13 WILLIAMS ST - BUILDING INSPECTION (3) i- The Cbmnwntveallh of Massachusetts
hoard of Building Regulations and Standards Cull' OF
I\ Y ��•r;, Massachusetts State Building Code, 780 CMR SALLAI
v Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Two-Fanrih• Dive/ling
This Section For Olrcial Use Only
Building Permit Number: _ Date Applied: _
Lf,-� � � r
Building Olticial(Print Mane) Silfflaurre Dmc
SECTION I:SITE INFORMATION
L I Pro erty AJdresr. 1.2 Assefson"lap& Parcel Numbers
%
I,Ira this an accepted street?yes no Map Number Parcel Number
$5jj
Information: I.d Property Dimensions:
t Proposed tJsa Lot Arco Isq It) Frontage(Il)
g Setbacks(R)
Front Yard Side Yards
Rear Yard
Provided Required Provided Required Provided
pply:(M.G.L c.q0,§Sy) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑ Zone: _ Outside Flood Zone? Munici al❑ On site disposals)Chock;e —M P posalsystem ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record-
PIA `
N;unc(Print) City.Slate,ZIP
/ 1 sr yjcf
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Cl I Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Aheralion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Specify:
Brief o[Proposed Wor ZP7 er S C , i^-
SECTION J: ESTIMATED CONSTRUCTION COSTS
lent Estimated Costs:
(Labof;Ind .\laterials) Offlcial Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'• Electrical S ❑Standard CityrTown Application Fee
❑Total Project Cost'(item 6)x multiplier _.. x
J. I'lumhing S 2 - ---
_. Other Fees: S
q. \Icchonical III AC) S List:
9 Mechanical (Fire S ---------- .—— —
tiu+ncssion) Toms kii Fees: S_
Cluek `o. ('heck Amount: Cash \nunuu:
a. Total P l
Project Cost: S // / 1 — - -.._B._al:..
(O / a �Q ❑ Paid in Ful ❑OulsrmJing mce Doc
ti y s T,- TC w k CANS 2,1,-
SECTION S: C'ONSI'RticrION SERVICES
5.1 C'onstruction Supervisor License(C'SL)
Li&nsc Norther r\plranon I)nl
' Name ol'l'SI. I folder AA ,,
I is[CSI. I')pelsecbelowl
a
���- ------------------ ----------- Description
MI—ind.Street r
U J I Unrestricted(Buildings ti0 u)35,000 kit. 11.)
�y��/ Re'treted 1r2 rumil MWIlin
C'i lcirown.St:uc.LIY .--_— -- bl Masonry
RC Rtxllill 'merinit
(I� / / u µ'S N'indo%v wdSidin
Sle Soli)Fuel Ilurning Appliances
I I Insulation
1'ele bona ('.mail address D f Demolition
5.2 Registered Home Improvement Contractor(HIC) /6 -f 3 6/
,q2 /,- I CMG
G G1tr� 6/ V � IIIC'Registration Numiwr Fsl teal tin Uatu
IIIC Co 1 my� N;unefir or I IIC Itcgistrunt f�amk 0 n 7��
No. wl treet 6/ 7 S Alf /OW Email address
vr� l� rn/j 01515
City/Town.State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 25C(6))
Worker 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...........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 IPZf le //;�- (' d n 1�) �7
to act on my behalf,in all matten relative to work authorized by this building permit application.
G7
yr >>
Print Owner's None(Electronic 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 applicatio is true and accurate to the best of my knowledge and understanding.
/ 2 5 /
Print Owne s ur: t xlrireJ Agent's Nunle 11 1cclnnue Signature) Du
NOTES:
I. An Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program).will1 have access to the arbitration
program or guaranty fund under NI.G.L.c. IJ?A.Other important information on the HIC Program can be found at
m.n, t y,l Information on the Construction Supervisor License can be found at tt>r+t.nl.l.: Sos -Ills.
2. 11'hen substantial work is planned,pros ide the information below:
Total floor area(sq. ft.) - I including garage, finished bascmcnCattics,decks or porclu
. Grosi lie ing area I sq. tl.l _ __-- _- habitable room count
\'tnuhcr of lircplaces_ -- Number of bedrooms
\umber of hathrooms _ _ \umber of half hullo
I%pe of heating s)stem .. . - Number of decks- porches . . .
I\pe UI iJ++hllg it i1Cl11 I'llcl++sad Open
I
t. '•f,ual Project Square rooclge-maN he substituted Ibr"1-otal Project C'oit-
CITY OF S.I ZNf, ttiLkSS.1CFj L:S ETTS
9LLLDLNG DEP.IRT iLsr
110 W.uHCVGTON STN'M", J A FtOOIt
Ill. (978) 741-959S
KMISEALEY DRISCOLL FAX(978) 740.9W
.tiUYOIt TI{O.SW ST.PfERRt;
DIRECTOR OP PLBLlc PROPERTY/9(:aMLNG C0.101ISSIOV Ell
Construction Debris Disposal Attldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I l I.S
Debris, and the provisions of MOL a A S 54;
Building Permit M is issued with the condition that the debris resulting from
ibis work shall be disposed of in a properly licensed waste disposal facility as defined by MOL c
111, S I SOA.
The debris will be transported by:
/C4nagrne
of haular)
The debris will be disposed
ofin :
P= _Sro S /f
(name of racily)
(iddress of fjciluy)
U
nature ofpermrt Jpplicint
' hrrvA!.�
CITY OF SMu E.Ms IL ss,. CHUSETTS
13UILDNG DEPARTMENT
120 WASH(INGTON STREET, 3'°FLOOR
�`t&�xalrn T)EL (97b) 74s-9595
FAX(973) 740-9844
KINIBFALEY DRISCOLL
INLAYOR THO6tAs ST.PlEma
DIRECTOR OF PCBLIC PROPERTY/BCIIDING COSMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please P�rtfnt Le ibl
Muni: tilusiiws&orpnniratiomind/ivvidual): 11Ae A- DNS /
Address:
City/State/Zip: � 104 O/M Phone N 4of/ 7
Are ya employer?Check the appropriate box: 'type of project(required):
I. I am a employer with_�_ 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hind the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attachcd.shect. t 7• ❑ Remodeling
ship and have no employees These sub-contractors have V. ❑ Demolition
working liar me in any capacity. workers'comp.insurance. 9, ❑ Building addition
(No worker)comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repuirs or additions
myself. (No workers'comp. - C. 152,41(4),and we have no 12,❑ Roof repairs
insurance required.)t employees. (No workers' 1).(�Other
comp,insurance required.)
;My upplirmr out vbLvka bax.rl mtur situ fill out the uctim bulow showins choir wwken'comrenndun puli y mr mention.
I tu,nuuwm"who wbmit this airdavit indicaina they an dains all work and then him outride contmcmn mull submit a new amdavii indio.ina such.
$onnxten Ihut shack ibis box mull anachoet an Adoiu,wl.heat shuwina the name of the aub.cumruWn and Ihelr workers'wrap.ptliey infamution.
/urn oar employer that Is providing worker'conspensatlon insurance jar my eaasployees. Below lr die policy and Job site
information.
insurance Company Name:
Policy 4 or Sclf-ins. Liu. d: - 7_1/, _ 3 Expiration Date:
Job Site Address: Z ? e\),
- 4 t 1 n G"t City/State/tip: S4/r'-+-r `?A Q '
.Vlach a copy of the workers'compensation policy declaration pigs(showing the policy number and expiration data).
Failuru to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500,00 and/or one-year imprisonment.as well as civil penalties in the form of STOP WORK ORDER and a line
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be furwardcd to the Office or
Invrstigatiuns of the DIA for insurance coverage verification.
/du hereby certify under the adlits an it pen r of per' that the bilonnatlmr providedd abuve b uue and correct
i
iO(/icial use only. Al"Of virile is this area,to be completed by city or town a/Jir1ul
City nr'I'own: __ Permit/I.Iccnsc.4
luuing Aulhurity (circle one):
i
1. llourd of Ilcallh IIluildim�Department .i.Cily/fnwn Clerk 4. Electrical Inspector 5. Plumbing Inipeetar
6.Other -- --- __
Contact Person: _ _ Thane;t: _._____
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 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 an 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 numbers)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. Sclf-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 rill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to till in the permittlicense 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"lob Site Address"the applicant should write"ail 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 aftidavit 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 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
Fax#617-727-7749
Rev.scd 5-26-05
www.mass.gov/dia
a
01 1 CITY OF SALEM, MASSACHUSET°TS
� -� _ ;Ita
BUILDING DEPARTMENT
sq_ 120 WASHINGTON STREET, 3AD FLOOR
TEL: 978-745-9595
FAx:978-740-9846
KIMBERLEY DRISCOLL
MAYOR
THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUILDING CONMSSIONER
December 8, 2011
NSCAP
RE: 18 Williams Street
To Whom It May Concern,
This office has reviewed and accepted a permit application for the property at 18 Williams
Street, Salem, Massachusetts (See attached). Due to time frame required to create the permanent
Permit Card, this letter shall serve as documentation for the Contractor, Bay State WX &
Construction LLC to begin the work stated in the permit submitted.
Thank you in advance for your cooperation. If you have any question please feel free to contact
the Building Inspector's Office.
Respectfully,
Michael E. Lutrzykowski
Assistant building Inspector
Cc: file
t