57 WHARF ST - BUILDING INSPECTION (6) < ' " " INCrry
J -- 1
APYLICA'CION FOR PLAN EXAMINATION AND BUILD ING NG PEIZMI"f
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELL_/NGS
IMPORTAN9':Applicants must complete all items on this page i
SITE INFORM /;", 1 _
I.ocation Name (/ Building j
Property Address
Map# —
Located in: Conservation Area YtN Historic district YiN
l6/-2
Use Groups
(check one)
Residential(3 or more knits) R2 x
Type of improvement Residential(hotel/motel RI _
(check one) Assembly(churches) AI _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants, recreation) A3_
Alteration Business B
Repair/Replacement Educational E_
Demolition_ Factory(moderate hazard) Ft _
Mube/Relocate Factory(low hazard) F2_
Foundation Only � High Hazard II_
Accessory Building Institutional (residential care) 11 _
Other(describe) Institutional (incapacitated) 12_
Institutional(restrained) 13
r. Mercantile .M_
Storage(moderate hazard) S I _
Storage(low hazard) S2_
OWNERSIIIP INI-ORMATION(Ple a or Print Clearly)
OWNER Name
Address 1�
Telephone �C
I SCR TION OF WORK'1'0 BE PERFORMED
L
ESTIMA"1'EED CONSTRUCTION COST
D �
CONTRACTOR INFORMATION
Name
Address
Telephone
Construction Supervisor's Lic #
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is true to the best
of my knowledge under the penalties of perjury
Signed
Date
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Avo-Family Divelling Ext 118
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
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 R) Frontage(fit)
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? Municipal ❑ On site disposal system ❑
Check if yes13
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) - Addressfor Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(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':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) I p Z 1 L I
t�l„ 1,.�,a `��f, k�}-} Licenss'e Number Expir Lion ate
Name of CSL- Holder List CSL Type(see below)
Ad Type Description
Aclo�
U Unrestricted(up to 35,000 Cu. FL)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
�°'J\ Q) RC Residential Roofing Coverin
Telephone Residential Window and Sidin L'cxmns�•cl
�s�..�•0�1- !a,tc:xn0— SF Residential Solid Fuel Bumin Appliance installation ,
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or I-HC Registrant Name Registration Number
Address
Expiration Date
S'igrtalure -- Te:epttone
SECTION 6: WORKERS'CeNIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Woruen("ompensation Insurance affidavit must bo completed and submitted with this application. Failure to provide
this affidavirvill result in the denial of the Issuance of the building permit.
Signe:l Affidavit Attached'? Yes .......... G No ........... ❑
SECTION7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subiect property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building.permit application.
S_iignawre of Owner Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Prim Name �—
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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)Prograrn),will not have access to the arbitratiun
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CN 1R Regulations 1 I O.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. FL) 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"
CITY OF SALL M f
PUBLIC PROPRERTY
} I4
DEPARTivIENT
lyM V.
Construction Debris Disposal Affidavit
(rcyuired Il)r all demolition auJ tenor:uiun.tcurk)
In accordance t%ilh the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of NIGL c 40, S 54;
t is issued with the condition that the debris resulting
Building Permit from
this work shall he disposed of in a property licensed waste disposal facility as defined by MCiL c
111, S 150A.
The debris will be transported by: `
1 name ut hauler)
I he debris will be disposed of in
luamr ul lauhty) I''
taJJres. ur l,lcJny'1 I
'lullatulc of penult .gtpl scant
,late
Information and Instructions
.%I:iss.ichuseus General Laws chapter I i2 requires all employees to provide workers' compensation for their employees.
Pur.u.mt to this astute, an employee is defined as"...every person in the service of another under any contract of hire,
e\press or Implied. oral or written."
An employer is defined as"an individual, partnership, .ssociatiou, corporation or other legal entity, or any two or more
,it the K,reeomg engaged in a joint enterprise, and including the legal representatives of a deceased cnmplu)cr, or the
recetmer or trustee ul or individual, patunership,association or other legal cnnty,employing emplo)ees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwclluig huuse of another who employs persons to do maintenance,construction or repair work on such dwelling house
01,011 The rounds 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 withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant motto has not produced acceptable evidence of compliance with the insurance coverage required."
Additiunally, :vIGL chapter 152, 4. 25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perforiance ufpuhlic work until acceptable evidence ci compliance with the insurance .
requirements of this chapter have been presented to the contracting authority."
Applicants
Phase rill out the workers' compensation affidavit completely,by checking die 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 dale the affidavit. The affidavit should
be inured to the city or town that the application for the permit or license is being requested, not the Department of
I ndustrial 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 he 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 nut in the event the Office of Investigations has to contact you regarding the applicant.
111;ase be sure to till in the pcnnit/license number which will be used as a reference number. In addition,an applicant
That must submit multiple penmitdicense 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 far 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. it dug license or permit to but leaves cic.)said person is NOT required to complete this affidavit.
I ts.; t)t6Kc of Io�Ysti.atiuns mWuld line to think )ou in advance for your cooperation and should you have :my questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OQice of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
aa:.,ad -'n-us www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
-.' DEPARTMENT
al%•.t to I1� vVnst u.�au alb 51:1 LL 1' • Sxa s+,MA�1.%a.III it I IS, 107_�
77.t. )78.7$3.9393 • f%s 979-74"'1846
Workers' Compensation Insurance :%fftdavit: Builders/Contractors/Electricians/Plumbers
t llicant Information Please Print Le ill/y/o
OG/�� Q-�f�� V J L/ L
V 81n1: l 0u,ulcvy I)rgaln r:uinn!I ndtvdual l:
Address:
-3 Srf
(.ilyr State,Zip:
Arc you an employer:' Check the appropriate box: Type of project (required):
1.❑ i :un a employer with 4. ❑ 1 ;un a general contractor and 1 6. ❑ New construction
employees(lull and,'ur part-tittle).• have hired the sub-contractors 7. ❑ RtmoJeling
2.❑ 1 am a sole pmpricuv or Banner- listed on the attached sheet.
ship and have pr etor or parucs These sub-contractors have 8. ❑ Demolition
working Air me in any capacity. worker' comp. Insurance• q, ❑ Building addition
No workers' coin 5. ❑ We are a corporation and its
P insurance officers I+avc exercised their 10.0 Electrical repairs or additions
I rcquircd.J
ri ht of excm tine per MGL I I.❑ Plumbing repairs or additions
3.❑ 1 ❑ni a homeowner doing all work c�152, §1(4),and w have no
inyscif. tKo workers' comp. f12.❑ Ruol'npairs
insurance requlred.J 1 cinployees. [No workers' 13.❑ Other
comp. in.wrance required.)
•Am ..pplaalll Ibul checks box BI must also lill out the WCaml Iwluw awing their workai cumpenaniw+juicily mlirrrn lion
' I htmuuwnen who sut+nul this aflidavil indicnling Ihcy.see Juinel all work mid lien hire"I%ide"uriulors must submit anew at'fdavil indiubng.u:h.
-C'emra wet%Ihul thcck this box mime neeaahed an adduiunal.dawt%huwiug the Willie of Ilse:sub<oneraceors and rhea wurken'camp.policy Infurmamue.
little un rrup(uyer that i.v providing workers'c•umpenrruion iet.rurituce jar rely entplayecs. Beetrov is die pu/icy and fob silt
.. inforinutiun. d-e,v` /�✓+ b-` //� — � S.
InILIMICe Campauy Name: r'�-`/J� `
t2 Zp 3 Expiration Date:_
Polley a ur Sclf-ins. Lic. N /�.,p. ---
Job ',ice -address: �UJ/ A `('�
Attach it copy,of the workers' compensation policy declaration page(showing the policy ntuuber and cspiratiun date).
Failure to.secure coverage as required under Scraiun '_5A ul'>IOL c. 152 can lead to the imposition of criminal penalties of 3
tine up ere 51.500.00 and/or une•)ear imprisonment, as %cell as civil penalties in the loran of a STOP WORK ORDER and a fine
of up ill 5250.n0 it J.ly against the violator. lic advised that a copy of this 5l ulcment may be lures arJeJ to the 011ice uC
Im.,m,.tuuns ut the DIA :or into ircc arvcrage %crilieacon.
/do hervhy t crtifv nude[the p,tins❑nd penaltiev of perjury shut the infurinutlon provided uboce is true unel correct.
Dttg:------
I'h r • 'r
Of idol nst wily. DO not write in this arcu, to he cwup/eted by city ur tolvn a/Jic'iol.
('ity or 1'nwn' _-_. __ Pcrmirll.icenxc�.
Issuing Aulhurily (circle one):
I. Iloard of llr:dlil Z. Iluddin(; Dcl)artincnt .i. City.Ioi%n C•Ierle. 4. L•'Iccirical Inspector 5• Plumbing Inspector
6. Other ..
Contact VVr1un; .. -_ Phone 0: