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20 FOREST AVE - BUILDING INSPECTION b The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards u. Massachusetts State Building Code 780 CMR, 71"edition Building Dept Building Permit Application T onstruct, Repair, enovate Or Demolish a � One- or ht'o-Fmrtih' This Section For Off ial Us Only Building Permit Nu er: at Appli Signature: Buildin Commissioner spector Buildings Date SECTI E INFORMATION 1.1 Property 1.2 Assessors Map& Parcel Numbers I.I a Is this an accepted street" es no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(R) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M,O.I,C.4n,954) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ - Public❑ Private❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) Address for Service: Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED RK'(check 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 of Proposed Workl: Poo e-2 �IS r-1 At L`nET2 e� X5� SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building f U� I. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees.S Su ression - Check No. _Check Amount: Cash Amount: 6. Total Project Cost: S •Q ❑ Paid in Full ❑Outstanding Balance Due: elf- 9�g a3s 14,:4 0S, 179 179 0) 37 1©9 l HJ SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) �r 5 Qa c n /C G CL License Number / � E!par tion Date Name of CSL- fielder t9—&-- ,/'-Cf� S 7- ��� List CSL Type(see below) � 1 Add T Description tion J U Unrestricted(up to 35,000 Cu. Ft.) g ature R Restricted 1&2 FamilyDwelling _ LL ,M Masonry Only RC Rcsadcnn atl RoofingCovering elephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Im oven Contr ct r(HIC) _ tic3a2oC/Jv c rJJ,ZS7-7 /` 0 l 7 9 if Company N e of HIC Registrant Name Registration Nu her A 1 N `7(J p, —,�v xpirat� Date �U Sign Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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. Si SEgned Affidavit Attached? Yes.......... No........... ❑ CTION 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 \^ SECTI N 7b:OWNER t OR AUTHORIZED AGENT DECLARATION ,as Owner or Authorized Agent hereby declare tha 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 (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 l0.R6 and 110.115, respectively. 2. When substantial work is planned, provide the information below. Total floors area(Sq. Ft.) (including garage, finished basemenUattics, 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 Syuare Footage"may be substituted for"Total Project Cost" w CITY OF SALEM 37 -,�, 1,At PUBLIC PROPRERTY DEPARTMENT 'wl Is II IMht,91 12. SAI I Is. M.I VS%I nI III IN JI I7: I'c1. 778.713-751)5 • IIx 979.74i '1846 Ii,Vorkers' Compensation Insurance %ffida\it: Builders/Cuntraccurs/Electricians/Plumbers %pplicant Informalion Plcase Print Leeihly V;I Inn 1 oll.nR',/S,�flta0 V.IIInIV I n/ds,'iduul l: �J �Lc,c/1-74 Addrass: 1 '-L 7TJ2erS% S �� cay'siame'Zip U(J Phone r, .\rc)ou an employer'! Check the appropriate box: I')pe of project(required): 1, .,,it a cmluyur with 4 ❑ P I :un a general contractor and 1 6. C3 New construction ❑ 1 Ivloyces(full .m,6'ur part-time).• hate hired the soh-contractors 7. 1 .un a sole proprietor or partner- listed on the anached sheet. �• ❑ Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition wvorking tier me in any capacity. workers' comp. Insurance. q. ❑ Building addition INo workers'comp. insurance 5. ❑ We area corporation and its I ired.] officers have exercised their 11 IO.❑ Electrical repairs or additions I ant a homeowner doing all work right of exemption per hIGL I L❑ Plumbing repairs or additions; myself. (Ko workers' comp. c. 152, ¢l(4),and we have no 12.E] Ruuf repairs insurance required.) P y LNo workers' � /� y ] r m 1. n,u 11.❑ Other 2� u +Zug/ comp. insurance required.) .�,,pLunt I• r m check boa II m ,:dau fill u.n the.ec own Iwluw.bowing Ihmr w'urkwi cumpunawiww puhcy ndbrmaliun. - wn� of lomcuwrwrs u'hu eubmit this a1TJavi,indicning they um doing all ooh mW Ihcn Ain uu41de ewurxmrs moa.uim,i,a new jfaavi,inairalmy web. -f',j,,,cw,or,than ah"k thus Dos imus arnxhai a t aold.liun.1 Awo.huwiny Ilse nam¢of ho,tub<cntrxtoniand Iheu workers*comprwhcy rnformanon /nw un employer thug i.s prus4din,q wurAers'rumprucarian in.suraisee fur ury employees. Be/nw is the puf ey and Jub site infurvnmion. Imurancc Company Name' _-- - -- - --------.-- Pnli:v y or Sclf-ins. Lic. ft: _--. . . .. -_ Expirauun Date:- ),)b Situ Address: _-_. Ctty,Smtc/zlp: Attach it copy of ole workers'compensation policy declaralion page (showhig the policy number and expiration date). Isalluic to secure cowcrage as required under SCLUon 25A ul'?IGL c. 152 can lead to the imposition of criminal penalties of 2 tine up n,51.500.00 and/ur une-year ifnprisonmcnt, as wrcll as ciw-11 Penalties in the lurm of a STOP WORK ORDER and a fine "full to )250.00 it Jay .,gains# the violator. lie advl.scd that a copy of this sialcincnl may be lurwarded to the 011ice of Llw can Comms ul-the DIA :or to,ma lc'c wancrage wclil icat:un. I du hereby n,rtifv nn./cr Ilse int IusJ prnuhia• u perjury that the infurmurion provided abut, is truerr d correct. 7-11 u/y. Du nor write in Mix orru, to hr•runupleKd by a'it}'ur Iowa u��iciu/. : _ Pct mit>Liccnse 4 rily (circle one): IvAth '. Ruddin:; Ilcpuruncnl 1. Cil) 'Ibnn Clerk 1. Electrical hi,pcctor i, Plumbing In,pcetor Cool:ut l'cnun: ,. _. Phone n: i Information and Instructions f aesadhueetts Gcncral Laws chapter 1 i2 fcguire) all emplo)crs to provide workers' compensation for their employees. por,ki urn to (:tis ,tatuic, in emplusee is defined as" .every person in file service ul anot er under any Contract of hire, :.press or iinphc,l. oral or written... \n :nrplaper is defined as"in individual, partnership, ,issocimiou. corporation ter other legal cntiry, or any two or more ,.f fhc lorecomg engaged it a joint enterpnsc, and Including the Icgal representatives or,' deceased entplu)er, or the re,eilcr or(rusice of .ui Wdrvtdual, pailticr)hhp,association or other legal cnnty,employing employees. HOwev'er the owner of a dwelling house having not fnore than three apartments and who resides therein, or the occupant of the ,h.cllutg house of another who employs persons to do maintenance,construction or repute work on >uch dwelling house or on the grounds or budding appurtenant thereto shall not because of such employment be deemed to be in emplo)er." NIGL chapter 152, §25C(6)also states that "every state or local licensing agency shall withhold the issuance or renewul ora license or permit to operate a business or to construct buildings in the commonwealth for any applicant it lie has flat produced acceptable evidence of compliance with the insurance coverage required." Xddiuonally. MGL chapter 152, a25C(7f crates"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfomlancc ofpuhlic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Plane fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s) name(s), address(es)and phone number(s) along with their certificatc(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 .\ccidents for continuation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should he rctumed to the city or town that the application for the permit or license is being requested, not the Uepartment of 1 nJus[rial 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 comparries should enter their -If-insurance license number on the appropriate line. City or Town Official Plense he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the afhdavu for you to 11II out in the event the Office of Investigations has to contact you regarding the applicant. PL,ase be sure to till in the pcnnit/license number which will be used as a reference number. In addition, an applicant that most submit multiple pennitllicense 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 tilled out each year. Where a home owner or citizen is obtaining a licenx 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 ho 1)(lice tat Ilrveitlgatiun) \vould line to diank )ou In advance fur your cooperation and should you hale .my questions, pleats do not hesuate to give us a call. rhe Ucpanrncnfs address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston, MA 02111 Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE Fax M 617-727-7749 www.mass.gov/tits CITY OF SALEM l `y. PUBLIC PROPRERTY DEPARTLIENT 111 v'8 '4;.0;0; '+: tt 4. Construetion Debris Disposal Affidavit (reyuircd for all demolition and renovation work) In accordance %pith the sixth edition ofthe State Building Code, 780 CMR section 111,5 Debris, and the provisions of MGL c 40, S 54; Building Permit N 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: LOd7-44-C-7-UlL. & t6 L-7- COT71AJ (name of hauler) I lie debris will be disposed of in : (name of facility) uiddres� of lacilitvl /� ;ua/l'�w[Ott p:nuu apphcani date