3 WHITE ST - BUILDING INSPECTION (2) -7
`i The Commonwealth of Massachti"s*VEC"T O AL 4; CITY.OF
a Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,7
�_ 15mb 13 P Ir IFFevised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
I - This Section For Official Use Only -
.� Building Permit Number: Date Ap d:
Aw
n(� Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
3 W41TF _.S4LLM MA 00-10
L l a Is this an accepted street?yes 1/ no Map 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:
F1pWAAD A. MAcDoNALU SALCM MA O 9 -7 v
Name(Print) City,State,ZIP
J 14I-11TE S-r
No.and Street Telephone - Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
BriefDescriptionof Proposed WorkZ:CM?)EWT ,y XERAIR �R � AeZ WIN®O&V
.RrM FL Si-iIN6
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:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ �� � �
4.Mechanical (I-IVAC) $ List: 67xeS I
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 8. OQo. ❑Paid in Full ❑Outstanding Balance Due:
°r M A,l
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) c 4.3
tor• Z 2o17
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) [l
To. Street / // !` -.... .CyPe ", " Description .
M A f0 9�s Unrestricted(Buildings u el ing cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
p,tTA tcK c>- o5G v-DG0^'`NAA1O SF Solid Fuel Burning Appliances
�/�8• '7�Q. 100� Oz1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /3*7-1 0 /a fz Z p/
0SGOOD P,4,A/j[MC :5ZAVI4n(=' 5 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
*+ AX lQuN RaA0
No.and Street Email address
T'oPSFrELD MA o /�Ir?3 978.?Ho- loo7 p�rQlc
City/Town,State,ZIP Telephone K oS o GoocoMOANlE , caNi
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT
(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must completed and p t be p 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 ..........O No...........O
o 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 RA %A t cX o.S G ta0/]
to act on my behalf,in all matters relative to work authorized by this building permit application.
b w 0 61 , ! �
Print Owner's Name(Electronic Signature) ate
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my na a w, I hereby attest under the pains and penalties of pequry that all of the information
contained in thi ipli time ' to and accurate to the best of my knowledge and understanding.
Print Owner's r Authorized Agent's Name(Ele-07inic Signature)n/I T/ll ac Q.5,60:MD 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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
lu; �. orrice or Consumer Affairs& Business Regulation
ost:; q __;.,;HOME IMPROVEMENT CONTRACTOR
- , ,?Registration: 134220 Type:
.. A, „Expiration: 10/12/2017 DBA
T:r�r>
OSGOOD PAINTING SERVICES
PATRICK OSGOOD
pj 44 FOX RUN RD.
TOPSFIELD, MA 01983 ---
Undersecretary
Massachusetts Department Of Public Safety
-� Board of Building Regulations and Standards
License CS-091643
Construction Supervisor
R
PATRICK M OSGOOD
POSOX till
MARBLEHEAD MA 01945
Expiration
COfnmisstoner 0512812017
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibl(y
Name (Business/Orgmization/Individual): �SGool PAkCrg4G A,1,, CQN1WAC�11VG-- S,�VICZ5
Address: P O. 6oX i/ 11
Ci /State/Zi 004�
ty P: M/ �H A0 A1,y Phone#: �7� O— /UD
Are you an employer?Check the appropriate box: Type of project(required):
1.L I am a employer with 'Z O 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' g Building[No workers'comp.insurance comp. insurance.: ❑ g addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions
myself-[No workers'comp, right of exemption per MGL
12.❑Roof repairs
insurance p
required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.Eabthev'F Am
comp.insurance required] Wwoolo rg,n M— oZpinlCr
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors 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 sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_..A :pn M tfT yA L l N SU M14 Cie
Policy#or Self-ins. Lie.#: V_MG_ 100• t O( N01 •-Z O1 5 A Expiration Date: O Z 6
Job Site Address: �7 W rT S% City/State/Zip: .SA4E M MA o/ 476
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as ell as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advise that a copy of this statement may be forwarded to the Office of
Investigations of the D1A for i ranee coverage ver cation.
I'do hereby certify under a. a allies jperjuiy that the iiiforniation provided above is true and correct
Signature: AN Date: b v t
Phone#: 9 it 4- O- 1 00
Of
cial use only. Do no[write in this area,to be completed by city or town oJrcial
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#:
s
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 ajoint enterprise,and including the legal representatives of a deceased employer,or,the
receiver or trustee of an individual,partnership,association or tather 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 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 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any 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
Office of Investigations
600 Washington Street
Boston MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax# 617-727-7749
www.mass.gov/dia