9 CONNERS RD - BUILDING PERMIT APP (002) 0
The Commonwealth of Massachusetts
n Board of Building Regulations and Standards Tom
Ali
t, Massachusetts State Building Code, 780 CMR, 7" edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *kiofto*M
One-or Two-Fanrili,Duelling d om
This Sectio or O i 'al Use Only
Building Permit Numb . /J ID#A plied: // c
Signature: Lbw> — V/trl0
Building Commissioned In ctor of Buildi ` Dau
SECTION t: SITE INFORMATION
1.1 Propert a.Address: 1.2 Assessors Map& Parcel Numbers
n,tn e r
I.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(B)
LS Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1,7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ ChecOutsk
if Floo
Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'° Recsrd
k7Q u7 S/1 iN ervi vi PrC 1/CCr -
Name(Print) Addressor Service:
Signature Teieph n
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition 13 1 Accessory Bldg. C! Number of Units Other 13Specify:
Brief seri ion of Proposed Work':
SECTION 4. ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 1. Building Permit Fee:E Indicate how fee is determined:
2. Electrics! is ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
S. Mechanical (Fire S
Su pression) Total All Fees: S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S ❑ paid in Full ❑Outstanding Balance Due:
7I0� P t?t'uh
SECTION 5: CONSTRUCTION SERVICES ,.
5.1 Licensed Construction Supervisor(CSL) OS�S°
C�!9 0 l �h �� Licen.e Number E canon Date /
N,4mc+f CSL. HVI r List CSL Type(see Ixluw) .L rrG��g$
S
Address ^ RResirdential
Descn tion
ricted u to 35,000 Cu. F(.)
N CCCYYY ted I&2 Famd Dwellin
atuf[
Onlntial Rootin Coverinlephone �� 7 r!� .r /' //� ntial Window and Sidin7l! , tial Solid Fuel Bumin A liance Installation
tial Demolition
5.2 Rhe t tered Home Imps vem t Contractor(HIC)
HIC Co y Name or HIC ist nt Nam Registration-Number T
Address
/ S Expirati n Dat
Signatu Telephone 7 607
TION dWORKERS'CO ENSATION INSURANCE AFFIDAVIT(M.G.L.c.'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 .......... ❑ 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..
Signature of Owner Date
SECTION 7b:OWNERt OR 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 of Owner or Authorized Agent Date
JSillned under the pains and penalties ofperjury)
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 M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.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 Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
110 . MIN IMh(.•1 1
Il: W,t it WIG 1,^5 rl I.eT • SAI 1\f• fvl.as-x.a III III r,31177
11,1. )78.7/5-9595 • 1:t.x 9714 74C 1.146
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
timijicant Information Please Print Lepihly
V:IITC t Bu.nluav I�r;;anv,uinNlndn dual l:
�7
lddress:
City,Srare,Zip Ithunc i':
.ire y uu as von player:' Check the appropriate box: 'ry pe or project (required):
4 I un a sencral cuutractor and 1 -
I. � I am a employer with � G. 0 New construction
vmployecs(full antL'ur part-bnle).• ha%c hired the tub-comracturs
2. 0 1 and a sole proprietor or partner- listed on the attached sheer. �• C1 RemuJeling
.hip and have no employees These sub-contractors have 8. 0 Demolition
working Ibr me in any capacity. workers' comp. insurance. 9, 0 Building addition
No workers' cum . iosurance 5. 0 We area corporation and its
I P
I
required.) officers have exerclxeJ their 10.0 Electrical repairs or additions
3. 0 1 amu homeowner doing all wank right of exemption per ht(7L 11.0 Plumbing repairs or additions
myself. [No avorkcrs' comp. C. 152, §1(4).and we have no 12.0 Ruof repairs
insurance required.) r anployces. iNo workers' 13.0 Other
comp. in,urancc required.)
-am .yphcaul tlst checks box fit nlusl.a1w IIII uut IM1C wctiju iwluw abowing IIWIr wurkos*lunipun,ation pltlicy iu iamuaiun.
' I lumuuwnvn who subnuo this affidavit vulm.ong Ihcy ore Joina all work wW then Ain uulslde caturxtun must submit a new aI r:Javil indiuf ng%mh.
-C\•,, radon Ihul ahcck the box must aaxhed.'n uddouinal nlwxa.ho.mil Ilk nauu of the sub.on•rxtun and Iheu wurkors'c ;,.q,hcy utfurmanun
/ant an emptuyer that 5-.v pro vidhnq ivurkers'c•urnpenrntion insurance jar sty employees. Be/aiv is rhe pu/icy and fob site
injor nutiom
In,urancc Company Name: _.__. -. - --------
Policv 4 ser Sclf-ins. Lie. Ewpirauun Date:
Jab Site Address: ---_ City,State/Llp:
.\ttach it copy of the workers'compensation policy declaration page (showing the policy number and expiration date).
Failure to,ccurc cuaerage as required under Section 25:\ul'.%IGL c. 152 can lead to the imposition of criminal penalties of a
tin: op ht$1.5110.00 andur une-year imprisamncnt, us %%ell at Iiia d penaltlu in the futfn of a STOP WORK ORDER and a fine
of till to $250.00 a Jay against the violator. lie advised that a copy of the statement may be forwarded to the Olfice of
Inu.au•,aa nt,antic UL\ :or act ilic.thon.
/du h¢rrhy a.•rri/'v nn✓cr thr pain•un✓ptnlrBicx u)'• erjury that the in/bnnutfon provided above is true uta!correct.
J/Jiciul toe wily. /)a not write in thi.v area, to he rwap/rtr✓by airy ur town u//iriu/. I
( ilv ser fawn: Pei initiLiccnse d
Issuing Authurily (circle nuc):
1. ❑1,arJ of Ilc.lhh 2. Ituddiu� Dc pamocot 3. 1.ity.-f uau C•lcrk J. L•'Icclrical ln,peccor i. Plumbing luayccror
b. Other _
C"Ittacl l'cnun: .. _. Phone 4:
Information and Instructions
'v Ia�s.rchusctU Gcncral Laws chapter 152 requires all en plo)crs to provide workers' compensation for their cmplo'yces.
I'lir.u.ult to rills statute.an rmpforrr is defined as" e.ery poison in the service of another under any :onnact of hire,
c%press or implied. ural or written."
\n employer is defined as'an individual,partnership, associanou, corporation or other legal entity, or any two or snore
,,t the loregomg engaged in a joint enterpnse, and including the legal representatives of a deceased empio)cr,or the
rceetsrr or Huarcc of.ul individual,paitnership,association or otter legal entity,employing emplo)ees. However the
owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant of the
,iv.rlling house of another who employs persons to do maintenance,cunstruciion or repair work on such dwelling house
or on the grounds or Mudding appurtenant thereto shall not because of such employment be deemed to be in employer."
SIGL chapter 152. i25C(6)also stares that"every state or local licensing agency shall withhold the issuance or
renevui of a license nr permit to operate a husiness or to construct buildings in the comnsuawcalth for any
applicant"Ira has not produced acceptable evidence of cumpllanct with the insurance coverage required."
%,ldiuunully. NIGL chapter 152, 4, 25C(7)states"Neither the commonwealth nor any of its political subdivisions,hall
anter into any contract for the perfortnince ot'puhlic work until acccpuable cridence 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 upply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their cerrificatc(s)of
insur'ancc. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees usher than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
entployces.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
lie ictunud 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 arc 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 he sure that the affidavit is complete and printed legibly, The Department has provided a space at the buttom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
1'I,;use be sure to till in the penniUlicense number which will be used as a reference number. In addition,an applicant
Omit must submit snultiptc pcnnitilicense applications in any giver year,need only submit one affidavit indicating current
policy information lif necessary) and under"Job Site Address"the applicantshould write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe 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 hone uwner or citizen is obtaining a license or permit not related to any business or commercial venture
f i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this atffdavit.
I li. i)t iiCc of hisestigationS woald line to thank you in ad Y'ance far your cooperation and Should)'am Ila\c:my questions,
plea+c du nut hesitate to give us a call.
ncc D:p.uuncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.mass.gov/dis
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CITY OF SALEM
., PUBLIC PROPRERTY
DEPAR"PMENT
\I " "; I': \\ \. II•. ..,'1:1;!I I r � 1,\I I \I, \I\.,V I. .. I •:I'I :
Construction Debris Disposal Affidavit
(required lbr all demolition and renuvaIion work)
In accordance \\ith the sixth edition ofthe State Building Code, 7S0 CMR section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit /I is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in :
(name of Iaeility)
(address of 13clllly)
NLnala oflcnnit apphcanl
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