36 HANSON ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Trio-Farm/ trel(ing doom
This Sec For ORc al Use Only
Building Permit N ber: ate pplied:
A J 7 0
Signature: A
Building Commiss r/I Spector of B Date
SEC 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
4i, Ikan sort S{ rGtt
i.la Is this an accepted street. yes ✓ no_
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
$:nto an,:(T
Zoning District Propose 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.a0,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Ii�
Public f� Private❑ Check if es0 Municipal n site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: 3 b f.�..txN Spot S{-✓e e-t
Na Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building O pied ❑Owner-OccuRepairs(s) ❑ Alterauon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. O Number of Units_ I Other ❑ Specify:
z - f -Is +- -lot 6
Brief Description of Proposed Work':. ^'i J n
Q A �, � yp�.-I i I -N O.+'� i✓L-I- Gill
T.i[� n dh . glaro ��12i_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllcial Use Only
Item Labor and Materials
I. Building Permit Fee: S Indicate how fee is determined
I. Building E :
Cl Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S ��> � ❑ Paid in Full ❑Outstanding Balance Due:
a.
•�� TI O�N P Oh�r, e
� �d
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
0/ C,
_ gyp-✓'"(-Q r.,l q c(-di..,(a License Number Expuauon Datc
N�mc of CSL- Helder List CSL Type(see below)
• � Ila.
Address Type I Description
U Unrestricted top to 35,000 Cu. Ft.)
Signature R Restricted I&2 Family Dwelling
R1 F 'Z.fa M Masonry Only
RC Rcstdcmial Roofin Coverin
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5. Registered Home Improvement Contractor(HIC)
�a—+e Ma c,i-ado
HIC Company Name or HIC Registrant Name Registration Number
4 4lbiun S+ rreL Vy/�Q
Address
'77&-2/O-RP2-2- Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... CaY No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize , 6L, 4E. Q. Ct,Gt -k) to act on my behalf,in all matters
relative to work authorized bythisbuilding permit application.
Signature a o� Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
rx-� 1-2 M CLC-1-`6L cl ) , 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.
u O--�-2 Ma Gkex ck
Print Name
US— 29-09
Signature of Owner or Authorized Agent Date
JSillned 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 I IO.RS, 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"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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12: \y,NHIM:Iwk\)I'.(LL 1 0 5.\I1 N, flf.w lx.wt 111 11 I I\JlrlJ:
IP.I. '171.7/3959$ • I wx 9711-74, 1346
Workers' Cumpensation Insurance 'lfftdasit: Builders/Contractors/Electricians/Plumbers
kimlicant Information / Please Print Leeihly
Vi1ITt:IBv.1lKsllr;;anlr.uirnvinlh,afoul l: �b iet Q_i— a r
Address: )y S
City,State.Ap. S0,(t-/r x,1."9 0lS74v ('hone •1: !J7 ZiQ -3 22
.\re y uu an culployer'.'Check the appropriate bac: I')pe of project (required):
1.Eg-1—m a employer with Z- 6. ❑ 1 :on a general coutraetor and 1 G. ❑ new construction
employees(lull and/or part•hme).• have hired the.:uh-eontracturs
2.❑ I .1111 a Yale proprietor or partner- listed oil the attached Yhcel. : 7. Q-RemoJeline
.hip and have no onployccs These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. Insurance. q. ❑ Building addition
INo workers'comnp. insurance 5. ❑ We area co,poration and its
I required.) officers have exercised their 1 10.0 Electrical repairs or additions
3.❑ 1 ;un a homeowner diking all work right of.:xcmption per MGL I I.❑ Plumbing repairs or additions
myself. (Ko workers'camp. c. 152, ¢I(4),and we have no 12.❑ Ruuf repairs
insurance required.) t employees. LKo workers'
conp. insurance rcquireJ.I 13.0 Other
•
All, .�,y,Lwma that ckccks box ill musl Aso lilt ull the,ecpan twluw showing Owls workless cunlp ary cion I,utiwy udiurruliun
' l Iameawrlen whu,uanue this affidavit indicating IN)are doing all work and then hire oatode coturxron mus,auhmit a new alrdavlt indi"lna.o.h.
-f-..nwa u.n that thick this box mime aochwd an addlli,nal nlwal.hawing tem"alar of the sub ernuaturs and,heir wurkors'comppuhcy mfurmanlln
/unr Be/aev is else pis/fay and job Qf
in�unnufion.
In,orancc Company Vmne:
I'olicv is or Scl Gins. Lic. a: Ufi `773e l(-604-o7 . .. -_ Eapiratlun Date: 0-7/S-/d 9
Job lite -\titlress: 3(a 4cnsove CIIy-Slater Zlp: S ct(e-A" r-1 Of
.\ttach a copy of Ihe workers' colnpensatlon policy daclaralion pulse (showing the policy number and expiration date).
Fallurc to sceurc cuwerdge as required under Season 25:\ ul'3IGL c. 152 can lead to the imposition of criminal penalties of a
ting asp m 51.5110110 ankVur one-year lnprisnnlncnt, is wccll as ciw it pcnalth:s in the fallen of a STOP WORK ORDER and a fine
of op to )250.00 a d.ry agaitbt the violmor. Ile advised that a copy of this matcmcnl may be Iurwarded to the 011ice of
I:Iw:,Iit dic DI,% :Ior m,ul.trcc wariliwaLon.
1 du hervhy arrufy under Jle pain,and penahiev uf/rerjarythat the i ifurinrtNan provided above is true asked correct.
t1/Jieiu1 u,r only. Dd nor ,trio fn this urea, to be awnp/eyed by airy•ur Imvn a/iiciu/. I
Oily ur fawn: _... __. Per snit/l.iccn,e 0
1w%uing .kuihurov (cirde nuc): i
I. Ilo.tnl of IIc.Jth ?. Iiuddimg Dcp.Irtucall t. <:i11.'I own Clerk J. L•'levtriad lu;peerot i, Plumbing luwyceor
4. Other _
Gutacl l'creoc .. _. I'honc tl:
1
Information and Instructions
N I.usaChusetu (icncraI Laws chapter I52 requires all eniplo)crs to provide workers' compensation h,r their cmployees.
(sunu.lnt to this .iatute,an empluree Is defined Is- esery pcison in it,,: service of another under any Contract of hire,
c vpre ss or unpI wd, ural or written."
\n :aployer is defined as "an individual, partnership,.tssociatiou,corporation or tither legal entity,or any two or more
�, the turegolrtg engaged in a print enterprise, and including the !vgal rcprescntallvcs of a deceased employer, or the
res Clr Cr or fru Jlet of Cul t,dlv,duai, pant„chbip,association or Other legal entity,employing cmployees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dw:ILng house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or ,n: the.-rounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer"
\IGL chapter 152, �25C(6) also stares that "every state or local licensing agency shall withhold the issuance or
renewal of a license tar permit to operate a business or to construct buildings in the commonwealth for any
applicant alio has not produced acceptable evidence of compliance with the insurance coverage required."
Additiunally. MGL chapter 152, j25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
mttr into any contract for the perfom,ance uf'puhlic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Phase fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) namc(s), address(es)and phone number(s)along with their cerlificale(s)Of
inswance. 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
cmployees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
dents for con of insurance coverage. Also be sure to sign and dale the affidavit. The all idavit should
.\cci
LIC rww
e emcd the city or town that the application for the permit or license is being requested, not the Department of
Industrial Acctdens. Should you have any questions regarding the law or if you arc 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'rown Official
please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of tine alfidavlt for you to 1111 out in tine event the Office of Investigations has to contact you regarding the applicant.
111:asc be sure to till in the pcnnit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit:licese applications in any given year,need Duly submit one affidavit indicating current
policy information lif 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
applicants 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
a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I h: t)Mice of would llwe to thank )'Ott In ad%ance for your cooperation and should you base .my questions,
pleasc do not hesitate to give us a call.
fhc Milafnnent's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
ORlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
a:•.:> d s-'t .u5 www.mass.gov/dia
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CITY OF SALEM
,.. s PUBLIC PROPRERTY
�,
DEPARTMENT
111 '/'X Vi.'1545 I \\: 'i'8 '4="i4.,
Construction Debris Disposal affidavit
(required litr all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 Ch'IR section 111.5
Debris, and the provisions ol'v1GL c 40, S 54;
Building Permit ft is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal Iacility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
Maer, dv
1 name uC hauler)
I he debris will be disposed of in
�/ (tante ul 19ciliry)
ImlJres. of I]nlilvl
'wiatwc nt pet III appllc ant
bs/2 7
Jalc