8 WILLOW AVE - BUILDING INSPECTION $ l ► 2- C 12
,} `f The Commonwealth of Massachusetts
Board of Building Regulations and Standar sCEIVED SALEM
CITY OF
Q �
Massachusetts State Building Codel W�r H� i h.,41. SERVICES Revised Mar 20I1
Building Permit Application To Construct,Repair,Renovate Or Demolish a
`.n One-or Two-Family Dwellin 15 or
LrQ This Section For Official Use Only
Building Permit Number: Date Applie
//
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
(� 1.1 Pro erty Addr5ss 1.2 Assessors Map&Parcel Numbers
'��o 3 /-'Jt
'— 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 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofR cord: D /
F (iZc_ , _ . N��ni iLJ 470
Name(Print) City,State,ZIP
918-4F2-3S(--7 Ytl ��r ��t'.co
No.and Street Telephone - Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑TEAZg Building fl� Owner-Occupied ffl Repairs(s) arl Aheration(s) ❑ I Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Z 1 Other ❑ Specify:
Bnef Descri tionof Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ yv00, 0 0 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ 7D00.00 ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $,S0co•O o 2. Other Fees: $
4.Mechanical (HVAC) $ List: (,
5.Mechanical we $
Suppression) Total All Fees:$
6.Total Project Cost: $ /.6,
000, d 0 Check No. Check Amount: Cash Amount:
❑paid in Full ❑Outstanding Balance Due:
dz� 6 wll�
SECTIONS: CONSTRUCTION SERVICES
{ 5.1 Construction Supervisor License(CSL)
CS-0576b1 S/-3o/Zo/7
C0✓t✓tp v S License Number Expiration Date
Name of CSL Holder
Z I t_Ta C1 Lis[CSL Type(see below) U
No.and Street �(��
Ty Description
Unrestricted(Buildings up to 35,000 cu.R-
b R Restricted l&2 Family Dwelling
City/Town,State, M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 ReWstered Home improvement Contractor C
P.�r c1C Con�ipr5 Cc ('� ul-r7 A wacx�/k 17&4 2/ 2�/
HIC Registration Number Expiration Date
HIC piny Namepr HI Registrant Name (�
c ✓` _0r1VJ0rS 1'CC�nvtovSdS3O ycvtLo , vl�
No.and Street 1S 1�fDGNL, V� Email address
4�[G�O
city/Town,State ZIP * v Tele hone 1 tf- 5ST`f ZS F
SECTION 6:WORKERS' C MPENSATION 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 p
Signed Affidavit Attached? Yes .......... ❑ No...........
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR AP
YLIES WR BUMMING PERMIT
I,as Owner of the subject property,hereby authorize
to act o�my half all ers relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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 at3M3y.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 haWbaths
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 Cosf'
.f
tl
Massachusetts-Department of Public Safety
Board of Building Regulations and Standsrds
—
Cnnstructior.SUPOI-"Snr
License: CS-057661
PATRICK J CONNURI
ISDANARD
PEAgODY MAFxPiration
61
r r
0513012017
Commissioner
Fully Insured Residential
Comme rdal
o` N11�OIs
�LO
Carpentry & Remodeling
Pal Connors
CS Lick 057661 978-854-2598
HIC Lic#176428 PConnors0530@vedzon.net
,A �ie tpoanimonueall/c a C��'�r
�\ Office of Consumer Affairs&Business Regulati�a onaP��
MEIMP.ROVEMENT CONTRACTOR
egistrahon: t$6 j28 Type:
r Viration. _86f2077_a DBA
i PATRICK CONNOR§ "�
- _ RPI�REMODELING
PATRICK CONNDRSs'• -'£ i I%
q
+; 15 DANA RD
- PEABODY,MA 01960 �
I Undersecretary
`+ CITY OF SALEA MASSACHUSEM
Buamw DEPAmmwr
120 TA9MC7MSMtEET,rF"A
UL(978)745-9595.
FAX(978)740.9846
KDde IEYDRISOOLL
MAYOR THC MAS ST.PE=
D.UtECrCOtOPPUBUCPROPER7Y/BtmDMOUMMMOI EU
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 g 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 hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information P - ph f/ Please Print Le11ibIv
Name(Bwmi s/Organintion/lndividual): IcL(r ctic L0400 -4 Cc.Pyis
Address: 1 ri P it h r~ R d
City/state/Zip: `► 019 d D Phone M
Are you an employer?Check the appropriate box:
Type of project(required):
LE]I am a employer with employees(full and/or part-time).*� 7. ❑New construction
2.y]am asole proprietor or partnership and have no employees working for me in g. Q;Remodeling
my capacity.[No workers'comp.insurance required]
3.❑I am a homeowner doing all work myself.[No workers'wrap.insurance required.]t 9. ❑Demolition
4.0 I at.a homeowner mad will be hiring contractors to conduct all work on my property. I will 10 aBuilding addition.
ensim that all contractors either have workers'compensation insurance or are sole I I. Electrical repairs or additions
proprietors with no employees. 12.E f ilumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-tontiactora listed on the attached shirt
These subcontractors have employees and have workers'comp.msmmce.t 13.❑Roofrepairs.
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§](4),and web av c no employees.[No workers'comp.insman.•regrmed.)
`Any applicant that checks box#1 must also fill out the section below showing their workers'compemation policy htfmmation.. ..
t Homeowners who submit this affidavit indicating they are doing all work and then hie outside convectors must submit a new affidavit indicating such
lContmcu rs that check this box must attached an additional sheet showing the name of the subcormactors and state whether or not those entities have
employees Ifthe sub-contractors have employees,they must provide their-workers'.comp.policy mvnber..,
lam an employer that is providing workers'compensation insurancefor my employees.-Below is the policy andjob-site
information.
Insurance Company Name: 9,C—=-
Policy#or Self-ins.Lie.#: l--i �P7: M��S) bOO�1 D Expiration Date: 0 il u
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required wider MGL c. 152,§25A is a criminal violation punishable by a fore 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 tip.to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Si J
Sip—nature: 6. �rnnrr+�i Date: I/ / Z / w
Phone#: �7 �/ ? 1;
Ojftcial use only. Do not write in this area,to be completed by city or town ojfrcial
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 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 perrnit/license applications in any given year,need only submit one affidavit indicating current
policy infommation(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 dqg 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. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia