37 WINTER ISLAND RD - BUILDING INSPECTION (4) r
>� The Commonwealth of Massachusetts — - -
1 ] ?i'}►Y Board of Building Regulations and Standards CITY OF SALEM
Massachusetts State Building Code, 780 CMR Revised.thir 2011
Building Permit Application To Construct, Repair Renovate Or Demolish a
One-or Two-Funtily eRit g
This Section F9KOfficial Vse Only
Building Permit Number: IDate plied:
/G
Building Olticial(Print Narne) , ig are Date
SE TION I:S FORNIATION
1.1 Property Address: 1.2 Assessors Nlap& Parcel Numbers
37 Wira>,.
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 It) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal Cl On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
."L UIYHLA_ IfO-1& —5dL cr;-7 /`fA 0I?70
Name(Print) City.State.ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': Sc�— t,p � �r �v2 .�curr.�-t/sz. Nory e' .d 0070�✓
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S mob b 1. Building Permit Fee: $ Indicate how fee is determined:
'. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier
3. Plumbing S 2. Other Fees: $
a. \0echalechanicul (FI\':\C) S List:
5, \lechanical (Fire $
Suppression) Total All Fees: $
Check No. Check AmounC Cash :\maunc
G. Total Project Cost: S 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Numbcr Fcpiration Date
Name of CSI. I[older - --------
List CSL'f}-pe(see bclo%v)
No, and Street Type Description
1.1 Unrestricted(Buildings Up to 35,000 cu. tl.)
JRC
Restricted IK2 Tamil Dwelling
Citylfo%m, Slate,ZIP Mason
ry
Rootin CoverinWindowand SidinSolid fuel Burning Appliances
Institution
Telephone [:mail address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Expiration Dute
I IIC'C'ompuny Name or I IIC Registrant Name
No. and Street
Elnall address
City/Town, State,ZIP 'relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 15C(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 ..........R No........... ❑
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.
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.
74n.� N. CdZLUt'Y �/emu/i
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 NI.G.L.c. I42A. Other important information on the HIC Program can be found at
\t w�s.n ia"g. oy��c:i Information on the Construction Supervisor License can be found at x%�N gip.n iass.�os 'dp_
2 When substantial work is planned,provide the information below:
Total floor area(sq. ft.) 66 Da _(including garage, finished basement'anics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of 11 replaces Number of bedrooms
Number of bathrooms _ _ _ _ _ Number of halfbaths
l)pe of heating systcna _ __-- — _-- Number of decks,porches
T)peofcoolingSystcm _ Enclosed _ Open
i. "foml Project Square Footage- ma) be substituted for"Total Project Cost-
CITY OF SALEM
./' [PUBLIC PROPRERTY
DEPARTMENT
. � I:.":I y xm ul I
Ntctst
IIC WAItII..Nt; JIxIL•T • J,\II'N. Itt.lUdl.III it t I,JI97�
I'"' nL7139i'+3 a 1'cx v7N•74-1446
Workers' Cumpenaation Insurunce \I(lduvit: Builders/Cunt racturs/ '\ a IIII:ant llettrl�hsn In unn�tlo a/Plumberf
PI •r� Print Le 'AI
NJ IncIIJ41 e,iOraamrninnlnJnnluulC � TF Y /o
J ti� �'9 �Ah r G'ry OB,U
\cldre.�.r: /� l3ac `Y7$ .f/t;'I.JIb.✓ nJf1 63 s
Cily,SmIc'%ip. I+hunei/ w3
Sz- /96S
I \re)uu it,vugaloyorl Check the eppruprlate boa:
I ❑ I ;un a empluyur with 4. (� I ;un a general eoutnetor and 1 I)Pe of project(requlrsd):
Linyu-If.
uyccx(iull antl/ur part•linir).• baud hire)tM;.vuh-cumraclop ' Kdw cunxUuctiun
u sole prnpriemr or partner- lured on theanachcd.chcct : y ❑ Retriodelin`
nd have no mnpluyeee These subcontractors haveng list me in any capacity, w•orkera'comp, msuraned. d' EJ Ihmolirion
orkers'comp. insurance J. ❑ We area cm q• ❑ OWWingaddititmd I pontinn and itsorl1cen have esutcincyl thou10.0 Electrical repairs or additions
homeowner doing all work right of uxcmplion par AIUL I I.Q Plumbing repaid ur aJditinna
.lf\'o worker ' mp, c. 1 J1,¢I(/),and we hnvo noce rcyuired.) t mnpluyees. Ino worker! 1 Roul'repairs
comp insuranrw rcyuIM4.1 17•Q Other
•4�y,ggnc�u4 that ch.cYx bait rl mal alw Itll tx+I t .
Il�m,luwtrn w M wcltun brh+.r awrtna thsir rrektei runt _W tW+nwr this affidavit inJ saline it"att wine.II.ark and Ihm hip"Side cuitum, a malt.mft"k Ilwa alndavil inaianain
C„nImftN that IMck this box muel anahwl•at.tldiliuyl..MM,Auuius the mina o/dla nleSepnetdra.mt thee wwkan'
_ Y is
/°rn un cntployrr thus lr prvvld/n,y purRrra'rvrnprnrnden Grrwrnnee for/ny rtnp/updrq Br/ury/i M�I y un%b a
irr/unnurGna
Imuramt:Company .Vatne: _
Policy 4 ur Sulr•ins. Lic.its: _ -
�— Eapiratwn Date:
Job Situ Addru.m:
Cuy'Stateizip:JiluiQ a copy of the worked'c fired uo aNuq pulley duclrretlun page(showing the policy nutstbur and e.aplratlue date).
Palluru w.+acute coverage as required un kr Secliull?J/\ul'\ICL c. 152 can lead to the imposition ot'criminal penelriea o/a
tine up h+S1.Jad.00 indluruue•year imprls.mnunt, as wull ax civil Iwnalllp in ihu 1'unn ol'a STOP WORK ORDER ando fine
of up m i'JQ10 a Jay.tlluinxt the violator,. Ile advt.w:d that a copy urthia,Wlc MM may bu l'urnarded to the Ullicd ul,
Inr;augan,ms ul';hu UL\ for 111,warve "sv rj;e i eI IIICahtln.
/du hereby I ertify IurJer the point wrJ t nu/tirr u
/per/iffy/hut t/rr hiformal/oe praaided above is true and correct.
�n•: tlota
II)//lciu/tar only, po not.mitt in this arru, ha is,rutrrp/rtrd by airy or roan a//JciuL
(Itv or 1'nwn:
(„ulny .\whnr11 (circle )ne)c N�'rmit/Llcemr e
t 1. J U(llvalth 1. Ihuldi,16
i Ikp.unucl+l L I.il1. ra11a Clerk J. Llvclric.d lotpevrur N• Plumbing In,pceror
Phone Y:
G. I)tllrr
I
i
information
and Instructions
r on In the service of another un,ler.Iny contract Of hire,
�Lus.rc b ea c on l :neral La ws chaylet I i2 reputes JII eugslo)crs to provide worked' cmnpensauun t Ir theft cnlp epees.
1`ursu.11u to[Ills .utula. Jn 01"Oluvrd Is Joined as'•...every Pe'.c
vprns or unplicd, oral or written." oraliun or other legal anhry,or any two or more
he
to employer 1+Jeeined as"an Individual.partnership.Including
ding chd a.Cory
d the I.IfegJing engaged vro loyees. However the
cd m a Jome enterpnsa, and including the legal representatives of a JeceuscJ employer,or t
Iccalver or uustee of An iodivrdual, p asmersbp, ,swewtiva or other legal entity.employing ' P ant of the
owner of a dwelling house having not more than theca apartments and who resides therein,ur e e ace
dwcllr IS huusd of another who employ'$persons to do mamtanunce, cunstruction Of repair work on such Dwelling haunt
,Iron the grounds or building appurtenant thereto shall Ilot because of such employment be deemed to be an crnpluyer."
r )it chapter 152. �15C(6) also states that"every seats or local Ilcensiog agency shag withhold the Issuance or
cable erldOne@ Of eumpUaace with the Instsranet coverage required:
renewal of a license or pernsil to Operate a bull or to construct bulldingf la the commonwealth or any
a pllcant wlro has not produced acceptable tI liana with the insurance
V + 'CSC 7t status"Neither the commonwealth not any Of its Political subdivisions shall
L chapter 1 S_, i- ( acceptable evidence li
AJJieionally, �lCa Pwork
enter into any contract for the pdrfomtan untpub the contracting authority."
requirements of this chaplet have been p'
Applicants apply to our fimation and.if
Illation affidavit completely,by checking the boxcwieAheu cartiAcate(s)of
pleatie rill gut the workers' cumpe ld�east„t and phone Ituntber(s)along with ' employees other than the
necessary supply sub-contractor(s)name(.,).
insurance. Limited Liability Companies(LLCworkers'Limitcompettsetioed Liability einsurance'(If an)LLC or LLP does have
members or partners• are not required to carry submined to the
employes,u policy ndustrial
is required. at advised that this�l�ei� ,to�lgr and daft At uflldervlb ttTile of l affidavit should
requested.
not the Dc;partmont of
Accidents ror confirmation of insutaneo¢overage the low Or if you sea required to obtain u workers
be retrlmad to fret city or sown that the upplicAdOn far the pannie or license f being ere
Industrial 1\cuidents. Should you lwvc any questions regarding
cutnpensation policy.Pieane call the Department at the number listed below. Self-insured companies should enter the
ir
COM11nsurance license number on the appropriate lion.
scif-iClty, or Town Officials
turn
the applicant,
Plcasc ha wee that the affidavit is complete :utd printed legibly. The Department has provided u apnea at the cyd
of doe aitiduvit for you to till ore in the event the OlTice of Inveftigations has to confect you regarding
bunions in any given year,need only submit una adidavit indicating cunent
I'I:asa be sure ro till in IhO perinitllicense mm�b:r which will be used ;is
a reference: number. in addition,an ap
thin must submit multiple pennitllicaruta app '
cd h marked b the cif or town maybe provided to the
Policy
inl'ormatiun of necessary) and unbar"Job 5iea Address"the upplicunychoulJY rite"ell luctiuns in.(city O
town b"�\coDY OPADOIf the affidavit that has been officially sump'
applicant. Ja It" that a valid affidavit is un file for future permits at licenses. Anew atTTJavit Illust be tilled out each
tu
Year. Where a home owner or citizen is obminin�a license or permit not related to any business or commercial canton
t i e. a .lug license or permit w burn leave ate.)said peramt is NOT required ro complete thi'$at(Ida a have.uly yuwuons,
I he 1llticc UI luvestlgatluns would Ir6a to thank you, Ito JJvatica ter your COapefallall and SItUUId y
please du not hesitato ro give us a call.
ncc D:parnncnl's JJdte", telephone and rax number'
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfAee of favesdigadona
600 Wuhifeston Street
Boston, MA 02111
'rei. # 617.727-4900 ext 406 or 1.877•MASSAFE
Fax M 617.727-7749
d ;.11I (is www.man.8ov/dig