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33 LAWRENCE ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of — Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, T"edition Building Dept PBuilding Permit Application To Construct, Repair, Renovate Or Demolish a *kmm*dW& U One- or Tyco-Familt-Duelling This Section For Official Use Only Building Permit Nu er: Date Applied: c� Signature: Building Commissio inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property,Address,Y S� 1.1 Assessors Map& Parcel Numbers -7� a MNumber Parcel Number I.I a Is this an accepted street?yes_ no_ P 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distnct Proposed Use Lot Area(sq R) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard RequiredProvided Required Provided Required Provided 1.6 Water Supply:(M.G.I,C.40,134) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes13 SECTION 2: PROPERTY OWNERSHIP' -------------- 2.1 wrier of Recorti� A�.9 AWS f S} t�d i�as n Name nnt) Addr�for Sery /�t.t� GG// �S� �o I Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ZI Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': 1 Ob ' SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: OMcial Use Only Item Labor and Materials 1. Building S I. Building Permit fee: E Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: f /) k 4. Mechanical (HVAC) S List: 5. Mechanical (Fire $ Total All Fees: S Suppression) Check No. _Check Amount: Cash Amount:_ 6. Total Project Cost: S 350 ❑ Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.I Licensed Construction Supen isor(CSL) r Jwrn-S 1 I IC�\��©� License Number Expiration Date N.4me of CSL jlpldrs1List CSL Type(see below) _ Em1` I� A A T- Description U Unrestricted u to 35,000 Ca Fe) g R Restricted I&2 Famd Dwellin "12,4/o RC %lason Only ` RC Residential Roofing Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Regis ered Home 1 rovemenI C ntractor(HIC) �rl� %y7Wrl HIC Co ppany game Qyr,�HIQRegtstrant Name Registration umber Add !`M` ° r /J 2zJ 7 �"vt ;� "/���j E iration Date Si Lure Telephone SECTION 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........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT ORCONTRACTORAPPLIES FOR BUILDING PERMIT 1, D O(.An O�(/t A'(�b as Owner of the subject property hereby authorize MGk rfnOT lC h•(1S (1 U C S} b/� to act on my behalf,in all matters relative to work authorized by this building permit application. aOwner Dat�11301o� Si nature of e —T SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I, 5`A�SJ 11 ' IC 1��'1 1(�(�� ,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. k Print me � �3u�o5 S n ure of Owner or Authorized Agent Date S ed 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 110.R6 and I I0.R5, 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 J. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALEM 1s PUBLIC PROPRERTY DEPARTMENT ,,con'. M'Ii IMHl, I1 12^ W,++11g\t:JON Scru:r • SAI rst, M.s>.Nsw ut it I I+J197-- Ih1. )78.76-9345 • 1:ex 97M.74,. 1.146 NVurkers' Compensation Insurance stridallit: Builders/Contractors/Electricians/Plumbers %oplicant Information Please Print Legibly �ialTC llh4+nw+YCl/�r�]nV.nimt'InJl+iduull:g Mill l'cSti: ' O L'fh\\� 11y\9-/ rn�� U���blhune. CirySlaca7lp 'Q._�e� ;•: .%re you an employer:' Check the appropriate box: 'Hype of project (required): 1. 0 I :un a employer with 4 I om a general contractor and l 6. New construction englloyres(full am6'or part-ague).' haec hired the sub-contractors 2, 0 1 ,un a sole proprietor or panner- listed on the :coached sheet. 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working Air me in any capacity. workers' comp. insurance. 9. (:] Building addition I No workers' comp. insurance 5. 0 We are A corporation and its ( required] officers have exercised their 10.0 Electrical repairs or additions 3. 0 I :cot is homeowner doing All work right of exemption per MOL I I.0 Plumbing repairs or additions myself.LNo workers' Lump. c. 152, ¢1(3),and we have no 12.9 Rocifrepairs insurance required) r cinployccx. LNo workers' 11.0 Other comp. insurance required.) -%I', .yphcaol that chcckt box 01 coup:Ibis till out the+emmos Iwiuw ihuwiny thea wonting cumpenusiws lwhcy udinnatiun. ' I Tomcat nen u'hu ud4mit that at'ndav it..J tooling they.rrc doing oil work a.d then hire"l%oe autur o:m,m must auhmit a new al Gdavil indiutma.u.h. (' )Atrol ihut whack this bot mewl ptaehcd.,n addaiwmal nlwet.how iva dw nalow of ow sub•contrserors and thou wurken'comp,puhcy mrurmarion /am un employer that is provirll workers'c•utnpenvation insurance jar uty ettiplayees. Below is rhe policy and job site inforinutian, ry Insurance Company Nameor A -- - —_—.---- 1'olicv a or Sclf-ins. Lic. F-:—w G 2.52'9_Y. S-0 _ ._ Expiration Date: G LZ S7- (I - Jeb Site Address: -' 3 Clty;Slatu"LIp: SA]LM1 MA 0IT7D .\(tach it copy of list workers' compensation policy declaralion page(showing rhe policy number and expiration date). Imadurc to secure coverage as required under Sccliun 25:\ul DIOL c. 152 can lead to the imposition of criminal penalties of a tine up ill 0.500.00 andel one-year iuspris.rmcnt,nas wvcll as cis d penalties in the lore of.a STOP WORK ORDER and a fine of up u) S250.00 is Jay .igainsl tilt violator. Ile advr+ed that a copy of this elatcment may be furca arded to the OI)ice of Ino an'Sa n,nb at :hc UL\ :or in+ot.mue a-seragu I anlScal:on. /,/a herchtilrtA under the pains and penullics u/perjury that the ia/urintlllon provided above is true and correct. �7 �-�' 3�Yzya tl f/icial rue only. Oo not ,ritsr its this area, tube co,uplrled by city or town official. t (-i Iv a fawn: ._ _ Put initi Lievnse 0. Issuing( .\uthurity (circle oni l: I. hoard of llv.dth 2. Btulding Dcp'.erunenl 1. Cily.-fuun Clerk J. Electrical Inspector 5. Plumbing; Inspector I 6. Od6er (lnctaet Pursuit: .. _. Phoned: Information and Instructions Io�s.lchusets Genesi Laws chapter I52 requires all cny)lo)crs to provide workers compensation fbr their employees. I'unu.mt to Clis statute, an rmp/uree is defined as" esery pclson in the service of another under any contract of hire, e%press or nnphed, ural or m men... .Xn e,npluprr is defined as"an individual, partnership, .usoeiatou, corporation or other legal entity,or any two or more ..r the h.rcgumg engaged it a pant enterprise, and including the !coal reprcseutatives of a deceased cmplu)cr, or the receiver or trustee of Al Individual, pwtucrshlp,association or other legal canty,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the ,Iwelhng house of another who employs persons to do maintenance,cunstrucnon or repair work on such dwelling house or 011 the.rounds or budding appurtenant thereto shall not because of such employment be deemed to be in employer." .%IGL chapter 152. §25C(6)also states that"every state or local licensing agency shalt withhold the issuance or renewal of u license ur permit to operate a business or to construct buildings in the commonwealth for any :ryplicani who has not produced acceptable evidence of compliance with the insurance coverage required." Additunal(y, MGL chapter 152, §25C(7) stades"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perforn)ance of puhlic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." .Applicants Phase rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of -ance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the instill members or partners, are not required to carry workers' compensation iluurance. 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 confimlation of insurance coverage. Also be sure to sign and Jule the affidavit. The affidavit should be I etmwd to the city or town that the application for the permit or license is being requested, not the Lhpartment of Industrial Accidents. Should you have any questions regarding the law or If You are required to obtain it wiorkcrs' n compensation policy, please call the Department at the umber listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials - Please he sura that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant. I'I:ax: 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 pennit�license applications in any given year,need only submit one affidavit indicating cunent policy information of necessary) and under"Job Site Address" the applicant should write "Al 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 petmim or licenses. A new affidavit must be filled out each Ycar. Where a home owner or citizen Is obtaining a license or permit not related to any business or commercial venture I i.e. a slog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I h.: •)f,kc 01 Invearlgjlioos lvuuld line to flank )-till in advance for your cooperation and should}vu base :u,y yuestiwls, please do not hesitate to give us a call. rhe Mp.utncnt's address. telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of lovesilradons 600 Washington Street Boston, MA 02111 Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE Fax 0 617-727-7749 d 5-rico' www.mas3.gov/dia 1 • � . _ Roaf0'LTBUPTBiit��BdB"R�� ;., _ '� HOME IMPROVEMENT CONTRACTOR , Registratton; 107847 1, Exp�i�tii 817!2010 Tr# 0 r 5'fy� ^1"n'ttNidual ,- - JAMES W. MCKINNON� James McKinnon 18 iEmily Ln L'L%..01960 AdministritGr Peabody, a N,.. iB "il'o u �h& eguYaito(s e` uB 9�"i'�Qs+'b ` 11IC6n` t'uctiO0$up Gvisor L��oB seg 1# ' iLicphs�a '�$ 27632ill" 'Birthdat v,928/19 ' ;� tiK 1 .{1(raa�* ;FOt 009; Tr*,45 4 11 JAMES'�W MCKINNQt(� 1 ; 18"E�MIL'Yi t.ANEF 'i PEAPROn Y,iMA�O]980 G"""� C0 ulilwlone.�, i '. s . Y a%" CITY OF SALEM Sul r; PUBLIC PROPRERTY - DEPARTMENT I I I 9-8.'4;.);a, • 1 t\ 'i7% 'J� Construction Debris Disposal Affidavit (required fior all demolition and rcnovaliun work) In accurdancc wili the sixth edition of the State Building Code, 780 CNIR section 11 1.5 Dcbi is, and the provisions of MGL c 40, S 54; Building Permit h is issued with the condition that the debris resultin.- from this work shall he disposed of in it pruperly licensed waste disposal I'acility as defined by MGL c I 11. S 150A. The debris will be transported by: WA3�� I name of hauler) I he debris will be disposed of'in �A A\x{11 rv�� I g�IL -..__.. (name ul 16cility) ai n I Y`n Z J`5 -IQo S+ �mldresv ul'ractlity) a�nwwc of p:nnrt.ytplicum � I. X165