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10 WHEATLAND ST - BUILDING INSPECTION (3) y� The Commonwealth of Massachusetts ' Board of Building Regulations and Standards CITY, Massachusetts State Building Code, 780 CMR, 7`h edition OF SALEM Revised January Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling ' - This Section For Official Use Only Building.PennitNumb Date Applied: Signature:. s+ -Building Commissioner/ rispector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers [() Guhea �l�nd Sh. I.la Is this an accepted street?yes ✓ no Mar Number Parcel Number -1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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 yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: L/ Name(Pr' t) Address for Service: 9.)rr- 7y1/ �So6 Signs[ Telephone .SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building 01 Owner-Occupied Repairs(s) Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work: vn a 1— a t IN ?✓� i1QuJ ���c.MCr COYn ffr5r— r5+__�I^L . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1. Building $ p?a 00 1 " 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ��0 _ ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6).xmultiplier x 3.Plumbing $ 3 tV 00, — 2. Other Fees: $ 4.Mechanical (HVAC) $ List: / 5. Mechanical (Fire $ Suppression) Total All-Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ a6 soo 0 Paid in Full. 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) y g. 1�7 q C-t-P% re b.- License Number Expiration Date Name of CSL-Hol er 6[ Pp 2 du se Rat S'/ List CSL Type(see below) Address Tye Description U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Sign �S_s6 M !Masonry Only `l�Fj 3 s6- RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Imp�trovement Contractor(HIC) `y s L,/ 7 Cra ' Kob-- �, 1 J HIC Comp,any Na e or H[C Re rstrant Name Registration Number 61 Ya�y�Q•-5p Yh. 1'7� a /ao 3 Address _ 729,-3s 6- e SS6 Expiration Date Si re 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, 4r1 9) 41 rrf o— , as Owner of the subject property hereby authorize Cror4 S ip to act on my behalf, in all matters relativ to work authorized by this building permit application. Si atu f Owner Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION I, Crti q RD bSo ,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. r Print Name® / I ' Sigr re weer or nze'a 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)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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,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.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" CITY OF S:IIE. I, .ILNSSACHLSETTS BL'iwLNG DEPARTMENT ' 1'_0 WASHL`IGTON STREET, 3'n FLOOR TEL (978) 745-9595 F.tir(978) 740-9846 U�[BF1tLEY DRISCOI� TioblASSTTIERRB, yL►YOR DIRECTOR OF PUBLIC PROPERTY/BuaDING CON0.115SIONER Workers' Compensation Insurance Aflidavit: Builders/Contractors/Electricians/PIurnben A t licant Information //''' rt^�� ( Please Print Legibly owS Naina IBusi &OrgantrmionrIndidividual): C 1\bG ) 0 Address: 6 ( (6 r d dSC� IL p of City/Statc/Zip:•-D5W)4, t l"/ D193� Phone N: a — s 6' 92 1�6 Are you an employer?Check the appropriate box: "Type of project(required): 1.©'ram a employer with 1 4. ❑ I am s general contractor and 1 6. ❑New constnxtion employees(full and/or part-time)." have hired the sub-contractors ❑ Remodeling 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1.ship and have no employees These sub-contractors have V. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition No workers'cam insurance 5. ❑ We are a corporation and its( p• 10.❑ Electrical repair or additions required.) - officers have exercised their right of exemption r MGL I I.❑ Plumbing repuirs or additions }.❑ 1 ys a homeowner doing all work c 6152, 1(4),and we have no myself.(\o worker'camp. $ 12.❑ Roof repairs insurance required.)r employees. [No workers' 13.❑ Other comp.insurance required.) -Any applicant Jut dtaW has el mud/also all out the sectim below showing thou wwkrai compemmion Policy mtonnation. 'I Lstwowttts who,ubmit this affidavit indicating they an;doing all work and that hire outride contractara most Mania a new afF avit indicating Such =(,ommctors that chvsk this bon must anxhd an addidund shael showing the name of the Ads<001`34301111 and their wutketa'camp.policy information. l um an employer that is providing workers'compensadion brsarence for my employees. Below/s the policy and Job.rite itrjarmatfon. - 1 Insurance Company Name: ^>r —�•�r `'� -- Policy q orSelf-im. Lie.ti: �DD S II�C7 g S Expiration Dote: O lob Site Address: � (�� �� d S F. City/State/Zip: SAP✓n �/7`n a� %ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tinc up to SI,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of - Investigations al the DIA fur insurance coverage verification. I da hereby certify under she pains and penaides ajperJury drat the hilarmurion provided above is true and correct 6 / Phone 4 OJJicfal use only. Do not write in this urea,robe cunrplired by city ur town )JJ/aluL City or Town: __, Pcfmlt/LIccnseN_._..__. ...____ ._— lasuing,ituthority(circle one): - 1. Board of health Z.Building Department 3.Cily/ruwn Clerk 4. Electrical Inspector 5. Plumbing; Inspector - 6.Other Contact Person: _ _.. . _ Phone to: i Information and Instructions %f.usachuscus General Laws chapter 152 acquires all employers to provide workers' compensation for their employees. Pursuaru to tins latule, an rn.plurrer is dclined as"._every pet sort in the service of another under any contract of hire. :.press or implied,oral or written." An employer is defined as"an individual, partnership,.association,corporation or other legal entity, or any Iwo or more -t this IOreguu,g engaged in a joint enterprise•and including the legal representatives of a deceased employer,or the i ccmvcr or trustee uf.ut individual,pwmershtp,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 maintenunce,construction or repair work on such dwelling house or on the 3rounda or building appurtenant thereto shall not because of such employment be deemed to be an employer." NIGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or renewal of a license air permit to operate a business or to construct buildings in the commonwealth for any applicant "lie has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally. NIGL chapter 152, a25C(7)states"Neither the commonwealth not 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 till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) namc(s),address(es)and phone number(s)along with their certifhcatc(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 inay,be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and dale the•aff1davit. The atfldavit should he rctumed 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 ap)ropriate:line. City or Town Officials Please he sure that the affidavit is complete and printed legibly. 'rho Department has provided u space ut the bottom Of time affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permitilicense number which will be used as a reference number. In addition,an applicant That meat submit multiple pennidlicense 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 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. it dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.- I he e)tficc of Investigations would like to Thank you in advance for your cooperation and should you have:my questions, please du nut hesitate to give us a call. the Deparnncnt's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents O18ce of Iavestigadons 600 Washington Street Boston, MA 02111 Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY,�NSURANQC:pQ61Y ,INFORMATION,PAGE :. :. ♦ i f AGENT NO 3590 OFFICE NO 3690 MICHAEL'A EMOND 857 .TURNPIKE ST- /:•,;i9; NORTH ANDOVER MA 01845-6140 FARM FAMILY CASUALTY INSURANCE COMPANY 978-208-4713 NCCI COMPANY NO. 16727 POLICY No 2005W6805 INSURED AND MAILING ADDRESS: RENEWAL OF NO. 200SW6805 EFFECTIVE 2/02/11 - CRAIG J ROBSON - -' 61 PARADISE RD - IPSWICH, MA 01938-1258 THE INSURED IS ,:INDIVIDUAL ! Workplaces covered.by this policy: INTRASTATE No. RTG.BUR NO. - ST WP NO. ADDRESS OF WORKPLACE -. MA 01 61 PARADISE RD 475436 - IPSWICH MA ..... ItEM NMI ::. The policy.pe riod is from 2/02/11to 2/02/12 12:01 A.M. Standard Time at the uvsured's.'•mailing address y A. Workers Compensation,Insurance• Part One of the policy applies to the. Workers Compensation Law of the state..listed here: MA B. Employers'Liability. Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury By Disease Bodily Injury By Accident Bodily Injury By Disease ' $ 500,000 each accident .-:. $ 600,000 policy limit $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the tasd, ifanyHlisAted haerna states except the states designated in item 3.A. of the information pageO VVY D. This policy includes these endorsements and schedules: WC 00 00 OOA WC 00 00 07• : WC 00 03 15 r WC 00 04?14 WC 00 04 22A WC 20 03 01 WC 20 03 02A WC 20 03 03D WC 20 04 05 WC 20 06 01A INSURED COPY PROCESSED 12/29/10 Copyright 1937 National Council an comps tion inamaam WC 00 00 01 Isauina Office - PO Box 656 9 ALBANY, NEW YORK 12201-0656 , tJ an usiness Regulation Office of ConlAf airs o Park Plaza —Suite 5170 Boston, Massa setts 02116 r for Registration Home Improvement 4 .. � Registration'. 145438- --= = Type'. individual Tr# 20751E Expiratiom 112712013 CRAIG J. ROBSON CRAIG ROBSON s - 61 PARADISE RD A IPSWICI I, MA 01938 yy Q �W Update Address and return E Mark e reason t Card ` Address 0 Renewal DPS-CAI O 50M-11a4-G101216 _ .. .. of Public safet) Massachusetts DcR`�uI ttiruns and Standards Board . Bw.t. ervisor License CQnstitl0tfc n;Sup ' 44icense:.GS $tricted,14 q� i� p k CRAIG J fOBSONIh -1 n• p1 PARADI IPSWICH MO?9�y8 Expiration: 911412011 Tr#' 2394 Cmumiyylmir}I' . .. '