31 WILLSON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7ih edition (3s SALEM
Revised Jmruury
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• =/)oR
One-or Two-Family Dwelling
This Section For Official Use Only
�`J Building Permit Number:)/ n I Date Applied: -- 7 / )
Signature: (/ ///�� / y`�C/
Building Commissioner/InKpector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers .t
o ST
I.la 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 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Sppply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage System:
/��,/ Zone: _ Outside Flood Zone? Municipal On site disposal system
❑
Public Privale❑ Checkif es0 p D� y
SECTION 2: PROPERTY OWNERSHIP[
2.1 IN
ti1d oLh
� \bh � �1tLt Sor.1 S l
Name(Print) Address for Service:
' i q A -7 � S'
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK[(check all that apply)
New Construction❑ Existing Building Owner-Occupied TAL I Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Uni[s_ Other ❑ Specify:
Brief Description of Proposed rk-:
a
l5 N +
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 01I1clal Use Only
Labor and Materials
I. Building S f—v-- 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost](Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
`` )� Check No. Check Amount: Cash Amount:
6.Total Project Cost: S
dI VC� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1�Licensed Construction Supervisor(CSL) e 5 e)?2/e;g
/ �c941N CIA_IyScC' Cqf4�1 License Number lispi lion Ua e
Name fCSI.- IIuIJer
y„� Lwkvr ��. List CSL Type(see below)
AJJres WDResidential
Description
° ��..�L/ stricted a to 35,000 Cu.Ft.
icted I&2 Famil Uwe..:nu
Signature Mason-
0Onl
ential Roulin Coverin
Telephone ential Solid Fuel Bumin A liance Installation
Demolition
5.2 R red Home Improvement C�entractor(HIC) `5 1 &
III(:Company ame or tIIC Rteltistrant Nye^ Registmli Number
AJJres 3'� (
�june
7'0 33C-I s 7qZ, Erpimtion Date
Signal Tekph
SECTION 6: WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 ..........O No...........AK
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application. ,
,
Simnalure of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, A/S 6A/"yeiialc7� -,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
beh f.
Pri t
ly
Signs ore ol'Owner or Awt
Agent Date
(Signed under the pains anies of 11duA
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 Mol have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I l0.R5,respectively.
2. When substantial work is pi , rovide the information below:
Total floors area(Sq. Ft.) f(;�P�X ADZ) (including garage, finished basement/ ttics,decks or porch)
Gross living area(Sq. Ft.) 0y Habitable room count (�
Number of fireplaces / Number of bedrooms --r
Number of bathrooms Number ofhalf/baths f
Type of heating system e2r-,f Number of decks/porches /
Type of cooling system N ,4- Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
,,;a, rr`` PUBLIC PROPRERTY
O DEPARTMENT
'..I VI'SRLIIY URISCUI.I.
4t.U't tR l2^.WAiFIING 10N S'I RELT • SALEM,MASSACI II till I'I S 0197'..
'11.1.;978-745-9595 • 1':(x:978-74C-7s46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
olieant Information Please Print Legibly
N line tHltalm:xsiOfganiratinNlndivirlualY.
Address: --2-- k L-I " CA t- �
CityiStatei%ip: -S-k--Zzems Phone €.-: `t7q
Are you art employer!Check the appropriate box: Type of project(required):
1.❑ I ;un a employer with 4. ❑ I am a general contractor and 1 6. ❑ new construction
em rlo ces full and/or art-time).' have hired the sub-contractors
l Y ( P 7. �,Remodeling
2 I ;un a sole proprietor or partner- listed on the attached sheet.
p:uul have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
INo workers' comp. insurance 5. ❑ We are a corporation and its required.] o 10. ] Electrical repairs or additions
officers have exercised their
3.El I am a homeowner doing all work S exemption P
right of per MGL 1 LE Plumbing repairs or additions
Pon '
myself. [No workers' comp. C. 152, j 1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
-Any.,pplicuul that chucks box nl must also fill out the Section buluw,showing their w'orkas cumpensatiun pulicy jollo n atiom
'1 Wmcowners who submit this affidavit indicating they are doing all work and then hire outside cwarxton most eubmif a new affidavit indicating such.
-Contracwn Ihat chock this box mull anach(xt nn additional sheer showing the name or the sub-contractors and their workers'comp.policy infuriation.
l runt un emrployer that is providing rvorkers'c•onrpensntiolr insurance for any eurployeec. Below is the policy and job site
information. (. N.S qq0 �of 6 �b� �Narx174
Insurance Company Name: .__.... __ -...._.—_---..—_.__--
Policy 4 or Self-ins. Lic.t: __...- .._ . .-_._____ Expiration Date:
lob Site Address: � V l LL S Ot,� -:5 -f— CityisoateiZip:
Attach it copy of like workers' compensation policy declaration page (showing the policy nunber and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
find LIP to S1.500,00 and/or one-year imprisonment, us wcil as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violomr. He advised that a copy of this slutement may be forwarded to the Office of
Investigations ul'the DIA for insurance coverage verification.
l du berth ce fi ma f •d pains ar d penalties•ufp '
erjary that the information provided a use s true and correct.
Si nalure: _�-f t� U:rtc:
Phtn:e?: ` �< `1
Official use only. no oat write im this area, to be completed by city or tmvn official
City or Town: - . Permitll.icense -
Ixsuing.\ulhurily (circle out):
I. Board of llcalth 2. Building Department .3.Citv/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cuawa Pcnon: ____ _ _.--_ 1 one :
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an einpft yee is defined as"...every person inthe 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 trusteeLuf an individual,paimership,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."
h1GL 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, biGL 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 otcompliance 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 till 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 must submit multiple pennitilicense 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 tilled 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.
I'he OI I ice of Investigations would like to thank you in advance fur 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
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05
www.mass.gov/tire
' "1 ' CITY OF SALEM
�l
=r' W PUBLIC PROPRERTY
DEPARTMENT
\C,\iI II]t...INS I it ld T 1 y.\I 1'M. \I.\ii Nt .II <i I .I I
978-745-9;95 ♦ 1'.u:978 74D 9.4Iti
Construction Debris Disposal Affidavit
(required liar all demolition and renovation work)
In accordance \vith the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit tl 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
l 11. S 150A.
The debris will be transported by:
V
LT 7
(name of hauler)
The debris will be disposed of in
(name of facility)
6Louc ,
taddress of facility)
s ignatuI'e of pe 11 applicant
datu --