Loading...
183 HIBERNIA LN - BUILDING INSPECTION r ♦ II The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7"edition Building Dept U/1 QQQ Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Tmo-F nnily Duelling dogma This Section For Official Use Only Building Permit Number: Date Applied: i Signature: Building Commissioner/Inspect uil Ings Dam SECTION .SI E 1 FORM ON 1.1 ro ert Add ess: sse n Map& Parcel Numbers I.I a 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 R) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(MITI,c.40-554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system O Public 13 Private❑ Check if XesO SECTION 2: PROPERTY OWNER$HIPI 2.1 Owner'of Record' I O � A7j0 s� rlService:L�Name(Print) _5 - /_&_ 8%( _/ �r 9'3�?- Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bld ❑ Number of Units_ Other ❑ Specify: f Description of Pro ed Work': i9.5 SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building 5 I. Building Permit Fee: S dicate how fee is determined: Cl Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing E 2. Other Fees: $ 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees:S Suppression) O Check No. _Check Amount: Cash Amount:_, 6. Total Project Cost: 5 �°� Q),j ❑ Paid in Full ❑Outstanding Balance Due: �YVri —7-0 C"—j(Z(J-LToh I ` �� SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) iD �yr mber Exptrauon Date N�me of CSL Helder CJ�T pList Type(scr below) Ad -s ° fy,� Description / nrestncied u to 35,000 Cu. Ft.) S natu estricted 1&2 FamilyDwelling 3 ason Only esidential RoofingCovering rlephone esidential Window and Siding esidential Solid Fuel Burning Appliance Installation esidential Demolition 5.2 R istered Home 1 o e t ontyactor(HI ) ucry�s�i6i � h�rarE a.,c�,3r��T /I3y3S HIC om ny Na a orPI Re istr t N e Reg suation Number Ad ss 0 o < p.� C53-Y)por,37A/3 Expiration Date ignature Telephone S CTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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...........O SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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. Signature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 1, Jerry 46, 41,�5 ,as Owner or Authorized Agent hereby declare thatkof0wner and information on the foregoing application are true and accurate,to the best of my knowledge and beh , PrinxSignr Autho zed Agent Date Si rs and penalties ofperjury) NOTES: I. n 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 IO.R6 and 110.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' ,i CITY OF SALEM PUBLIC I R PRERTY O DEPARTMENT I,li'. wI) In I,t ,'l l kl""« 12: WA It 11\\;IU\SIALL I' • 5.\I I'M. M.\a.\c III it 11,3197-- 11%j, 1x/7-- Ih.l. 17871y93115 . 1'\x `1711-.'1;'1816 Workers' Cumpensation Insurance %fffdax]t: Builders/Contractors/Electricians/Plum ben xmilicant li furtnrlion /) Please Print Legibly �L V;IITh:tuu.11ksinr;;anlr.oialvinal,iJuun: W<Y(.(fh')�/�Sy'��0�',�Ge riS /Yf7A/��Q���/ Address: cily,slare,iip:_7 1y/ �/ � r00 fO Phont .ire \ " an employer?Chec the appropriate box: 'I)pe of project(required): 4 I oro a general coutraetor and 1 1. I :un a employer with ❑ fi. New construction e ntployces(full amL'ur part-time).• hake hired the sub-cuntracturs 2. ❑ 1 .un A sole proprietor or partner- listed on the anachc, sheet. 7. ❑ Remodeling ship and have no employees - These tub-contractors have K. ❑ Demolition - \.urking Air me in any capacity. workers' comp. insurance. q. ❑ Building addition I No workers' comp. insurance 5. ❑ We area corporation and its I rcyuircd.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 unn it homeowner doing all work right of exemption per MGL I I.❑ P11 robing repairs or additions myself [No workers' comp. c. 152, §1131,and we have no 12. uuf repairs in.urance required.] r cinploycea. [No workers' comp. insurance ruquired.1 13.E] Other •I." yphcma Ihot checkt box ell mold alba Till oro the wLlion Iwluw allowing their w•urk<n'cumpen s ion puhcy in6urrutiva ' l tomeownen who ssdlmil this atildav it indicating They tie doing all work and Ihen him uutslde cumraenon must auhmit A new,ardav;l;ndi"'ng ankh. -(„m rxlun that shock this box Mimi anxhcd.m aedaional bfwcl,huwmv tike matte of the sub-Contrxion and their wurkan'comp.policy Mfurmanun /,,or un employer that dx pruvidiog lvurkerx'c•unrpermuian• iin.rurance jar my�+eurpluyeeerte. Belinv iis'rhe pulity mu/jab site njurrnuriun Irsuraucc Company Name: xftw/rO/ Policy aur Self-ins. LicaK: t,19O V/o0/T2�9ls4u. _r__ YEw-p—irC att/o1n.—Da rtye:I_J�G -0 lab ,it,: Address: 43 p may, Coy:StatuLlp: 5 �/✓/3`r ©l/!(/ .\each it copy of the workers' cumpcnxatlon policy declaration pale(showing the policy nwnber and expiration date). I•atluic to secure cu\erage as required under Section 25:\ul'\IGL c. 152 can lead to the imposition of criminal penalties of a Ane up to il.500.00 andlur ung-)car imprisonment, as well as ci\II penalties in the form of STOP WORK ORDER and a fine of op to is-50.00 a J,ty .Igaitut the violator. rte advl.wd that a copy of thisstatement may be f'urwarded to the Office of Ian;.I r,aa ms ul"',liv UL\ :or Into ircc a\k cr.l,c \elI iLiLon. /ala hereby e errify uuJer else pour ua Ie t drirx filer'a that the in/brimadon provided above it true mid correct. :1•.,.111,_- - -- -i).,t�-- [ity u!u\t ally. Oo nat Ir rite in this arra,to bet uruple lyd by city or town a//iriul. i r I ;%vn: Pur mitiLiccnce At g.\ullwrily (circlenoe): ill L Iholdiny Departmunl 1. lit..'I'own Clerk J. Electrical Inspector 5. Plumbing Inspcetor crct Pcnuu: .. .- Phone It: Information and Instructionso \1.1�5.tillUSClt) VCncral Liwi ehapler I52 Iegwre)ail employers to provide workers' compensation for their employees. I)urmi All to Mis +laude, an empfuree is defined.s " es ery person in time scrviee of anuiher under.my contract of hire. %press at implied. oral or wvnnen." .\n empluyer is defined as "an individual, partnership, association• corporation or other legal cattily, or any two or more .r rhe Ioreeoujg engaged m a joint enterprise. and including the !cgii representatives of a deceased cmplu)cr,or the rr it,. t Jr Iru)IeC UI .til individual, palrnehhlp,association or other legal clarity,employing employed. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the ,lwrllulg house of another who employs persons to do maintenance•construction or repair work on such dwelling house L11, ot, the.rounds or building appurtenant thereto)hall not because of such employment be deemed to be in employer." NIGL chapter 152. �25C(6)also states that "every state or local licensing agency shall withhold the issuance or renelval of u license or permit to operate a business or to construct buildings in the comtoonwealth for any applicant wlio has not produced acceptable evidence of compliance with the insurance coverage required." Additionally. MGL chapter 152. 425C(7)slates"Neither the commonwealth nor any of its political subdivisions,hall enler into any contract for the performance of puhlic wurk unit] 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-contracior(s) name(s), address(es)and phone number(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 erployees,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 aff idavit should be: reuinled 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. Sclf-insured companies should enter their self-insurance license number on the appropriate Linc City or Town Official please he sure that the affidavit is complete and printed legibly. The Department his provided a space at the bottom of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant. I'I;asc be sure to till in the penniulicense number which will be used as a reference number. In addition, an applicant that must Submit multiple pcnnitaiceise 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 i.e. a Jog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I h: i)tYiic UI Invelrt.ationi would Ilse to drank )'nu in ady;iilce for your cuoperati011 aild should you Imasc any questions, pleise Jo 1101 hesitate to give us a call.- - fhe Dcpamncnt's address. telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 :f:•. ,..d '�,-us www.mass.gov/dia A _ ,', :e VI CITY OF SALEM Il` PUBLIC PROPRERTY DEPARTMENT I11 7'8-'4i.7;aj • 1 %C:•;-% V=•iib - Construction Debris Disposal Affidavit (required ler all demolition and renovation work) In accordance %%ith the sixth edition of the State Building Code, 780 CAIR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit N 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: If 70;7 (flame tit'hauler) - - 'I he debris will be disposed of in (mune of lei ii yi ) (addrex.of fay Iity) JUL/!- . a�namrc of lxnnit applicant G � date