178 WHALERS LN - BUILDING INSPECTION (2) 00
3 0-7 Wo
s The Commonwealth of Massachusetts
4
Board of Building Regulations and StarIONEIV SERVICES CITY OF
Massachusetts State Building C fl, Sq ' 13l jt`�l. SALEM
Revised Mar 2011
OBuilding Permit Application To Construct,Repair,Renovate Or DpnVsbi A
One-or Two-Family Dwel JUL -1 H 1`U�
This Section For Officia Use Only
Building Permit Number: Date pplied:
\� Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
/7B W� cjer5 Lone
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(it)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIPt
2.1 Ownert of'Word:
lt SIC-VA l J-1A I 6i4Yo
Name(Print) City,State,ZIP y
178 U)kwlers LCL -� 978-ygg-y$SS �pr+ oppe�l �to*tias�. 't
No.and Street Telephone E ail Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : Gonva V 3er_�zzi +u IrN-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ G i o00 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard Cityfrown Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 500 2. Other Fees: $
4.Mechanical (HVAC) $ List; (J
5.Mechanical (Fire $
Su ression Told All Fees:$
6.Total Project Cost: $ G g o v Check No. Check Amount: Cash Amount:
t ❑Paid in Full ❑Outstanding Balance Due:
Vn fa t LE'O Tt::> l ( c7 —1 l )o
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) cs- 103250 Zy
EuJe,e fY e 7 f License Number Expiration ate
Name of CS Holder L )
List CSL Type(see below) t/
tql gyA4� r S4 .
No.and Street Type Description
5eAt 1 M P J,y1 O U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) j7��fo j /I 6 ?o t 5
i I
t J lr.a N HIC Registration Number Expiration Date
HIC Comp. Name or HIC Registrant Name
S�nr�ye.ito vC4'tbY'+S
No. Street Email address
City/Town,State,ZIP 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 BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by t is building permit application.
Va-.1 cOY-a 1� 7.17115
Print Owner's Nam lectronic Signature) Date
SECTION 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.
Gt eY R �v�y -7 tg
Print O er's or AuthorizedAgent's Name(Electronic Signature) Date
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 arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
wM1vw:mass.aov,'oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
I
QTY OF SALEA MASSAQHUSEM
BLIILDINGDEPARTMENT
120 WASHNGTONSTREET,3' R .00R
7tL(978)745-9595
F
KIlvIBERLEYDRISODLL FAX(978)740.9846
MAYOR THomm STYiERRE
DIRECT'OROFPUBIXPROPERTY/BUMDINGMM MSIOMR
Construction Debris Disposal Affidavit
(required for all demolition and renovation work
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of ha ler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Sign ture of applicant
ate
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston,AM 02114-2017
www mass.gov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNIfITING AUTHORITY.
Applicant Information Please Print Le 'bl
Name(Business/Organization/In
dividual): < ^ ✓�
Address:
City/State/Zip: sa(evi, Phone M p 1 7 U
Are you an employer?Check the appropriate box: Type of project(required):
1.❑1 am a employer with employees(full and/orpart-time).• 7. ❑New construction
2.[gl'am asole proprietor or partnership and have no employees wonting Tor me in g. Remodeling
any capacity.[No workers'bomp.insurance required]
9. Demolition
In I am a homeowner doing all work myself.[No workers'comp.insurance required.)t
- ❑
10❑Building addition.
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.=
6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.)
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation polity information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such.
iContractus that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jobsite
information.
Insurance Company Name: _,(,,c_A
Policy#or Self-ins.Lic.M Expiration Date: 6 S / (O
Job Site Address: 10, W �Qh lam^c City/State/Zip: S+�e� ��1/� o14 7c-'>
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGI.c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certiyffy�under the pains and penalties ofperjury that the information provided above is true and correct
Sign ature: t^ i— 41-me Date'
Phone#: A0
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee 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 legal 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,partnership,association or other legal entity,employing employees. However the
owner 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 employment be deemed to he an employer."
MGL chapter 152,§25C(6)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."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth 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 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 their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members 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 fill in the permit/license 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 filled 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-7274900 ext. 7406 or 1-877-NMSSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Massachusetts -Department of Public Saf
Board of Buiidi.9 . 9
Re ularvbons �,hd$t�ndard<
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Construction Supervisor :
License: CS-103296
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41 BUTLER ST '"
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Salem MA 01970;
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�r Commissioner 01/29M17