nai)q v+f w.� � . ) 31-- (� Expiration Date Signature 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 he building permit. Signed Affidavit Attached'? Yes .......... - No ......""" 13 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN C)—(�l7 v 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 Si nature of Owner SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare I, that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name _ �`J L�� Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of per'u ') NOTES: 1. 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 at 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.R5, respectively. 2. When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) (including garage, finished base ment/attics, decks or porch) Habitable room count Gross living area(Sq. Ft.) Number of fireplaces Number of bedrooms Number of half/baths Number of bathrooms Number of decks/ porches 'Type of heating system Own "Type of coaling system Enclosed —OP en 3. "Total Project Square Footage" may be substituted for "Total Project Cost"