19 WOODSIDE ST - BUILDING INSPECTION (3) 5 CP c(c 3 ( S1
The Commonwealth of Massachusetts ' '
;'W d 1sC, iLEM
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR ,I,tisee2oll
Building Permit Application To Construct,Repair,Renovate Or DUAha HH ba
One-or 7Wo-Family Dwelling
Thin Seeon Ft+r OIt:ia1 Lk .
Building permit Nimrlaer -: Hate Ap ed:
b° i iiildktg Ot(1Ciel(1'rild e) stub" Hue
`Q :'>SEGTI(YA11:SITE 00bRl►II*'i'"
1.1 Pro rty Address: 1.2 Assessors Map&Parcel Numbers
^^ l toe r7S(D ST-
l11 1.1 a Is this an accepted street?yes_ no Mep Number Parcel Number
L� 13 Zoning Information: 1.4 Property Dimensions:
Z =g District Proposed Use Lot Area(sq ft) Frontage(ft)
;;;]
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Providedii9d
Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: stem:Zone: Outside Flood Zone? stem ❑Public❑ Private❑ Check if es❑ osal sySECTION2 PROPERiIWNER
2.1 Ownert of Record:
WAS r-�.S S i ��✓S
Name(Print) I City,S t ZIP
v r Q_ca, -
D UY_ ( al � s
a oc� p S.`,ter= 5'T- fdf �5599 � � @ erJ
! to)
No.and Street Telephone Email Address
SECTION 3,DESCRIPTION;OF P4OP03ED WORK=(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of U _nits Other ❑ Specify:
Brief Description of Proposed Wore: t n S to«
xi€2t-.%Oz wsl (I- -
SECTION 4:ESTMATED CONSTRUCTION COSTS
Item 0unated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Penmk FVT$ Indicate how fee is detertnined
❑Standard City/Town Application Fee
2.Electrical $ O Total Project Costa(Item 6)x multiplier - - x -
3.Pltmbing $ 2 Other Fees:
4.Mechanical (HVAC) $ List'
5.Mechanical (Five $ Total All Fees:$
S ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 't ?j g ❑Paid inn Full ❑Outstanding Balance Due:
' ffiECITUN 5: C(#V�TRUCTIOPV SERVICES
5.1 Construction Supervisor License(CSL) D ��
S�I.�/+—rn�1 License Number Expiration Date
Name of CSL Holder
(r List CSL Type(see below)
No.and Street ti
�. /�� � n^ A. l G U Unrestricted Dwelling
l in 000 w.ft.
Restricted 1Bc2F ilv
City/rown,State,ZIP M Masonry
RC Roo Coverm
WS Window and Si
SF Solid Fuel Burning Appliances
5040tt s 370- 1 Insulation
Telephone Email address D Demolition
5.2 Refg'Oered Home Improvement Contractor(HIC) t(oC)'-�-7
ff/f,/0 6 P?'o'r t L L..G HIC Registration Number Expiration Date
HIC Co pray Name or HIC Regi Name
!��G<
No.Egtreat J P d 7�^ lL C ^j Email address
Ci / omm State ZIP Tel hone
sECTION 4:WORKERS°COMPENSATION H�UIRAN CE AFFIDAVIT(11LCs.L.,a 1 a.3 ?SCQ(446))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Faihue to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... 0
7a OWNER AUTHORIZA TO BE COW&LETEll)W1REN
OWNER'S AGENT OR APPI.MFOR _ lING7x_/rVRMIT
1,as Owner of the subject property,hereby authorize `�' L/(G ``"(
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 AUTHORUED 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: '.
1. 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
w�tnv.mass. oQ v,�oca Information on the Construction Supervisor License can be found at wwwmass.gov/dos
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 half/baths
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 Cost"
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Construction Debris Disposa/Affidavit
(required forall demolition and.renovation work)
In accordance with the sb A edition of the state Wiling Code, 780OAR, Section 111.5 Debris,
and the provisions of MGL coo,S 54; Building Permit 8 is issued with the
condition that the debris resulting from this work shall be disposed of in a pnVe►IV licensed
waste deposit facility as defined by MGL c 111,S 1WA.
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
(name of facl ty)
(address of facility)
Signature of applicant
Date
'\ The Commonwealth of Massachuseus
Department oflndustiialAccidents
I Congress Street,Suite 100
Boston,MA 021I4-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNIITTING AUTHORITY.
_Applicant Information ,JD Please Print Legibly
Name (Business/Organization/Individual): /"v. 6'/LSjy�l [,(�C
Address: q ��k LC( ,5-1
City/State/Zip: �IOtIL�S 41V� Phone#: 97aa
Are you an employer?Check the appropriate box:
JF& E]of project(required):
1. I am a employer with 3 employees(full and/or part-time).•
w construction
2. I am a sole proprietor or partnership and have no employees working for me in
any capacity.(No workers'comp.insurance required.] modeling3. I am a homeowner doin a]I work m elf. ] molition❑ 8 ys [No workers'comp.insurance required. t4.❑Iam a homeownerand will be hying contramors to conduct all work on m lding addition
y p operty. I will
ensure that all contractors either have workers'compensation insurance m are sole ectrical repairs or additions
proprietors with no employees.
mbing repairs or additions
5. 1 am a general contractor and I have hired the subcontractors listed on the attached sheet.
These sub-contractors have employees and have workers'camp.insurances of
repairs
6. a are a corporation and its officers have exercised their right of exemption per MGL c. er 1 n 5 t.J( G
152,§1(4),and we have no employees.[No workers'comp.insurance required.] G-J.a WS
'Any applicant that checks box 91 must also fill out the section below showingtheir workers'coin pmsctors tmi icy information.itan
- t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information,Insurance Company Name:AE i & /
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: J 1 J '&5.7Ala ,S7 „City/State/Zip: '--��(�� ti4
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine 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 up 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 certi der the pains penahies ofperjury that the information provided above is true and correct
Signature: Date 0�0 /i 6
Phone#, '7 3 5-7 oZ�
F
only. Do not write in this area,to be completed by city or town official
n: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son• Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. j
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 perfommnce 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 permit/license 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 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 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-NIASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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mass save TINGPARTICIPA
s".,w t�rq�y aNEancy �►
PERMIT AUTHORIZATION FORM
I, WESLEY SIMONS owner of the property located at:
(owner's Name,printed)
19 Woodside St SALEM
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor
listed below to act on my behalf and obtain a building permit to perform insulation and/or
weatherization work on my property. n^ /
X ✓�`}'/
Owner's Signature
511!fL$
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
0NFmf
ForotRce useonty
Rev. 12132011
Office of Consumer Affairs and Busmess Regulation
k 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 160479
Type: Ltd Liability Corporation
11 1 k -.(Ti Expiration: 7/31/2018 7Rt 419291
HRM GROUP LLC _j
MICHAEL SALMON
4 HASKELL ST Jr.
GLOUCESTER, MA 01930 --
• +`y 'Update Address and return card.Dlarkne reason forLost Card
-r ' Address ❑ Renewal [] Employ G
nCA t 0. 20M-0511
License or registration valid to
individual use only
Office or cunsumer Arfain&Bnsiness Regulation before the expiration date. If found return to:
^ HOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulation
Registration: 160479 Type' 10 Park Plaza-Suite 5170
Expiration: 1/31/2018 Ltd UaNlity Corporati Boston.MA 02116 ,
HRM GROUP LLC
MICHAEL SALMON
4 HASKELL ST L.+
valid without signature
GLOUCESTER,MA 01930 Undersecretary' I
. r
i
1
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-066671
Construction Supervisor _
MICHAEL R SALMON y
4 HASKELL STREET. '.,
GLOUCESTER MA 01930
„M CA,,,: Expiration:
Commissioner OW8412018
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