11R WINTER ISLAND ROAD - BUILDING INSPECTION :a 1'he C'onunonweahh of Massarhusctls __ .
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 730 CNIR/- SALIih V 'ti"•• I Res is"(1.l ,r_'Ol t
Building Permit Application To Construct, Repair. Renovate r Demolish a
One-or I m o-F iunilr Uu vllirr},r
This Section or Of Icial se Dull
Building Permit Number. Date, plied: _
Building Ullicial(Print Nurne) Signatu I(P
Date
SECTION I:SITE INFORMATION
1.1 Property /Addre s: 1.2 Asper Map& Parcel Numbers
I.la Is this an acre led street? -es no Nfap Number I'urcel Nw
IJ Z ning lnrorrnatlon: 1.4 Property Dimenslans:
Coning District Proposed Use Lot Area IN 11) Frontage Ill)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.a0.§Sq) 1.7 Flood Zone Inrormalion: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal❑ On site disposal s)stem ❑
SECTION2: PROPERTY OWNERSHIP'
caner'of Record:
,L� �A, A- D/97o
Name I PrmO Lily.Stale,ZIP
Nu.and Strew Telephone F.muil Address
SECTION]: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ .4cctssory Bldg.❑ Numberof Units Other ❑ Spccify:
Brief Description of Proposed Work-:
I.0 Per Ch5 SU ,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
I teal Estimated Costs:
(Labor and Materials) OMCIAI Use Only
I. Building S I. Building Permit Fee: (J Indicate how fee is determined:
2. Electrical S ❑Standard CityTown Application Fee
j
❑Total Project Cost'(Rena 6)x multiplier _ x). Plumbing S '. Other Fees: 5 P —
a. \Icihanicd 111\.\(') S List:
5 \fcdlanic;d 11'1ru - -_-- --- — —
�u+ncssion) S Totaru Fees:
('hock No. ( heck Amount: (',uh n
o. Tidal Project Cnsl: S �t7 p _.__ \mou t:_ _._._..
/Oo ❑ P;iid in Full ❑Outstanding Bul:mcc Due:
SF,CTION 5: ONS fltlic-rION SERVICES
5.1 ('onstruction Supervisor License(('St.)
1: piradoa Date
Nallic 0101, 1 lidder I ist 01. 1 IV I see lie I L)%i)
No Micription
and SIrM 1nrcs1ricA'(Buddinus ub to 35.001)cu. It
R Re,tri-cd/1&2 F-11116 M%vililig
RC' Rix)(ing Co%cring
%S Windo" ;wd Siding
SF Solid Fucl Burning Appliances
's I Insulation
I JcPhong Finail address D D......
tiun
5.2 Registered Home Improvement Contractor(HIC)
]tic Itesibiration Number Expiration Date
I 11C Compan) Name or I 11C ltqistrunt Name
No.and Street Email address
City/Town.State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152.1 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 .......... 0 No...........C)
SECTION 7a:OWNER AUTHORIZATION TO COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPMS FOR BUILDING PERMIT
1,as Owner of the subject property,hereby author is
to act on my behalf,in all matters relative to work ,I by this b tag permit application.
Print owner's Niunc(Electronic Signature) Date
SECTION R' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties or 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 Nialitirilvdagent's Name(clevtronic Si4naturcl Date
NOTES:
I. An Owner who obtains a building permit to do his,her own %vork,or an owner who hires an unregistered contractor
(not registered in the Hume improvement Contractor(HIC) Program),will!U) have access to the arbitration
program or guaranty fund under M.G.L.c. 142.A.other important information on the HIC Program can be found at
W%1\ mi-,, % of i Information on the Construction Supervisor License can be found at �o\ -111,
2, \\lien substantial\%ork is planned,provide the infurmation below:
rota) floor area H4. A., I including garage, finished basellient.attics.decks or porch)
6rosi li%ing area 154 11.1 Habitable room count
bedrooms
\Limber of firvillaccs \wnhcr ofbedrooms
Numherofhathrooms \kalibcrofhalfhalhi
f)lie of heating S)i(cill Number of dveki, porches
61,eofaoolillg s.\ilelll 1"ndoscd
I "fatal Project Square Foolaee maq be subtittacd fior"Total Project 015C
{
CITY OF S,V-ENf, )tiL1SS.ICHL'SETI'S
9LILOLNG OEP.1AT1LLST
120 WAS)ILNGTON STAEST, Jw FZOOA
r9L (978) 743.9595
K1113ER? rqy OUXOLL FAX(978) 740.9844
MAYOR ITto+w Sr.PtPruts
O"EcTOlt OPPLBLIC PROPfi1tTY/gE:MDLYG CO\OIISSIONEtt
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 790 CMR section 111.J
Debris, and the provisions of MGL a 400 S 54;
Building Permit a i
1 11 11, S I JOA. s issued with the condition that the debris resulting from
1 work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
The debris will be transported by:
CncC a r e�
(name of hauler)
The debris will be disposed of in :
_ — . (name o—f/a�ly)
(Jddraia of r4nli+y)
f
+ dnJmre ofpermit Jpp6unt
4 . crry OF Sm Em, NWSACHUSMS
BUILDING DEP.IRT\tE.NT
;)�.,�V., i�• 120AV.\SLN HGTON STREET, 3"FLOOR
TEL (978) 745-9505
FAX(97s) 7449846
ICI�IBEALEY DRISCOII,
INLAYOR T 1iO. ASST.PIF-UH
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSLMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
1lrltl1cant Information /Pleas e Print Leo�hly
N;IITiC Ba.flncs.Lt)f' nRa11Un,I nthvldaal : �IL W t.r1/L
Address:
Are you an employer?Check the appropriate g:
1.❑ I am a employer with 4. I am a general contractor and I rI
yt,project(required):
anlPloyces(full and/or part-time).• have hired the sub•conlractors 6' "eat construction
2.❑ I am a sole proprietor or partner. listed on the attached xhecl. : 7• ❑Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working lilt mein any capacity. workers'camp,insurance,
INo workers'com .insurance 5. /• ❑Building addition
p ❑ We are a corporation and its
required.) officers have exercised their 10.[] Electrical repairs or additions
).❑ 1 am a homcuwncr: nog all work right of exemption per MOL I LC]Plumbing repairs or additions
myself.(No workers"comp, C. 152,§1(4),and we have no 12.C] Roof n:pain slice required.) t employees. (No workers'
comp. insurance required.) 13•❑Other
la a
r n _pPli'ara slur d�.w5+ Huhw rill out th,r seclim hvtow showing choir woken'compensadun p----------------------------------I hvneuwn,.•rx who., Janie irslic aing they am doing ell work sad than him wside contractors most mhmit a new amdovit indicting sock
:C,wl tan that ch v, ma ay.,must machud an twitiurul.hmt showing the nwno artho sulawenuactore and thalr workers wmp,policy inremoui of
/r•rK Wn nnpluyer that Lr "YoWding workers'cumpenradan has srunce jot my etnp/uyeex Below/s the policy and job site
it "s,
Insa.,. -.: Company None
Policy 4 or Self-'As, t!:
' -- Expiration Date:
Job Silo Address: City/StatrJZip:
Altach a copy of the workers' compcnsatlon policy declaration page(showing the policy number and expiration data).
Failuro to secure cuvcmge as required under Section 25A of bIGL c. 152 can lead to the imposition of criminal penalties of a
tine V to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form ot•a STOP WORK ORDER and a line
of up to$_'S0.(10 d day against the violator. Ile advixed that a copy of this statement may be furwarded to the 011ico of
6lvestigatiuns ol•dle IA for insurance coverage vcrilicatiun.
/du lrerrby c• rJy corder th"AtFins Will pen o •rjury 1/101 fire iaj-uraruNar provided above iv True and correct
I' o ik _—�
i D/jkial Wse only. Do not write,in t/fir area, to be completed by city or fawn njjiriuL
City,)(Tnun: ,
— -- { srmiul.lccme d
--. i
Issuing,\Whurily (circle one): �— ------
i I. hoard ul Ileallh ?. Ihaildlm„Ueparluleul .l.Cityawvo Clerk J. F.laetrical Inspector i. Plumhin>: ["specter
6. Other
Contact
1.-- --. - — I'hotle;h
5'
information and Instructions ,
.*,lassachuscus Gc tie raI 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 johe legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
int enterprise,and including t
house having not more than three apartments and who resides therein, or the occupant of the
owner of a dwellingintenance,construction or repair work on such dwelling house
dwelling house another who employs persons to do ma
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,c immonwealth for any
applicant who has not produced acceptable evidence orcompllance 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 certificates)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. as 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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 filled out each
year. Where a(tome owner or citizen is obtaining a license or permit not related to any business or commercial venture
(Le.a dog license or permit to bum leaves ctc.)said person is NOT required to complete this affidavit.
The Oftce of invcsrigaactru 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. -
rhe Department's address, telephone and fax number:
. The Commonwealth of Massachusetts
Department of Industrial Accidents. v'
0f11ce of Iavesdgations
600 Washington Street
Boston, MA 021 I 1
Tel. 9 617-727-4900 cxt 406 or 1-877-NIASSAFE
Fax Al 617-727-7749
ltevi;cd 5-26-0 ,vww.rnass.gov/dia
J. y
CITY OF S.U.S.NI
PUBLIC PROPERTY
DEPARTN[ENT
y 1Y�.lY NWL.
Vwwe 130 WAMwawm ftum•SuaK VAa1011XM01si'e
HOMEOWNER LICENSB EXEMnI01*4
Pfes+e Fr1et
Daft
Job Location GJt�+�t2� �Sc-4-�-D /&44D
Home Owner Address I CA&AC-
Home Owner Telephone
Present Mailing Address
The current exemption o["Homeowners"was extended to include owner-occupied
dwellings of two Units or feat and to allow such homeowners to engage an individual for
hire who does not possess a Hcana4 provided that the owner acts as supervisor
DEFINITION OF HOMEOWNER
Perwo(s) who owns a parcel of WW on which he/she resides or intends to resides,on
which ties is. or is intended to bs,a one or two family dwelling, attached or detached
structures accessory to such use and/or farm stmcturea A person who constructs more
than one home in a two year period shad not be considered a homeowner. Such
"homeowner"shall submit to the Building 0®cisk on a form acceptable to the Building
Ofilcial. that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homeowner"assumes responsibility for compliance with the.State
Building'Cods and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understmda the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
mill comply with said procedures and r ifiarscrnwents.,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDNG INSPECTOR
See other side for state code
r/r 41y 10,4, ooz Z
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION DATE
�( ASSESSOR DATE / 2,
93 Washington St.
CITX RK DATE
ashin 'ton St.
PUBLIC SERVICES DATE
120 Washington St.
WATER DATE
120 Washington St.
CROSS AIiVCT
elTersoat_ _
X PLANNING � -. J DATE 2 )q I2
120 Washington St.
)' CONSERVATION TE
120 Washington St.
ELECTRICAL DATE
48 Lafayette St.
�Q FIRE PR NTION DATE
29 ort Avenue
HEA DATE
120 1Va ton St.
1;shin
BUILDING INSPECTOR DATE
120 Washington St.