90 C WHARF ST - BUILDING INSPECTION a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
r t 1y Massachusetts State Building Code, 780 CMR, 7'"edition OFSALEM
Hrvixed Jutrnary
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
(� e-or Tiro-Family Duelling
JI his Jrx4on For Official Usefifrify
Building Permit Numb r: Date A led: �4/ 02 8
Signature: f
Building Comulissioner/InsPflor VB^i4je Date T��T
ION 1:SITE INFORMATION
Lnper �� , S r 1.2 Assessors Map Sr Parcel Numbers
[Aa 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(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage D osal System:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal Onsite disposal system 13
SECTION 2: PROPERTY OWNERSHIP'
2. Owners of Record: 2 p Q�+�ci �7S eq�v�� /
�irrart W c.Crl-/G�/�'� aJ,(,�,/.(>
Nam Print) alph,-4
forScice: _ ���
L�93Signature ne
SECTION 3: DESCRIPTI N OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building rOwner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Num er f Units_ O her ❑ Specify:
Brief Description of Proposed Work': �-
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
L Building S e) L Building Permit Fee:S Indicate how tee is determined:
2. Electrical S 13 Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S (36�r� ❑Paid in Full ❑Outstanding Balance Due:
va OG woRe- S�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS 5-765 S 6 /
(fie.FZer cC IS License Numtcr Expiration
Nan ')f C:SI I folder
1, r.`� /[f S VVf�. I.i,tl'SL I'rpelseebelow)
:\ dress IU I%-PC Description
Il I Unrestricted(up to 35,000 Cu.Ft.)
It Restricted 1&2 Family awellin
Signature M Masonry Only
q?&`37Sr Yy3f RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SFResidential Solid Fuel humin Appliance Installation
U Residential Demolition
5,2 Registered Home Improvement Contractor(HIC)
I IIC om y Name W HIC Registrar ne Registration Number
o e rFu-1 f4' SSR J 0(J Y a s is
n dress
G" imtion Date 3
S� P
SICnature "relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 .......... No........... 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR A ES FOR BUILDING PERMIT
I, G , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative t work authori d by this building permit application.
//,2 /&
Si. ature of Owner Date 11 1
SECTION 7b: OWNERt O AUTHORIZED AGENT DECLARATION
I, ,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
behalf.
Print Name
Signature ot'Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to Jo 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 and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I I0.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 (inclosed Open
3. -Total Project Square Footage"may he substituted for"Total Project Cost"
�N CITY OF SALEM
; , it PUBLIC PROPRERTY
DEPARTMENT
.iuH;N:1Y:1kI1Cl'I1
\fsl tits 120 WAvfa.\ci ION 5'fx ELL' 1 SAIL`e/,MA]s.u;I II 11,17\x/1)7.'.
V8.176-9395 is f.sx.978-74C-9346
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumber9
kimlicant Information L Please Print LeRihly
N.aint:lliuuoess/Or;;,tnintinNlnJlwiJuall: ' �t-t� � �. " (GAL)L'T
ddress: IdS- Nek.) 6p_7riz7- 24
City,Statci%ip la_✓ ✓ if C33fi"(�l'hune i:: Q7�-37f-`f�f 3�
Are you an employer? Check the appropriate box: 'Typo orproject(required):
4. ❑ 1 :un a generacontractor and d 1
L C] I :un a employer with 6. ❑ New construction
employees(full and/or part-time)." have hired the sub-cuntracturs
Im a sole proprietor or partner-
listed on rhe anachcd sheet. ; 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working liar me in any capacity. workers'comp. insurance. 9, ❑ Building addition
No workers'comp. insurance 5. [1 We are it corporation and its 10.E] Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 all a homeowner doing all work right of exemption per MCL I I.❑ plumbing repairs or additions
myself. [Ko workers'cunip. c. 152,j 1(4),and we have no 12.❑ Rouf•repairs
insurance required.j t employees. [Ko workers' 13.❑Other
comp. insurance required.]
-Ally:gpheanl Iba checus box in must alba lilt uut the seclion bcluw slwwinx their w•urkus cumpcnwion policy inhrrn adore
'I lemcuwhan who udi nil this allidavit indicating Ihcy ate doing all hwrk and then hire uutside comrmton must.uhmil a new atfdavll indicating such.
-fomrwmrs thud check this box mhnr atachcvl an additional sh.xl hawing the name of the subrantractors and(heir wurkan'comp.pdicy infarmauon.
/am ml e,aployrr that lc providiue rvurkers't•umpensntinn insurance jar tray rnrployeex. Bel,ry is the polity mrd fob.site
i,fonnation.
Insurance Company Name: --. .. ..
policy is or Self-ins. Lic.t!: __. ___._ Expiration Date:
lob Site Address; Cay/state/Zip:
Attach it copy of ate workers'cmnpensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to(lie imposition of criminal penalties of a
Fire up it)S1,500.00 and/ur ane-year imprixonmcnt, as well its civil penalties in the form of a STOP\WORK ORDER and a fine
of up h, S250.00 i against the violator. Iic advised shut i copy of dtis tllatcmcnt may be furwardcd lu 1he Oltice of
Invcsngaunn fthc DIA for insurance coverage tciilicalion.
I tin hereb certify ,der ae Laine'and penullies of perfnrychar the informurlori provided abbOV C is true and correct.
Date'
I'lua:c;i: — 7S
official use only. Do not o•rire in this arca,to be rutnpleted by airy or trovn officio[
City or'I'ovvn: .._ Permit/License A_
,suin>;.\ulhurily(circle one):
1. hoard of Ilvalth t. Building Department .1. Cityi fuwu Clerk 4. Electrical luspector 5, Plumbing; Inspector
6. Other
Contact 1'cnuu: __ _. Phone.Y:
Information and Instructions
.V assachusets General Laws chapter 152 requires all employers to provide workers' compensation fix their employees.
11ursuam to this statute,an rmplurea is defined is-...every person in the service of another under any contract of hire,
cypress or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or tither legal entity,or any two or more
d the 6neu,ing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee UI an nrdividual,paamership,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."
'vIGL chapter 152, y<25C(6)also states that"every state or local licensing agency shag withhold the issuance or
renewal of u 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, 4. 25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acccpttble 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-contractors) name(s),address(es)and phone nunmber(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 dale the affidavit. The affidavit should
he remmed 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 Ofnclals
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of doe 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 pennio'licetse applications in any given year,need only submit one affidavit indicating current
policy int'ormation(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. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I'he 01'icc 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 Deparnnent's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ottfce of Investigations
600 Washington Street
Boston, MA 02111
Tel. H 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 596%
LAWRENCE M LEGAULT
105 NEW BOSTON RD
KINGSTON, NH 03848 -4,
�"'^�- •-�'-��" Expiration: 611=12
C 1,mmisimor Tr#: 1217
a.rw-nw-ww�
HOME IMPROVEMENT CONTRACTOR Type:
In
Replstratlon:h 22878
Expiration: 12 tik Muxi
NCE M.L
I!
LAWRENCE LE �X,
105 NEW SOST
``
KINGSTON,NH 03 � - t7xgenerregry
6
CITY OF S'U E" 1, LL
BI:LMLNG DEP\RTMEINT
' 120 WASHLNGTON STREET, SO FLOOR
TEL (978)74S-9595
FAX(978) 740.9846
KS(9F U RY DIUSCOLL
I
MAYOR }tO.�us ST.PtERRB
DIRECTOR OF FLBLIC PROPERTY/BIUMNIG CONNISSIOVER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris wi II be transported by:
CJW12AeT-C2 ✓1-t �G�> =1— IA) E�J'j 2UCf C
(name of hauler)
The debris will be disposed of in :
(name of facility)
133 6-cP!,�e-sc)L4y
(address of fa dity)
signature of permit applicant
date
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