10 HAYES RD - BUILDING INSPECTION t
The Commonwealth of Massachusetts
�! } Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 730 CMR, 7"editionjaa
OF SALEM
t, Revised January
Building Permit Application'ro Construct, Repair, Renovate Or Demol !. 21108
One-or vo-Family Dwelling
his Se ion For 00' ral Use Only
Building Permit Numbe ate Applied: 2
.
Signature: '2� -0
nuilding ommission Ins o Buildings Date
CTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
��� NAyEs e�
1.la Is this an accepted street'?yes_ no Map Number Parcel Number
1.3 Zoning Information: - 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) 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.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ Onsite disposal system 13
SECTION 2: PROPERTY OWNERSHIP'
2.1 Oer of R cord:
�T�(En� MiiLUA)S /C) kwt5 ka4 Aam, t4fA a/9?6
Name(Print) Address for Service:
q2,0-7y/-23d V
Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Speedy:
Brief Description of Proposed Work': :Met,0 e 01slAo5L 61c JA GF ASOe/ar,7 /lea
s iub[Es, eA) // Ab9k� 3'0I 5a,A445
csFsNIA/(o5 .2 Ick w�a�fE.� ru�,[uI/,�,Qr/ks d��f o.J de'roG�r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofliclal Use Only
(Labor and Materials
I. Building S G I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $
13 Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S-
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No._Check A nount: Cash Amount:_
6.Total Project Cost: S
496 13 Paid in Full ❑Outstanding Balance Due:
l
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed
,�Construction Supervisor(CSL) /G/I
40 'r u�ct"�/�
O-e I� License Numlar / lApiratiun Date
Name W CSI.-I lolder
r nimcy./ List CSI-Type(see below)
11 i Y Y
:Wdre ` Description
/ ✓ U t l®restricted IU 35.000 Cu.R.
R Restricted 1&2 Family Dwellin
Sigie q M Mason Only
/7�--s3�•/ / RC Residential Rooting Covering
Telephone V.' Residential Window and Sidinst
SF Residential Solid Fuel Burning Appliance Installation
Residential Demolition /L
5.2 Re IstercdHomelmp�ovemen Contractor(HIC)
rt. ,te C17-y G.FR
I IIC Com anxx Namc or flIC Registrant ryttme M Registration Number
K. Cn/u Y A- _ 17 /1
AJdres /yj!i731./,(/�f' ExlAimtioli Date
Signa u e 'relephone
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 ..........❑ No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Signature of Owner Date
",�\ q�
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, N /r MC V6AA?,, ; 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.
rLA) MWE160,72li—
Print Name
Signature o Owner or Auth rite Agent Date
Si ned under the pains and pen-Mies 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 10.116 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total Iloors area(Sq.Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable 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"
i'
CITY OF &U&M. NLxss kcHusET rs
BuumLNG DEPARTMENT
130 WASHNGTON STRM.Yo FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI\tBERLEY DRISCOLL
NUYOR THOaus ST.PmRRa
DIRECTOR OF PUBLIC PROPERTY/BL'II.DLNG COMMISSIONER
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 l l 1.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit# 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:
��+,wtl�2 Carr Cry
(name of hauler)
The debris will be disposed of in
1 wohSTt
(name of facility)
ad ress of facility)
Y)
signature of pe mit plicant
date
debnvlf J•e:
fi CITY OF SALEM
=y ,, PUBLIC PROPRERTY
DEPARTMENT
a,m:of I y:)x[%(VI 1.
�l%)t nt 1 2-�WASHING ION 5 rxEkT • SAI1i M,MASs.ua tt iri j i%0197.".
Ila.:V11-76.9595 • Ksx. 97R-740-9S46
Yorkers' Compensation Insurance Affidavit: BuildersiContractors/Electricians/Plumbers
\wyiicant Information Please Print Leeibly
NamClllochMavnrganvatinNlndtvuluau: IflPh( /T� /'0�7�fAG�afJ•
Address: -WALAVi sl
City,smic,Zip: P`A \/, 144 / 191.0 Phone i!: enp,-5-31
:\,ryeQ,vouan employer!Check the appropriate box: 'Typo of project(required):
L LJt am a employer with 4. Q I am a general contractor and I f
C] New construction
employees(f ull and/ur part-ante).• have hired the sub-contractors
?.❑ I ;un a sole proprietor or partner-
Listed on rhe attached sheet �• C] Remodeling
- ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q. Building addition
I No workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repair or additions
rcquircd.) o8iccrs have exercised their
3.❑ 1 ant it homeowner doing all work right of exemption per MGL I LE] Plumbing repairs or additions
myself. [No workers'comp. c. 152,j I(4),and we have no 12.❑ Roufrcpairs
insurance required.) t employees. iNo workers' 13.❑ Other
comp. insurance required.) _
•any:yq,hcaut thm cheeks box AI muct:dao lilt uuuh<suction ln:low,hewing their w'utkui cumpensmiat pulicy intiurtutiun
'I lumatwtwn who.uarmit this affidavit indicting lhry arc doing all,wrk mvl then him outside eauraetom must suhmit a new affidavit indivasing uah.
4'ontnwmrs that check this box must auxhed.m additiunai.hetet showing the Cattle of Cho sub<onlrutun and their svurken'carp.policy infurstarion.
l ran wt eaydoyer drat i.t providing workers'c•untpen.eation imtturance fur umy enrpleyeet. Belnry is the policy wed job site
information.
Insurance Company Name: ,r -jtWAVAL 1A) s'. _....._----..------
Policy A or Self-ins.Lic.0: ,LJ C 1 -3L5 'J��l S2/- 4�.6_ Expiration Dale: G' 6, j
Job Site Address: /ak� 45 2d citylstateizip: o1976
,
Attach it copy of the%workers'compensation policy declaration pulse(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ul'.%IGL c. 152 can lead to the imposition of criminal penalties of a
Linc up m$1500.00 and/or one-year imprisoncnt,as well as civil penalties in the funn of a STOP WORK ORDER and a fine
of up in 5250.00 it Jay aguinst the violator. He advi.scd that a copy of this,mtctncnt may be furwarded to the Office of
In\'cstlgattons ul tlw DIA lbr iosurance covmgu,criticatiun.
Ida hereby certifyan ¢r thr pato,•mr prnoGics of prrjCity that the infunnution provided above is true and correct.
<ica;uuru
Date. /1? a116
rht.t:
Official use only. Do not write in ihi.t urea,to be coutpleted by city ur town u/jicia/.
Cily or Town: Nrinit/Licume 4_ ._
Issuing Authority(circle one): i
1. Board of Ilealth 2. Building Department 3. Cilli fmso Clerk 4. Metrical Inspector 5• Pluutbing Inspector
6. Other
Comact Tenon: _ - .. Phone.Y:
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this saatwe,an empluree is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
�rt the IJregoing engaged In ajoint enterprise,and Including the legal representatives of a deceased employer,or the
receiver or trustee of am individual,piumership,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 maintenunce,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."
NIGL 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 ally
:applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract far the perfomwnce 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-contractors)name(s),address(es)and phone nuntber(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 docs 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 stare to sign and dale the affidavit. The affidavit should
he 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. Salf-insured companies should enter their
self-insurance license number on the appropriate line.
City or'rown Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided is 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 till in the penmiLdicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pcnnitllicense 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 chat 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 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.
I he of lice of Investigations would like to thank you In advance fur your cooperation and Should you have any questions,
please do nut hesitate to give us a call
rhe Deparnncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oftice of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-7274900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
R:%iscd 5-10-05
www.mass.gov/iiia