183 R FEDERAL ST APT 3 - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Town of
c �y Massachusetts State Building Code, 780 CMR, 7'h edition Building Dept
Zi > Building Permit Application To Construct, Repair, Renovate Or Demolish a
— \ One-or Two-Family Dwelling ANN&
c� This Section For Official Use Only
(\� Building Permit Numb Date Applied: e
Signature: t 2 , r U
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1�operty Address: 3 1.2 Assessors Map& Parcel Numbers
L 3 - !
1.1 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 ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ner of Record: C
V4 m <� IPr�c<ut�
Warne(P int) Address for Service:
i 9�6? aye l
54 ature Telephone '
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building( Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. D Number of Units Other ❑ Specify:
Brief Description of Proposed Work=: �P/a fGrftc�.� Gq drS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $", 6e 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ om ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ ��" `� 2. Other Fees: $ �j� 1
4. Mechanical (HVAC) $ List l
5. Mechanical (Fire $
Suppression) Total All Fees: $
vc Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S/� 7 D ❑ Paid in Full ❑Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Li used Construction Supervisor(CSL) Q KY<3 e6
' s_S;; License Number xpirauon Date
N me of CS Helder
ist CSL Type(sec below)
a S�
T
Addre Fny Descri tion
ZD U acted u to 35,000 Cu.Ft.)
Restri
Z R Restrcted I&2 Famil Dwellin
ggnnature M as nry Only
<ala-f�� � RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 tate Home Improv meat C ntractor(HIC)
. � 2 Z /!
HI Company Nam or HIC Registrant Name // Registration Number
Addre Ex nation Date
S nature Telephone
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 ..........grnc" No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize - - i9e to act on my behalf,in all matters
relative to wor authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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
Signatur Owner or Authori gent Da e
(Signed under the pains and penalties of perjury
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"
y i
CITY OF SALEM
a r PUBLIC PROPRERTY
'��• DEPARTMENT
I I I: i'8-'4;.9;a; • I \c 1;7,q,'4- 984t.
Construction Debris Disposal Affidavit
(re\luiICd bor all demolition and renovation work)
In accordance \\illi the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
t-lOvhe GGeJ h 7�4.
I name of hauler)
I he debris will be dispooss�ed of in
(name u(lacility) _
(aJdre.. of lacilitvl
NIgnature of pc n applicant
9
,late
CITY OF SALEM
At PUBLIC PROPRERTY
, a DEPARTMENT
vl+:'al IY WMIHM,1 r.\Sew LLI • SAE l v1, M.\v+.\t IIII I nJ197�
I IA. )71_7 t 1.9345 • 1:%.x 9711-NGIY46
Workers' Compensation Insurunce %iftdavit: Builders/Contractors/Electrician&/Plumbers
koolicant Information ,(n/ Please Print Letihly
ViltnC lnu.u+owsit)r�antratinminJlw uluall: �(/ e- / ✓�f l(-oe�S
City Scale,Zip:,
'�1Y��1� "fel Mone
.\r.you an cin player?Check the.appropriate bus: I')pe of project(required):
4. ❑ 1 ain a general contractor and 1
L ❑ 1 ;un a employer with G. ❑ New construction
�tpluycea(lull .md/ur part-unic).• have hired the sub-cuntracturs
2 1 ant a sole proprietor or partner- luted on the:coached sheet. 7. F2emodeling
ship and have no empluyucs These subcontractor have S. ❑ Demolition
working Air me in any capacity. workers' comp. Insurance. 9. ❑ Budding addition
S. ❑ We are a corporation and its
req workers'comp. insurance T'° 10.0 Electrical repair or additions
' I
required.) oiticen have caerciscJ their
3. ❑ I ant it homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.[No workers' comp, C. 152, j 1(4),and we have no 12.❑ Ruuf repairs
insurance rcquired.j r empluyccs. (No workers' 13.0 Other
comp. insurance rcquired.j
•,u, .yphcaui Iliol:hocks boli 01 must also fill an the,cam"Inluw,howuty thou workcts'cumpenu ion lwhcy Inliunutium
' I lomeur'ncn who,abmil this affidavit indicating they ate doing all work alto Own him outside contrxtun must auhmil a new alfidavit indiubny u wh.
.(\.nirxn,ry that whack this boa must anachwd an additional slwel,hawing oto nmlic of the sub.omrxtoni and their worken'comp.policy tnfurrnanon
l Ion un employer that 1r pruvidbig wurkars'cmapencntion insurance jar my enipluyeer. Belrnv is rhe pulfsy and job.wife
infurnrvtiott.
Ir.,urancc Company Naine: _.__. --- - ---_._.—_—
I'olicv a Or Sclf-ins. Lic. ft: __. . . .. - Expiration Date:
lob Site -Address: _._. C1ty;SIjLcizlp:
Attach n copy of the workers'cumpeniallon policy declaration page(showing the policy outuber and expiration date).
Ioallurc to,ceurc cuwerage as required under Scctiun 25A ul'MUL C. 152 can lead to the imposition of criminal penalties o(3
lin: up to il.500.00 and/ur une-year imprisonment,as well is civil penalties in the form of STOP WORK ORDER and a fine
,,f up it) >n_50.00 a day ogainsl the violator. lie advLkd that a wpy of this mateinenl may be lurwardod to the Mice of
tw.augan'ni,Mahe DIA :or m,,u�uxc ern era,u wa ili,ilmn.
l du hereby tcrtify tinder the pct and penaltiev u rjnry that the information provided above is rrr a and correct.
Ph-, . :r
Ofjh ial u%e unly. Du not mrite in Chir cora, to be runryletrd by a icy ur tatvn o//iris/. I
( itv ur hnwn: Permiul.iccn.e 0
I„uing.whurily (circle one
L Di.ud of Ile.illh 2. liuddi 1" Dcpartun•nt 1. Cih."I'u+su Clerk J. Electrical Inipector i, Plumbing iuspcctor
6. Dlher _
Conuctl'cnull: .. .- I'hone4:
Information and Instructions
�t.usachusett>Gcncral Laws chapter 152 require,it euq,lo)ers to provide workers' compensation fin their employees.
pt.rn,,.mt to this statute, an rmpluree is dclined is" celery pclson in the service of anther under my contract of hire,
c xpre>s or iinphcd, oral Jr wrnten."
An e,npluyrr is defined as"an Individual, partnership, issociatiou. corporation or other legal entity,or any two or Inure
.'r the lor"ou;g engaged in a joint enterprise. and including the legal representatives of a deceased cmplu)cr,or the
wicin or other legal ennt ,employing cmployces. However the
1.m uhd,ndual, aimcr>hnp, aislx b Y
fC�e1,Cr Jr IrWICe U P
owner Jf a dwelling house having not more than three apartments and who resides therein, or the occupant of the
,Iwclhng house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or Jn the rounds or budding appurtenant thereto,hall not because of such employment be dCCoaCd to be in employer."
NIGL chapter 152. �N25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to uperale a husiness or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
kdditwnally, :vIGL chapter 152, $2517(71 states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtance of public work until acceptable evidence of compliance with the insurance
requirements of(his chapter have been presented to the contracting authority."
Applicants
Pleilse rill 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 number(s) along with their certificate(s)UI
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employLes 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 Depurunent of Industrial
.Xccidents for con fimsation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
Ile resumed 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
elf-insurance license number on the appropriate line.
('try or Town Offlelals
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
tar the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pl:ax: be sure to fill in the pennit/license number which will be used is a reference number. In addition,an applicant
that must submit multiple penniEdicense 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. w here a home owner Jr citizen is obtaining a Incense or permit not related to any business or commercial venture
(i.e, a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I i1J I)I Ilio UI hnveHl.ation,\could lest to thank )'flu in advinllce fur your Cooperation and should yuu hast :my questioni,
please du not hesitate to give us a call
ncc Dcp.unnent's address, telephone and fax number'
The Commonwealth of Massachusetts
Department of industrial Accidents
Olflce of Investigations
600 Washington Street
Boston, MA 02111
Tal. # 617-72741900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.mass.gov/dia