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12 GENEVA ST - BLDG PERMIT B-16-1023 X325 etc 1 � 8 � t The Commonwealth of Massachusetts �t " "` ffi � _� s1 Board of Building Regulations and Standards AM SALEM Massachusetts State Building Code,780 CMR �p�� Cep RP,Yise¢Mgr�011 Building Permit Application To Construct,Repair,Renovate Or IId11ibI�1 a N One-or Two-Family Dwelling Q Thti Sed3on Fer UR1o�l Use ti Building Permit ittanber Date AP yeti:, . ..eisl(P aint Signahue l SE", 1 SITETPORMA I InN 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning DLstrict 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 Supply:(M.G.L c:40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public❑ Private❑ Check ifyes❑ SECTION 1. PROPIRTYQWNERSMr 2.1 eRecprd; --- - :A/ i�c JJ�� Pi✓d� J�/e1+�1� �1 0� ?� Name(Print) City,State,ZIP �¢wTlt 7d No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK;(ehe&WOW aPPIY) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) I Alteration(s) ❑ Addition ❑ Demolition O I Accessory Bldg.❑ Number of Units_ Odter ❑ Specify: Brief Description of Proposed World: A/t:w kr T 6� ti�GrJ Q�f�� SECTION 4:ESTIl1"<ATED CONSTRUCTION COSTS Estimated Costs: OfSeial Use Only Item abor and Materials 1.Building $ 3Q 1. Buiktittg Permit Fee:$ Indicate how fee is determined: m p Standard City/Tovm Application Fee 2.Electrical $ O Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ Q O© 2. Other Fees: S ,.en 11S 4.Mechanical (HVAC) $ K -e)0 Lam' —2jL 5.Mechanical (Fine $ Total AB Fees:$ suppression) (ham No. CheckAmount: Casb Amount: 6.Total Project Cost: $y D p Paid in Full 0 O,utstandin#Balance Due.' SECTION 5: CONSTRUCTION.SERVICES I ) 5.1 Construction Supervisor License(CSL) Lt�i tuber Exp on Date Name of CSL Holder' - - - (� List CSL Type(see below) Dean! No. and Street �+ migs up to 000 w.8 R Restricted 1&2 F Dwelling City/Ibwn,State,ZIP ' M I Masonry RCI Roofma Covering WS I Window and Siding SF i - SF Solid Fuel Burning Appliances Of) y byy b S(,� V-e ��y{�L P%/ I Insolation Telephone Email address D Demolition 5.2''R��,/stered Rome Improvement Contractor(HIC) c O lti /" 0✓Ly`G )e HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name/^ No.and Street7 Email address Ci /Town State ZIP Tel hone SECTION t r WORKERS°COMPENISATION l SLM ANCE AAF .ANiT(NLG.I,c:152.4 25C(6)) Workers Compensation Insurance affidavit mus completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Iss ce of the building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTM&N 7a OWNER AUTHORIZA T6 BE WP&LETEA W11EN 0WWRSAG1KNTQRC0R FOR MG 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. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORMED 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 d ace t e t of my knowledge and derstandiag. Print Owner's or Authorized Agent's Name Data NOTES: . . 1. 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 fiord under M.G.L.c. 142A.Other important information on the HIC Program can be found at wtivw.ntass.aov'oca Information on the Construction Supervisor License can be found at wMv.mass.gov/das 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 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" The CoinmonwepJt/i ojMassaderfsett's Dep&ftent ojlndustriaAeddents I Congress Sdeey suite 100 Boston,AL4 021141017 www.ma=gov/dna Wwarkers'Compeasation Insurance Affidavit;Builders/CoMradors/Eleehicians/Plmnbera. TO BE FILM WITH THE PERM rnNG AUTHORITY. - Plena hint 14d Name(Bosioess/OrgamzaHon/Inmviduetj: . . .�--�� . Ada :_�O 1q �TYC v S TSL e q 1 / City/state/zip: S ��0"� Gly lq �/�?L Phone#: AR70-pm W Cbedr the apprgrJate boa: - .. ofPro) d(�9I�►?d): yerwith euwby�s(furl endforrert-rie). T. Q New construction 2. wparmembt nd have no empbyees wv4mg fume in 8. p Remedeliog aoyeapeeay.(No wadcefs`wmp.niGaaox nquved.] 3.p lam a homemmerdomg as wojk mymtl:(No workms•gyp, es*e9 1 r 9. O Demnlieia-add", 1O O Building aait. 4.01ama bora o er and will be hiring conhaams to comicct BE workon mypmperty. IwBl ena edul all commatemaidwhave workers'eompea8eem mawanceamsok 11.0 Electrical repairs or additions pmpaietam w;di ten myloyees• . 12.Z]Plnmbmg�i+epefrs oi'edditifro"s 5.0 lam a Several umtamorandlhevehhedfin sub4oli achashoo-dwkdoaftichMaheet 13.pxoofrepaQs 7hm ffi*�cannamwhavemployees and bevewudrwe oomp.msmeaxi , ... .. ., . p 6.0Weareacnpnmpm'mdits offleahiviwoxti dibird9dofexam 'perMGl.a 14. 011ier 15$II(4),and weliavem emploYe�:(Noworkeie:.ia0p::.'iminmm.?equied.) '. . vq�algfiah(tkmehada has Cl must ahw SB omPoe sestina bekrw ehowioffhabr wakens eompmsodm poll htibmahon. t Homeownem who submit dins aBdavitindieemgdiey eredomg all woAi Poedhhe ovimde mut subma a neav d5davit iodieemq nrch 7Conoaamn the check this box aturbed m addrbonal shxtshowing the mue;ofate mb-cbhvmm;and sure Whoder mint dims entaim have . employees..Ifd*j± maeamhagemployee d ynmdp n*dmr wodess'mop.poneyrnm6ea:, I am an eatployer that iepropldi7ag ttnr/rers'eoarpeasaejon insitrancejor ay eoipiPyeea Below iss thepottryam l site - lnjorriaatYoa Insurance Company Name Policy#or Self-ins.Lic.P. Bapuation Date: Job Site Address: City/S p. Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGI:c. 152,§25 4 is a criminal violation punishable by a fine up to$1,500.00 and/ a year imprisonment,as well as civil penalties in the farm ofd STOP WORK ORDER and a fine of up to$256.00 a day hmor.A copy of this steteinent may be fotwanled w Die Office of Investigations ofthe DIA f«insurance coverage ti I do hereby an thepains and penahies ofperjwy that the information provided abf ..il..nue and correct ature-\ PAL vp Phone 0OA&al use only. Do not write in this area,to be completed by ctty,or WPM o,BfoiaL City or Ttwvn• Perce tRdcense# Issuing Attthmity(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1, 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 w"...every person in the service of another under any contract of hire, express or implied,oral or writtep" 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 in individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apamnmts and who resides therein,or the occupant of fife dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenam thereto shall not because of such employment be deemed to be sm 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 eommonwealth 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 cf 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 sub-contractor(s)name(s),addresses)and phone number(s)along with their certificates)of insurance. limited liability Companies(LLC)or Limited Liability Partnerships W)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LI.0 or LLP does bave 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 lime. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Departrrerrt 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 pemtittlicense number which will be used as a reference munber. In addition,an applicant that most submit multiple peroutAic®se 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.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dqg 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 I Congress Street,Suite 100 Boston,MA 02114-2017 Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia , ' Q7 Y OF SALEIK MMSAa-REE M BuanmDuAimmm 120 WASfIDCWNSUWs 3IDIhAM UL(978 745.9595. S7MBERLEYDRISQ7IL FAx(�)74109846 MAYCR 1)ICMsSTYMM Mmcma cFAMUCROFMIYAUMMOOMMISSICHM Construction Debris Disposa/AfdOW (required for all demolition and,renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL M, S 54; Building Permit it is issued with the condition that the debris resulting from this work shall be disposed of in a property licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by. (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) ' n tur o a at