24 WILLSON RD - BUILDING INSPECTION Y
The Commonwealth of Massachusetts �
t Board of Building Regnlattuns and Stand:n"ds I OR
S
If Massuehuutts State Building ('ode. 7SI1('M11R. 7"' edition Mt NJ('III.\1 I It 'til.
r .
Building Permit Application To ('unsu"uct. Repair. Rrnoxatr Or Ih•nn,li,lt ❑ It, 11.11/ /1um.0 k �
one- or Tut)-Famih, Do d1ing
This Section For Official Use Only
-1
BuilJinu Permit N the Date Applied:
- 1
5ien;uurc
BwlJmg Conunn.wncri In.prrlur of BudJmgs Date
SECTION 1: SITE INFORMATION
1.1 ty dress:Proper 1.2 Assessors Map & Parcel Numbers
--
- w 9 2� rs_ - --- -
1.la Is this an accepted street". yes no I Map Numhef Par.cl Nuwhci
--
1.3 'l..onuth Information: 1.4 Property Dimensions:
I
Zonin, District -. Pngxced Use
._ L,:i A,ca(sy It) Frunluge Ui)-
1.5 Building Setbacks (ft)
Front Yard Side N'ards Rcar.)aid
! Rcyui rcJ Pn)v(JeJ ReyuueJ PnroiJeJ Retuned PrusiJrJ
I �
1.6 Water Supply: (M.G_L c. 40. §51) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone''
Public ❑ Priaate❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
z.l—olucLcriR
Name (Print) Address for Service:
natu e Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairc(s) Alteration(s) ❑ Addition ❑
Demolition , ❑ Accessory Bldg. ❑ Number of Units--!— Other ❑ Specify:
Brief Description of Proposed W,ork': J 0-1` ' as+ems _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials) II
I. Building s 2000 � I. Building Permit Fee: $ bT Indicate how fee (s delcrmi nc2.
J. l
Standard City/To wn Application Fee
Electrical $ ❑ otat Project Cunt' (Item 6) x multiplier x
;. Plumbing 3 2. Other Fees: g
4. Mechanical 1HVAC) 'S List: __-
i. Mechanical (Fire 5 --
Su ) ressiun) Fotal All Fees: S
Cheek No. Check Ain...ni ('.(sh \muunr -
0 Total Project Cost: 5 /2 � Paid to Full ❑ Ouistandnt�' Balance Dar
A/c/ )V ewka,�,-_
SECTION 5: CONSTRUCTION SERVICES
SA Licensed Construction Supervisor (C'SL) vy
-�rJLfsJn'�''�-I _ Li.Cnx Nuinhtr I`.ynr.m on U.u.• L
Nai11C u((SL- IIoIJer Liol SL l\pe i,ra hehl,sl i
Dcolptioll
WJie �
4r 'v l I'lll C,llli led illtlll ji.lNl0l�l1 I'1.i
R Re,oicleJ IN2 F.IIIIII\
l.
Tir9m2.1 VI AI.uonn Unly y
R(; 12c,i JCIIIWI Roidmc
fClrphnllc \1-S Rt,u 'nual \1 u1Jo,, :.ud_Si do ice._. —_
�SF RC�IdCnu.d Sol J I-.Irl Ifuifuns \ L.in lu II Ili u
D Rea J.•nli.J Uc All ll wlo _ .__----{
5.2 tgistered Home i orement Contructor (HIC)
Rcgutrauun Number
fI .i anv ..Name or MC,Registrant Futile
n gate
b lgna:c leltpnuac
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))__
Workers Compensation Insurance alfidavit must be completed and suhmi ed with this application. Fadurc (o pr,I1ldc 1
this affidavit will result in the denial of the Issuance of the buildm2 permit. _
Signed Affidavit Attached" Yes .... No ........... ❑ -- _ --
SECTION 7%: OWNER AUTHORIZATION 'TO B:i COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BI'ILDING PERMIT
as O\vner of the sLJbject property hereby
/—_,� -- -
� uuthon te �- ___ to art on my brltal f. wall maticn
ic!:ti e io •.vork authorized by this building permit .ipplicanon.
_SiLnalureot Ow net _—_Datt__._..__--_ --
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
— I
1. .1) ��. tna..,.t — --_-- as Owner o .A onzed A'•� .. hereby declare
that the statements and intormation on the. hiregoing appiicar.:;n are true and accurate. to t e es of my knowledge and
behalf.
Print Nw _- /? �f
gitau ul Uwner or Authorized .=.gent ---- Dale
(Signed under the pains and penalties of PCr Lffy)
Ntrres:
I. An Owner who obtains a building permit at do his'her own w otk, or ;m owner who hues an ur.re�'I,ItrcJ .'IIIItr:I�1I
i not registered in the Hume Improvement Contractor (H1C1 Program), will nut ha.e access to the mhnruion
program or guaranty fund under M.G.L. c. IJ'_A. Otter important inhoamation on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 7,80,CMR Regulations I IO.RO and I II1.R5. ic.pectrvely.
' When ,ubiainual work is planned. provide the inlormanon below:
Total tlours area (Sq. Ft.i oncluding garage. timshed baotrnen Uaulcs, decks or pinch)
Coos living area ISy. Fe) I-laho.ible room count
Number of fireplaces :Number III
1 Number of ha(hmoms Number of 11AW17alh, _----- --_-_. _..
1'cpe It heating sv,lem _ ---_-- Numhrr of deck,/ poi,hc,
Type of cooling ,stem - I:ncb"ed -- _ Uprn . .---_—
i. 'fatal Project Square Footage— may he ,ubs(ituted tier 'Total Pnrlcc( Uo,t"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT -
\L <:ail t.• e1;': tL \11,.1, 1., ., , . :11 :
1': I 9'8--4;.;;'); • 1 1\: 'I-8.-4:-'i8t„
\\orkers' C'onipensation Insurance Allidaiiit: Builders/ContractorsiElectricians/Plumbers
Please Print Le ibl
\ ) )licant Information
y cV J
N,II I1Q i Ilu.rlr„ t h_}anl/,I u1�n Inds iJu.d C
Address: f
('It) State.Zip: �avb/ r G- a fk Phone 4: )�� (°
Type of project (required):
\re you an employer? Check the appropriate box: .: ..
I ❑ I am a employer w ith
J. ❑ I sun a general contractor and 1 6. ❑ New construction
ogees(full and'ur part-time).' listC hired t (Ile slched sheet.
7. ❑ Remodeling
2. listed on the attached sheet.
1 .1111 a sole proprietor or partner- -I here Alb-contractors have 8. ❑ Demolition
ship and have nu employees workers' comp. insurance. y. ❑ luilding addition -
working for me in any capacity. 5 We are a corporation and its
No workers' comp. insurance 10.0 Electrical repairs or additions
otficers have exercised their
required.] 1 I. Plumbing repairs or additions
1.❑ 1 am a homeowner doing all work right of exemption per Iv1GL ❑ g p
myself. tNo workers' comp. C. 152, §1(4), and we have no 12, ouf repairs
insurance required.] employees. [No workers' 13.❑ Other
comp. insurance required.]
•:\IIy applicant that checks box ql must also till our the section below showing their workers'cumpensainun policy in formal ion.
' I lomeuwners who submit this atRdivIt Indicating they are doing all work and then hire outside contractors must submll a new an1J.1'VII indicating such.
.('ontro lots chat check this box nlust anachcd an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I inn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance<bmpany Name:
Expiration Date:
Policy ;$ or Self-ins. Lie
City,State/Zip: !
lob tine Address:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
F+ulure to secure coverage as required under Section 25A of hIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.511O.I)11 und'or one-year imprisonment as well as civil penalties in the the form of a STOP WORK ORDER and a fine
Ill Ilp to S250.1 l)a day :1_l'alllnt the t lolator. Ile ad%iced that a copy of tills statement Inay be lorwarded to the Office of
In1r>n_atlans of the DIA for insurance cotcrage tcnficatlon.
l,lo hereby tertiJi' rr rh pains and alti' perjury that the injirrtnatiom prrrsir/ed abot-e is trite and a'orrect.
//'�,y Dare 9� lr>G
i <iyn,o1 ro� C
�f/ & -YF -2 zlk
U/Jicitd mte un(r, Do not write in duc area. mr he aantpleted by city or t(nvn ojjiciaL
---
Cilt or town: __ - .. . -_-._ —. - --
Issuing Authority' (circle tine):
I. Huard ut Ilealih 2. Building Department 1. ('ifhi fown Clerk J. Electrical Inspector S. Plumbing Inspector
6. Other —_. -----
Contact Person: _—._-- - __ Phone ----
Information and Instructions
\I.I,.a;Inl,cus (Ic tic rll 1 aw, chapter I rryuurs .ill cInploscI, to prop Ide hsorkcrs' cianpcnsatlon for I lie tr employees.
I'lu.u.uu to till,, .1.11utc. .111 ernplur'ee I.. JclincJ -is " ch cn person in the .cn ice of,uunher under .uly contract of hue.
or mph,:d, oral or i%micn. . .
V:'.1np6rrer Is detined as ".uh :n.hy,dual, p.uu:cr,hip, .I,sucl.uton, corporation or oilier IeLal cnnn. or any tvvo or more
,.I the I0L•_01119 cn_a Led in a iolnt cntcrprl.e. and Imiuding the le al represcntatn e, ofa Je.c.1,cJ cntploj rr or the
nclycr or tru,tce of an uldn(dual, p:utncr>hip. .1—ocl.won or other Ieval Cohn. ennploy me colployce.s. l lo%%e%er the
net of ad%kcl I I rig house hay mL not more Ih.un Iltrcc .waruncnts mid oho resldcs thercut. or tale occupant of the
d�yei:mL house ot,unother y%ho employs per.on, to do nlaullenance. con;trucuon or rep;ur work on ouch yhselling house
r .111 the grounds or building .ytpurten.uu thereto ,hell) not 11Cc ALISC of .uch employ nlcm be deemed it, he an employer.
\Il il. chapter I i?, s i( (o) also ,Iarcs that "escry state or local licensing agency %halt ssithhold the issuance or
renessal of a license or permit to operate a business or to construct buildings in the commonssealth for any
applicant who has not produced acceptable cs idence of compliance with the insurance coverage required."
Additionally, .` GL chapter 152, �2-i :
( (-) slates 'Neither the contnnmyvcalth nor 'fly of its Political suhdivi,iuns shall
enter into any contract for the performance of public work until acceptable es idence of compliance with the insurance
rcyutrcnhents 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-con(raclor(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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the altdavit for you to fill out in the event the Office of Imestigations has to contact you regarding the applicant.
Please be sure to till 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 intixmation (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
y ear. Where a home owner or citizen is obtaining a license or permit not related to any business or eomntercial venture
(i.e a dog license or permit Io burn leaves etc.) said person is NOT required to complete this affidavit -
I lie (Rice of Imesnuations would like to thank you in advance for your coopeialion and should you ha%c any questions,
plea,c do nol he,Ittte ro give us a ;all.
I he Dhr.ulntuu , adJrcus. telephone.ud tax 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
www.mass.gov/dia
r CITY OF SALEM
PUBLIC PROPRERTY
DEPAR"I' �IENT
A r S.v i fit. \h.,N' ... i . _r+ _
I'\F: 'i'8-'4,'I5ai1
Construction Debris Disposal Affidavit
(required lix all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Code, 780 ChIR section 1 1 1.5
Debris, and the provisions of'vIGL c 40, S 54;
Building Permit ft is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
I name ut hauler)
The debris will be disposed of'in
(namr ut tacihry)
171 �r�l r � f �•�.�
Iaddre+<u(lac i1v)
C
'iguaturc of permit applicant
S �
d ute