1-3 HATHORNE CRESCENT - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR RevisedMor 2011
BuildingTemtit Application To Construct,Repair,Renovate Or Demolish a
t ' One-or Two-Family Dwelling
`I3tis Secd3on Far Old ides
BmldmgPerathNumber '�: �
,^�ni vignaletre �"�
SECTION 1;SIZE INI OMATI}N
1.1 Properly Address- �PSGCV 1.2 Assessors Map&Parcel Numbers cGi i
/-3
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Frontage(ft) .�
Zoning District Proposed Use Lot Area(sq ft) t�z
1.5 Building Setbacks(ft) k�5'
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:
Public❑ Private❑ Zane: _
On
Flood Zone? Municipal O On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY'OWNERSI�t
2.1 Owner'of R ord: ��/ M ^ O -
to� � J City,State,ZlP r'7
Name [) J ,
7 4- ,7$-9�.53G9,7�t7PG11 vise APf/o
No.and Street Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) W1 Alteration(s) ❑ Addition ❑
Demolition Sri Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work: ,"
R :r7
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only .
Item Estimated
and Materials
1.Building $ 1 Building Parroit Few:$ Indicate howe feis determine&
❑Standard -ty/fown Application Fee
2.Electrical $ O Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ '
5.Mechanical (Fire $ Total All
Suppression) - - -
Check No. (7tuek Amount: Cada Amount;
6.Total Project Cost: $ sdG -/ ❑Paid ul Full ❑Outstanding Balance Due:
(t1�tl_ _ D
1
sECTtt iv s coN uarlcz�r sERVIc s
5.1 Construction Supervisor License(CSL) G-,Vf'O 7 f ,
V /—/ License Number Expiration Date
Name of CSL Holder
List CSL Type(seebelow)
Ve
No.and Street //r�
pfd EX�D MA B� Q U Unrestricted estrito- 000 cu.R
R Restricted 1&2F Dwe
"City/I'own,S M I Masonry
RC Rootm Covering
p� WS Wmdow and S'
9e. /5?ng--. 6 9'7 SF Solid Fuel Burning Appliances
i02PibS�Q.�/A4 Insulation
Tel hone `7�J� D Demolition,.
5.2 Registered Home Improvement Contractor(HIC) /3
�dS�� G/( JA10� HIC Registration Number Expiration Date
e
cc Name or HIC Re ' Name
i A
s�-E /P lu 7A� r Vic �D e 4 A l –Al
*gd—L2��e�a y7V 9 , a5
Ci /town ate ZIP Tel one
SECTION f:S3 oRIK tts'C0MPE1?SATII?N llWURANCR AMDAVIT t?N.G.L.e.152.§ 2SQ0
Workers Compensation Insurance affidavit must be completed and submitted with this application. Faihue to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........0
Tai OWNER AUTHORIZA TO RE C011WLETED W1I1ulV
WNER'S AGENT()R C9 AR.: .FJ3V"INQJPEJUAIT
I,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:OWNEW OR AIITHOWZED AG] 1V I I)ECLAAATWN
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 and accurate to the best of my knowledge and understanding.
Print2n9fs or Authorized A 's Name(EI 'c Si lure) Date
NQfiES;
1. An Owner who obtains a building permit to do his/ber 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 can be found at
www.ntass.eov/oca Information on the Construction Supervisor License can be found at MMMgss.gov/dos
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 beating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
C71Y OF S&EK MASSAa"E1fi
BLULMDsPArrr
]ZD W.ts MVMSTNBrjrROCNt
7 L X978 745-9595.
BDi�ERIlYDRiSQ�LL
PAxg78 7449846
MAYOR THMASSTAEUM
DntscrtcaPmwc> rmr/stttttvaomaamt
Construction Debris Disposa/Affidavit
(required for all demolition and,.renovation work)
In accordance with the sbtth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40,S 54; Building Permit B is Issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed "
waste deposit facility as defined by MGL c ill,S 156A.
The debris will be transported by.
(name of hauler
The debris will be disposed of in:
(nami of facility)
(addr (s of facility)
1 n ure of appli ant
S-> —/e,'l
Date
F
The Commonwealth ofAfassachxseds
Depadment ofltMasIXW,4ecidertts
I CongressSlreey Suite 100
B.estois,M.4 02114-2017
WWW.Ma=gov/dia
Workers'Compensation Insurance Affidavit.-Bnflders/Con&adora/Eledriclam/Plwnbus.
TO BE FILED WITH THE PERMITTING AUI'HOWIT
Naves(Bosine3s/oi�raronllnuiviPoal): 5�� loe r . 4 / .
Address:aX/ l NC d Q r✓
City
�sffit�!ztp: dao Pl>o7>e M98 � g7 ..
Are you an empbyw?Check the apprgprlate bort:
1.O1 am a employer wlPo�empkyea(full®d/ekm4time).' 7. O New cosiFt n lion
2.Olam e,wk Ptopoie orpartoasbip hod have W tMOR OI wglpog fwm io g; O ede];ag
aapactty 1No miW® 'eamy. tutince iojammed.) 9: a Demolition,.
3 e homeowmr doing an wjk myself:iHo wmken aompiaucsnce!e9uffedl t
10 0 su�amg eaairi .
4.Ejlama homwwner.mw,ll belikingcmaaatmsmaonductm woilc on my popaty. Twill - -
aovaeatatall contna;maadwhaw kers'wmpwsadwiasmanceorarewte 11.QElectrical repairs oradditions
papeietpra wimao employees. . 12.�Plumbmg'ta�iis oradditia®s
5. 7®ageoaal cameadlfuve tibed meeutitcmaatlae listed oa me aaei3ed sheat:
07b=embcanaewashaveenooyoeawdhavewinkms-comp i xaamxf. 1 .OROOfrepaaa.
6.0wemaoorpomumaodinofficaslnweereiciseddicirdskof MQ.o. 14.0Other -
exempanoper . ..
152,§1(4),and we laws o employees:[No workers`ea®p.inpuranae mPmed.) -
.eAnrappb'mii>iat ehWuboa tl inns tdaoIM om the eealloa bakwdhawiag met.-vadkeia pohryinfgamahm -
tHomeowaeawhomft*Poisaffidavi[fudicetmgtkey ace doia�g all condi add thedhbe oulaWeca�MpmlitIDat suba6aaaewaf6devit gmali
tCuavactoms mat check tlui bw must attached amaddirional shedsbowiog dare:ofdhe sub ois and amteavkem"is 4nmtliaseemkteshave -
amployeea..Iftbecubcgntraema 6eve,®p1.oY may--Apo- dib -Owyi song P4Pr m� ...-
law as emu&*er t W&provfding rrorkws'Compwira*e insuraaeefor lay sem. Below a ihepol ry andJob si(e-
injoiareNon.
Insurance Company Name:
Policy#or Self-ms.Lic.#: Expiration Date:
Job Site Address: gyp:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and aspiration date).
Failure to securecoverage as required under MGI.'c. 152,§259 is a emsnal violation Punishable by a fine up to$1,500.00
and/or one-yea imprisonment,as well as m civil penalties in the forOf a STOP WORK ORI)ER and a fine of up to$250.00 a
day against the vioLrtoi.A Copy of this atffiemeot may be forwarded to the Office ofloveshgationa oftbe DIA for immune
coverage verification.
I do hereby eweify ander Ihepains 4yAraftieuc ofperpay that the informadan provided above is true and correct.
Date; .�� ✓'
Phone M 7
OJ acia/are only. Do not write In this arca,to be cooydrled by mN or(own oBfeinL
City or Town: Perndt/License#
Issuing Authority(circle One):
1.Board of Health I Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for thea employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,
express or implied,oral or writtep"
An employes 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 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 an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issueoce 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 cornmonwealth nor any of its political subdivisions shall
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 fill out the workers'compensation affidavit complctely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),addresses)and phone mmrber(s)along with thea ceatificete(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employee 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 DepaMrent 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-insuredcompanies 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 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 sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permiUiiceose 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 earl
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog 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
1 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