33 HANSON ST - BUILDING INSPECTION a The Commonwealth of Massachusetts
1 Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Cute, 730 CNIR, 7"'edition
Revised Janu<vl•
r 1 Building Permit Application ro Construct, Repair, Renovate Or Demolish a L 2008
One-or Tiro-Fumily Dwelling
This Section For Official Use Only
Building Permit Number: / 4 Date Applied: j2•t ' 3a
Signature:
BuildingC issione'/ ns or of Buildings Date
SECTION I:SITE INFORMATION
t.l Property ddress: 1.2 Assessors Map& Parcel Numbers
3 3 ci/1 , St
Lla Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) ProviJed Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
J Zone: _ Outside Flood Zone?
Public['J Private❑ Check if yes❑ Municipal❑ Onsite disposal system 13
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow rt of Recur
U4,111 �w1 t7dffzhsov� S� •/ S !�lf�.
0
Na—e(Prin /J� Address for Service:
Signature 'relephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied f3"I Repairs(s) e Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brie�ffDescrt tio/n of Proposed Woor[k'":
/-3o i / A �1 �i S�'l YsC n%yY7 /�•Y.i9 ci.1
I-ST y11 cox !P A ..AlA 4AlI ,i- 3 117" 133 AI) ^-P:R
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building g 17,d0V I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S .SC)J ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ y UV J 2. Other Fees: S
4. Mechanical (fIVAC) S List:
5. Mechanical (Fire 3
Suppression) Total All Fees: 5
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S y 7(JU ❑ Paid in Full ❑Outstanding Balance Due:
%rte J-D & �r�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-I Colder
7o LC44,J(�.��e Sj �fjlPM ("V/ List CSL Type(see below) rip
Tv Description
�... Address / L U I," it Ya a to 35,1100 Cu.FL)
R estri
Rcted 1&2 Tamil Dwelling
Si mwurn M Mason Only
-335- 3&c.)I RC Residential Rooting Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 3S o
t=S /3N�hP�3 CcnS•ivy T
111cco Name or HIC Registrant N nej Registration Number
S S Cen fry I St cey l[�
Address_ �,(,�c�ri ��� �(�k•335 -3�/
Expiration Dam
Signature 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 .......... Nu...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, A/,14•.4" /(--cqC/A e `r , as Owner of the subject property hereby
authorize CAr` Io S 6�/-•r S to act on my behalf, in all matters
relative to work authorized by this
building
ld�permit application.
til. afore of OZ `j O Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or uthorized Agent reby declare
that the statements and information on the foregoing application are true and accurate,to the est 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(MIC)Program), will mgr have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the FITC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 1 IO.R5, respectively.
2. When substantial work is planned,provide the information below:
Total Iloors area(Sq. Fl.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabilable 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"
�N CITY OF SALEM
s
PUBLIC PROPRERTY
a DEPARTMENT
.)%W;N:1't•:)919(.1iI 1.
Nitros 1^�WA9tf1\I:I USSIXELT • SAtk\I,MASSACI II %I is J197.�
11,1.:'978•:$5-9595 a P.\x. 978-740•7446
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
konlicant Information / Please Print Letihly
V i11TC lBu9intssiOrp,]nir4lioNlndlvuluall: �Gr/O S l-c7)/t'1 �S
$dress: �P
S A / �!27YAy,Iy Sf
City,Statc;/.5-p SQdc'�r�1J' U/°6/y I'honen: 9 335_- 3(f-10 /
Are you an employer!Check the appropriate box: 'Type of project(required):
1.C3I am a r with Y'em lu e 4. ❑ 1 am a general contractor and t
P G. El New construction
employees(full and/or part-time).` have hired the sub-contractors
y r�J +r,�en the anachcd sheet. 7- Lmodeling
_.tCl r am a cele proprietor or partner-
listed o
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, D Building addition
I No workers'comp. insurance 5. ❑ We are x corporation and its 10.❑Electrical repairs or additions
required.) officers have exercised their
3.D 1 ,nn a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. [No workers' comp, c. 152,¢1(4),and we have no 12.❑ Rouf repairs
insurance required.) t employees. [No workers' 13.0 Utter
comp. insurance required.)
•,bq;ylilicaonhut checks box BI must;&o IIII WI the wctian Wow glowing their work as cumpensatiwl policy infiarrwtiun
'I fomeowners who sullntif this mlldavit indicating Ihcy.ne doing all work and then him outside contractors mull suhmit a new ai'rndavil indicting amh.
-rumm�u,n thus check this box most atowNd an additional nllcel.howiny the name of the sub.onfractors and their wurk trs'comp.policy information.
/aur mr e+npluyer that Lr Bret/ding rvurkers'c•o+npenanlion iuwnurerJar l+ry enrplupeez. Belory is rhe pu/icy au/job.Sift
injonnurion.
Insurance Company.Name: __....
Policy 4 or Sclf-ins. Lic.i+: ___._ ....._ Expirution Date:
Job Site Address: _ city;Stateizlp:
Attach it copy of Ilse workers'cumpenxation policy declaration page(showing the policy number and expiration date).
Failure to sccure coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties of a
line up or 51500.00 and/or une-year imprisunincnt, a.9 well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. I Ie advised that a copy of this smlemettt may be l'urwarded to the Oil ice of
III\"callgal Ulll]UI Ilfc UTA IOr i,t9ur:u:a arvctagu tcrilicatiun.
/da hrrrby ccrrijy under die p. 7r.c and penultius ujprrju
or she information provided above is trite arid correct.
tin✓;mIitI Daw /2-
P1, e r1y7� 33S 3�/
Official use only. Do not noire in this area, to be completed by city or town o/jiriait
i
(:ity or fotvn: .._ Pcrmit/Licensc'4__ _
Issuing Aulhurily(circle one):
1. Huard of llvalth 1. Building Ucpartmeut 3.Citvi Tomo Clerk 4. Electrical Inspector i. Plumbing Inspector
6. Otter
Comae IVS011: ._ Phone Y:
Information and Instructions
.�,lassadmsetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,in emplured is defined as"...every person in the service of another under any contmet of hire,
e%press or implied,oral or written."
.\n empluyer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
d the 6uegoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee at an individual,patmership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be in 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 commonwealth 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 iltall
enter into any contract for the performance of public work until acceptable evidence of compliance 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)namc(s),address(es)and phone nutnber(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 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(he 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 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 Slue to fill in the.permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennidlicense applications in any given year,need only submit one affidavit indicating current
policy information Jif 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. Anew affidavit must he filled out each
year. Where a home owner or citizen is obtaining a license or pennit not related to any business or commercial venture
(i.e. it dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he 01lice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
Please du not hesitate to give us a call.
The Dcpartmau's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of luvestlgatlons
600 Washington Street
Briton, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax 11617-727-7749
itcei>eJ ?-m_li-I15
www.mass.gov/dia
CITY OF S.XI.E.NI, NL-kSS.kCHUSETTS
BUILDLNG DEPARTNMNT
t 130 WASHNGTON STREET, 3 °Roo&
TEL (978) 74S-9595
FAX(978) 7449846
Kl.%jBE RY DRMOIL
MAYOR T Ho.+tAs ST.PmRn
DIRECTOR OF PUBLIC PROPERTY/BUHMLNG CONMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 t 1.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit At is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal 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
lei,'
(name of facility)
(address of facility)
signature of permit applicant
��- 3 - /v
date
dabnvlf J,k