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0004 CHARLES ST - BPA-16-1134 I'15 G t -73 'Z The Commonwealth of Massachusetts ' '" ,1F6`.% it 3`y Board of Building Regulations and Standards ' ' =+ ?TY M SALEM Massachusetts State Building Code,780 CMR lot a 4 vtd Mor 2011 Building Permit Application To Construct,Repair,Renovate?d� tja One-or Two-Family Dwelling !� This See"For lair ciai Llac . _ r ' Bttil drag Petim{t Number . De:e Al?p . Baiimng cial(PrietNam signature e �ECTIoI»r;sIT�loB�nTil�l 1 1.1 Pro a dress: 1.2 Assessors Map&Parcel Numbers co co 1.1 a s this an accepted street?yes no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yam Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage tsposal System: —/ Zone: Outside Flood Zp'e? Municipal WOn site disposal system 13Public y' Private❑ — Check R'yesg Sl CITUN 2: F1tOPERTI''OWNERS}IIP' 2.1%Oewners of ecord: l✓ `� �- l 7a Name(Print) City,State,ZIP No.and Street�Cet Telephone Email Address SECTION 1 DESCRIPTION OF PROPOSED WORKfabeck all that apply) New Construction❑ Existing Building❑ Owner.Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description fProposed Wont=: G 2� a If 1<0 SECTION 4: TED CONSTRUCTION COSTS Estimated Costs: Official Use Only . . Item shot and Materials 1.Building $ QQ(� �• BnikB is Permit Fee'$ Iudl[mte how fee is determined: O Standard City/Town Application Fee 2.Electrical $ O Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2: Other Fees; $ 4.Mechanical (HVAC) $ List - - 5.Mechanical (Five $ Total All Fees:$ rS ession check No. Cheek Amount: Cash Amount: 6.Total Project Cost: ❑Paid in Full ❑Outstanang Balance Due: �O( y —eMP[tx- TO G• C-- M ta,l asp TO �•d. SECnON 5; C0IVSTROC ITOR sSRNWES 5.1 Construction Supervisor License(CSL) a GQJ� ase umber Expiration ate N re of CSL Holder_ List CSL Type(see below) No.and/S�treet y G�IJ �7ti� ( `��/ Unrestricted uil ' ft.) to 35 000 cu. Y - R =M2 Family Dwelling City/I'own,State,ZIP M RC RoofinCovering � Window and Si —` F Solid Fuel Burning Appliances O(1 Q I Insulation TelTel on ail ad emolition 5.2 Registered Home Improvemen Contractor(HI ®® �o O r C Registration Nt ber xpira on Date HIC Oman am t Nam C-Ok ����� YT w! Y7 g! / Stare,-ZIP Tel hoce SECTION A:WORKE93 ITON MURANCE AFFMAVIT(ALG.L c.152.1 25t:(ri`)) 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...........❑ SECTION Tai OWNER AUTH6RI2A ON T6 BE COWLIMI4 WHEN OWNE$'S AG 19T QR COTQR AJ'PLIF .)! INGrMar IMMM 1,as Owner of the subject property,hereby authorize to act on my beh ,m all matters relativ to wor ylja by this building permit application. Print me(EI c Signaturee S CTION 7bt OWNEW OR AUTHE)RIZE. 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 hives 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 www.mass. ovp /oca Information on the Construction Supervisor License can be found at wM•.masUMidos 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 halFbaths 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" '\ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: �/i/ Address:// �" City/State/Zip: /�/jZ,2�&A2/, /7,,yI Phone#: F© O�jt`1 7)(=' Are you an employer?Check the appropriate box: Business-Type(required): 1.[9"tam a employer with�_employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑Health Care 4.E3 We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **Ifthe corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensate/ott insurancejor my employees. Below is the poli�c^y informaJtiaq. Insurance Company Name: ��/¢/� ( �"k�h�/Z= � 1.qu�U 1 Insurer's Address: I lY s..w�" /R1WUyf. �`1"] *U _ ,1J.Jx /"1- T 1 City/State/Zip: �w�\{..C.(�— I CCC r 11-1 - y l 1 U, —W?_0 —1 Policy#or Self-ins.Lie.# 9 1 Il..Wc VO ll I Expiration Date:�N nl1 1 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby cert , under the pains an aJ6 of perjury that the information provided above is true and correct L Signalure: Date: AZ Phone#: _ Official i4amily. o not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.inass.gov/dia Information and Instructions Massachusetts General 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 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 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 your insurance company's name,address and phone number along with a certificate 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). 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Font Revised 02-23-15 07Y OF SALEIK MASSACHLEE77, BMWMDBPAAMWrr uow snWvr 1kL74-5, 996. 1�BRil'1, 1 Fix 7109846 MAYCR 11< MUSSUUM DnmcimcipPuuwPxatmAnavDiGcmaosuaNn Construction Debris Disposa/Affl*Vit (required forall demolition and.renovation work) In accordance with the sixth edition of the State Building Code, Igo GAR, Section 111.5 Debris, and the provisions of MGL coo,S 54; Building Permit B As Issued with the condition that the debris resuitft from this work shag be disposed of in a prgx*licensed " waste deposit facility as defined by MGL c 111, S 1564. The debris will be transported by: _ (name of hauler) The debris will be disposed of In: (name of facility) (address of fa ility) 4 4 Signatur of applicant Zl ate p z �\ Office of Consoumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR k,wje,gistration: 150039 � Type: iration 3/71201.8. ., Private Corporatior. 6:��1 MCSWEENEY CONSTRUCTION INC' BARRY 24 SHELDON CIRCLE MIDDLETON,MA 01949 — Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-051242 �.GVT1', BARRY P MCSW a 24 Sheldon Circle) f Middleton MA 0949( J y Expiration Commissioner 04/30/2017