12 LOONEY AVE - BUILDING INSPECTION The Commonwealth of Massachusetts RECEIVE _ �l�1 OF
9 Board of Building Regulations and Standards SPECTIONAL 5 RV1QU,I
41 / Massachusetts State Building Code, 780 CA��� Revised.L/ra•101/
rBuilding Permit Application To Construct, Repair, Renovate A4rtljlij4 Z. Q Q
t� One-or Avo-Family Dtivelling ( 7 IVU
i This Section For Offic a)Use Only
L Building Permit Number. Dat .Applied
Iuilding Official(Print Naive) __ Slgnat" - Date
SECTION 1.SIT9INFORrMATION
1.1 P r Address: Assessors Map&Parcel Number
i? E
L I a Is this an acre to street?yes no Map Number Parcel Number
Zoning Information: 4 Property Dimensions:
Zonin District Proposed Use LorArea($q R) Frontage(R)
1.5 Building Setbacks(R)
:.. .. .
- Front Yord Side Yards - Rear Yard -
Required Provided Required P.rovfded Requited - Provided
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Inrormatloa: 1.8 Sewage Disposal System: '
lie❑ Private O. Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check lr esO
SECT[ONZ: PROP61tzv-OWNERSHIP!
l Ow ert of Record:
w(Pn )
. . —�y Telephone El
No.and StmM Email Ad
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)`
New Construction❑ 1 Existing Building O Owner-Occupied O Repairs(s) C3 Alteration(s) O 1 Addition O
me t' n D Accessory Bldg.O . Number of Units_ Other O Specify:
Brief Des iption of Proposed Work':
SECTION 4:ESTEMATED CONSTRUCTIOV COSTS
Estimated Costs: Official Use Only
Itan Labor and Materials -
1. Building s j I• Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee.
2. Electrical $ ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S ? Qther Fees: S
4. Mechanical (FIVAC) S List:
S \Ieressiocal (Fire - ,5�� 'total All Fees:S
$11 rC55i0a) �/ -
��JJ �
Check No._Check Amount: Cash Amount:
G.Total Project Cost; S� 7�,�� ❑Paid in Full ❑Outstanding Balance Due:
-1'0 N o �a)
�` VE—fC�At_ L1ty (:--1---)
fn,(a tL�'.7 tt'Z3
SECTIONS: CONSTRUCTION SERVICES
5.I Constructs n Supervisor License(CSL)
License Number E.piration Date
Name
SL Mulder
Clan" List CSL Type(see below)
No.:md 'trect p Type - Description .
Unr
U Restricted
1 2 Family
up to Dwelling cu.Il.
R Restricted I&2 Famil D+vellin
Cityfrown,Stale,ZIP M masonry
RC Roolin Covcrin
WS WindowanJSiilin
SF Solid Fuel Btaning Appliances
I Insulation
Telephone Email aJJrcss D Demolition
5.2 Registered Home Ira rovement Contr ctor(HIC) �
HI/Regis ton Number Expiration Date
IIIC Company N e or f11 egistra t e
No.and S rn e� Email addressf
Ci lfowri State ZIP Tel hone
SECTION 6:WORKERSP COIVIPENSATION INSURANCE AFFIDAVIT(M:G,L,c.152.i 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 Isivance of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION Tat OWNER AUTHORIZATION TO BECOMPLETEDWHEN'
OWNER'S AGENT OR CONTRACTOR APPLIES.FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize
t9 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:OWNERt OR AUTHORIZED AGENT DECLARATION
Dye in name bel hereby attest under the pains and penalties of perjury that all of the information
contained in this. Ion is true and accurate to the best of my knowledge and understanding.
Print Owner's or Aulho zed Agent's Name(Electronic Signature) ate
NOTES:
1. An Owner wh6 obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
_knot registered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important mfoimadon on theHICYrogrim can a au r#�t—
www.massyg_ov'oca Information on the Construction Supervisor License can be found at+y �_(ww.rnass. ov;J(rs .
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. ft.) xx ,(including garage, finished basement/attics,decks or porch)
Gross living area(sq. it.) 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
7. "rotas Project Square Footage"may be substinncd i'or"'rutal Project Cost"
The Commonwealth ofMassachusetis
Department oflxdumidlAceidents
I Congress Street,Suite 100
Boston,MA.01114-1017
www.masxgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers-
TO BE PH.ED WITH THE PERMUTING AUTHORITY.
Amplicaut information le
Name(Business/Orgamzation/fadiv dual): _ .
Address:
Ci
zT
• ..t e/ /�
/State/ZiP Phone#:
IY
AR1.
oa emp]oyer7checkthe pp"Prlatebox: jy.peofprojeci(re u[red):
I. am a employei V VA L_ CWIDyeea(full and/orpart t®e).• - 7. []New construction .
2. a soba proyietoror pM1Maxhipapd have no empbyem wodldn frac in & 0 Rrmodelm$
oral'�pa�ity.INo waken'comp.instxance requved.] - -
3.0Ism a homeowi'er doiog all work mrae]l:[No workers'mmp.,iaamance aqu6ed.,I t 9. ❑Dtartolitian
4.01 am a homeowaerand will be h rms eO5 tractmto 000dMct all work Omy .property. I wrB 10 Q Bw711ing atklihOn.
emme that all contractors eifierhave workers'compensafion msmaace orm sole 11.0 Electrical repairs or additions
pgpdaters.withmeenpl%easbase onthe 13.[:IP]nflbmg repairs or additidiis
5.E3 Ism a general convector and 1have hued Poe sub•coOae[ora listed heaaeahed ehwe
] sub-cootrectoes have employxe and have wmkm'comp,mnnaooe.t ... _ pairs
6.0 we are a corporation and its officers have exercised thelrr4m of exemption per MGL c. 14.0 Other
152.§I(4),and we have M employees.[No workers'COMP msmance requked.I -
•Am eppliiutihetcfiecka toa#]must aleoY`id dieowakes Ompmmbon policy mfmmahon.
t Homeowners who submit this affidavit indicating they are donig as work end then like collide wdmctas moat suLit a nnv t%davtt mdtmOg ouch:
IC,aa airon that cbeck this boa mustattached O additional sheet showing �
do ecfdte sub-w as and slate vd m or eat tLme emkies have
emp]oyeea. If dm sub—haGaa have employees,lbeymustpuovidethear-wtera:.c®Rpolicya®bar. ..,:.
I am aq . to er that a vidtn rworJrets o jor nay employees. 8ehew is tllepoliry and%ab s#e -
�p Y pro 8 ' utpenarmoon ins ce
Infonnadon.
Insurance Corryany Name:
Policy#or Self-ins.Lic:#: Expiration Date;
Job Site Address: �� City/S�t� P
Attach a copy of the workers'co tion policy declaration page(showing the policy number and expiration date).
Failure to segue coverage as required under MGL c. 152,§25A is a critmnal violation punishable by fine up to$1,500.00
and/or one-year imprisonment,as well as civil pmehies in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day tagaiost th y of this statement may be forwarded to lfi'Office of Investigations of the DIA for insarance
covers aificatiou.
I ereby certify under sins and penaities ojperJary thaf the information provided above is tgfe and',n
one C/t�
011iefd use only. Do not write in this area,to be completed by ay or town qfficfal
City or Town: Permit/iicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town 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 their 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 writ"."
An employer 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 an 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 Issuance 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 commonwealth 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 completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)narce(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
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 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 Deparmrent 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 line.
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 permit/license 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 proofthat a valid affidavit is on file for f rtre 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.e.a d(?g 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. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
111 pip 11,1,11 ''1
0
IT'cc Of Consumer Affairs&Business Regulatiun
OME IMPROVEMENT CONTRACTOR
egiStration: ;?36580
'Expira Typo:
tlon:�BIM2616-
Pdvate C
OrPorati
�;'RINE HOME IMPRQVE
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*Undersecretary
----------
Massachusetts -Department of Public Safety
Poard of Building Regulations and Standards
�Conktruction Supen isor Specialt
License:.CSSL-106010
MICHAEL TRANYE,
273 CENTER SME
Hanover MA
TV
f 'i I Expiration
Commissioner 05/11/2018
07Y OF SALEM MASSACHUSE M
BEaDngGDEPARnam
120 WA9fiJG7UNS7REET,3"FiooR
IkL(978)745-9595.
K11A FAX(978)740.9846
F.RLEYDRISOOLL
MAYOR T KUM ST1'EW
DntEcrcutOrrURUCPAOFMY/BUUDMOOMM 9ONER
Construction Debris Disposal Affidavit
(required for all demolition and,renovation worky
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL coo,S 54; Building Permit 8 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 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be dispose of in:
( a of facil ty
(address of facility
Sig ature of ap licant
Date