31 FLINT ST - BUILDING INSPECTIONI
l I
The Commonwealth of Massachusetts
�y Board of Building Regulations and Standards Town of
�M I "Massachusetts State Building Code, 780 CMR, 7edition
�➢ Budding Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a i 'i
One- or Two-Family Dwelling doom
This Section For Official Use Only
Building Permit Nu erJ/ F Date Applied:
Signature:
Building Commissionefffnspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Prop�rly A j re,:i �—�- 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
r 1.3 Zoning Information: 1.4 Property Dimensions:
". Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Djsposal.System:
Public Private❑ Zone: Outside Flood Zone? Municipal On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
z.1 �u sf�eLL Fe ) 3 ( F L I t \ ST
re(Print) Address for'7 i—';e:S — ? -2 �b
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) F1Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Descri tiorwof Pr ed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ o0 )U 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No._Check Amount: Cash Amount:
6.Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due:
1 °No,j "V
SECTION 5: CONSTRUCTION SERVICES
5.1 tcensed Construction Supervisor(CSL) l wO 9 U 1
License Number 1` Expiration Date
N e of CS H Ider List CSL Type(sec below)
A dress Type I Description
,•^ U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
T.n1at` �_( � I I r ` M Mason Only
v �l "I RC Residential Roofing Covering
elephone �� V� 2 Q WS Residential Window and Siding
lJ J l SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 51stered Hone Improvement Cp nt actor HI I
L-)Lc) 1J ei�t�v 10/J % po ( Vo 0 1
HIC Compal t Name ot,HIC registrant Name p X ��, Registration Number
OV
ftp DJC D-I22//O
Add ss \M ,� (COO') W-1 I q Expiration Date
Signature 1 `�"`, Telephone 1
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 perm' .
Signed Affidavit Attached? Yes ..........❑ No...........
111
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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 I r ted"'`^--, ,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 L4 (�! 0 q
Signature of Owner or Auth ozed Agent Date
(Signed 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 halfibaths
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"
l _s
CITY OF SALEM
PUBLIC PROPRERTY
�,..r.� DEPAR'I''�tENT
I I I ')'S '4; 1 XS 'i'Y V:'641.
Construction Debris Disposal .affidavit
(rcyuired l'ur all demolition and rcnovation work)
In accordance \%ith the sixth edition of the Slate Building Code, 780 C NIR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit It 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
I 11, S 150A.
The debris will be transported by:
rr
1..e5
(name of 11anler)
I he debris will be disposed
of in
(name of facility)
So�' PI-v" -
taddrex, of lacililvl
\
,luv is of pcnmt.tpphcant
dale
,
CITY OF SALEM
A
PUBLIC PROPRERTY
DEPARTMENT
_.
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Ii,1. 9rh713-9393 • 1:%x 979 74;:'+.446
Workers' Compensation Insurunce :\fftdaxit: builders/Contractors/Electricians/Plumbers
itf tlicant Infnrmalion Please Print Le ihly
Nil Inn duull: QSZI�� Q114,4
llldra,s: U �O
City,Sr:uaZip
Phone ;!: YJ UU —LA
.% y ma employer'! Check the appropriate box: Type of project(required):
Q I aln a general contractor and I
I. I .un a employer with�_ ❑ G. Q New construction
cngtluyces(lull anLVUr parl-ume).• huvc hired the tub-cuntracturs
?.❑ I till a sole proprietor or partner-
listed on the anachcd sheet. 7. ❑ Remodeling
,hip:aid have no employees These subcontractors have S. Q Demolition working lir me in any capacity. lvorkers' comp. Insurance. if. Q Building addifiun
I No workers'comp. insurance 5. ❑ We arca corporation and its
I required.) officers have exercised their IO.Q Electrical repairs or additions
3. ❑ 1 um a homeowner doing all work right of exemption per NICiL I I.Q Plumbing repairs or additions
myself. (No workers' comp. c. 152, ¢1(3),and we have no 12.Q Rout repairs
insurance required.) r :mpluyecs. (No worker' 13.❑Usher
comp. insurance required.]
•\u, .pphnnt Ihp.Cocks box 11 roup:Jou lilt uta the wamn Wow.huwiny their work as'cumpensleion 1w6vy m6umaliva
' I lommwcen..hu submit ibis affidavit indicating]hey are doing till work alwl Own Aire uuhlde cwuraecom most.ut mk a new atrdavii indiutmy arch.
.(,witmutc,that thvck this box most anached an uWaiunal shcel.huwiny the nark of fho subtonfracmn and their wurI comprmdlcy mfurmanun
/,,,or an traplayer dint i.r pruvidinr)vurAers'c•urtrpenrntion itr.saraitce jar toy enfployees. Be/nry is the pu/icy and job site
njunnutioa e�
irnurancc C ompany Name: S
Policy a or Scif-iay. Lic. Expirauun Date:
Job Site -Address: _._. C1ty:swctZlp.
Attach it copy of flit workers'cumpensatiun policy declaration page(showing the policy number and expiration date).
Imatlurc to,court cuxorage as required under SCLtIUn 25A til'\IGL c. 152 can lead to the imposition of criminal penalties of a
rin: up to 51.5110.1)0 and/ur one-year i inprisumincnt, as hell as cn it rx hulloes in the I'unn of a STOP WORK ORDER and a line
of up to 5'_30.00 it Jay against rhe violator. Be advi.e d that a copy of Ions malclnenl may be tures arded Ise the 0111ce of
Im:..lir;aunro ul-dw DIA for ut,m amcc a»:ra,c \crilicalmn.
/du hereby t errify under dm p +nrd pen'thicx of perj /ry Mal the injunnu(lon provided aabo�vle�is true and
I'correct.
[1,,uing
ic"I rut mdy. Dd oar brit[in rhi.+arra, ru hr runtp/rtrd by airy ser Io rvrt a/jiria/.
v ser town: Per iniul.ieamse it
Aulhorily (circle nuc):oird of 11 call It !. Iluddiug Ilcparlun•ut .I. Cil�,Tonn Clerk J. L•'Iccfrical Imspecfor i, Pluwbing luspccfor
lhcr _
G+nlacll'cnun: .. .- Phone 4:
Information and Instructions
t.us.n I,u:eus Gcncral Laws chapter I i2 requires all emplo)crs to provide workers' compensation for their employees.
Ptir.uamt to mIs ,Iatute, an rmplusee is defined-is" escry person in the service of another under.my contract of hire,
e%press or implied, oral or carr ltten."
.\n empluprr is defined as"in individual, partnership, .usociauau,corporaton or other legal entity,or any two or more
,r the t recou,g engaged m a joint enterprise, and including the legal representatives of a deceased empluycr,or the
recover or trustee of an Individual, paiulenhrp,association or other legal cnnty,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
.iwelLng hou:c of another who employs persons to do maintenance,cunstrucuon or repay work on such dwelling house
,x on the.,rounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer"
NIGL chapter M. §25C(6) also states that"every state or local licensing agency shat[ withhold the issuance or
renewal of it license or permit to operate a business or to construct buildings in the commonwealth for any
applicant villa has not produced acceptable evidence of compliance with the insurance coverage required."
additionally, MGL chapter 152, 425C(7)crates"Neither the commonwealth nor any of its political subdivisions shall
COW into any contract for the p P erfomlance of uhlic work until acceptable evidence ufcunlpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)nanic(s), address(es)and phone nunlber(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 confimlatiun of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he rcnmled le the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should YOU Ilave any gUCstrons 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 till nut in the event the Office of Investigations has to contact you regarding the applicant.
Phase be sure to fill in the pcnniulicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit license applications in any given year,need only submit one affidavit indicating current
policy infmmution(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 hone owner or citizen is obtaining a license or permit not related to any business or commercial venture
(1, a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lha t)I Itee UI lnvesrl.,attos would lrwe I,) thank )UU in advance fur your Cooperation and should you have any questions,
please do Out hesitate to give us a call.
ncc Dcpamnent's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
ACORD. CERTIFICATE OF LIABILITY INSURANCE ,DJE2LH7 DAYS IZl/"" ZoDg '
RiOWLOTr'ER THIS CERTIFICATE IS ISSUED ASA MATTER pF INFORMATION
Risk cat rAer geldings ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE.
J19 eapt Livingaeon screpc HOLDER.THIS CERTIFICATE FOES NOT AMENp,EXTENp OR
or1a,WC, PL 12601 ALTER THE COVERAGE AFFORDED SY THE POLICIES SELOw.
_, ___ __ INSURERS AFFORDING_COVERAGE NAIC# _
AccouINSURED INSURERALumbetmppp Undnrwr£rin A11£ance/LUA
acnaurce Management, Inc. -, 8 _
2a1 Rain Street INSURER B'
suite e
Fitchburg, MA 01430 WSURER C:
INSURER C
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED.NOTVWYNSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUC IES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IITR NSR POLICY NUMBER pa-eI rl 5A VEp�gTg �tMO' 4Mft ' ..
GENERAL LIABILITY EACH OCCURRENCE S
COMMERCIAL GENERAL LIABILITY 'TIAMAGETO RENTED— -' '--
CWMSMADE OCCUR - PR MIS S(Ea IIB S
MED EXP(Myane peroan) s ....
PERSON_ALAADJINJURY _ S
.....___ GENERAL AGGREGATE $
GEN'L AGGREGATE LIMO AppLJES PER: PROO11CT8•CONP/OP ADO 5
POLICY PRO- �•--
au OMOe1lE UA NLITY
COMBINED SINGLE UMI S
ANY AUTO (Efi acodsn0
ALL OARED AUTOS _ .. ._ .,..
SCHEDULEDAUTDS BODILY INJURY S
(PW Pam*
BODILY INJURY R
NON.OWNEOAUTOS (Feracodank)
—. .. PROPERTY DAMAGE ... ...
(Par ntederd) S
AUTO ONLY-EA ACCIDENT S _
_ ANY AUTO
ll AUTOO ONLY H`ACC S
Auro ONLY ADD R
MESWUMMULA LIABILITY EACH OCCURRENCE _ S _
OCCUR F7 CLAIMS MADE AGGREGATE S
DEOUC'NULE
6
RETENTION $ 6
A WORIER6 cwpENsamw AND 292050
ENPLOMRS'LIARLLITY 01/"/20092009 01/0112010 X STATU- I I 0
ANY PROPRIJTOP/PARYNERIEUCUTIYe f.L.EACHACCIDENT d _ 11000,000
OFFICERMEMHSR EXCLUDED? EA.DISEASE-FA EMPLOYEE S 1,000,000
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ECTAL PROVISIO Shww E.L.DISEASE-POLICY LIMIT S 11000,000
OMSR F- -
DESCWPYION dF OMRA110M I LOCATIONS IVIMOOURS I EICLDSLONS ADDED BY ENOORMNRNT1 SPECIAL PROVISIONS
Coverage is extended to the leased employees Of alternate employer (All States, except Monopolistic, Hawaii and
Alaska) ; Colonial Rewdeling 0301486 (Effective 1/01/09) OISCLAINBR: The Certificate o8 Insurance does not Constitute
a contract between the issuing insuxer(01 , authorized representative or producer, and the certificate holder, nor dots
it affirmativuly or negativaly amend, extend or alter the coverage afrorded by the policies listed thercon.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OPTNSABOYB DESCRIBED POLICIES BE CANCELLED SWORETHE 00M110N
DAffETREReoF,THE ISSUING INSURERMLL SNDEAYORTO MAIL M MYB WRRYEN HOn015
THE CERMCATe HOLDER NAMEDTOYMB LaMY,BUYFALLUk2Y0 DD SO SRALL IMPaBE ND
OBLUL4y"M LIABILITY OF ANY ILND UPON THE WS'URE6,ITS AeENTI OR
RPYRRSENTATIYES,
Ruaaell Felt
31 wStreet
8alcm, AUTNDRI3ED PPPAMBI 7WE
MM A 01970
Page 1 O1' 1
ACORD 26(2001/08) 0 ACORD CORPORATION 1988