8 LORING AVE - BUILDING INSPECTION Too '", ia
sa�h The Commonwealth of Massachusetts `I
Board of Building Regulations and StaandaYsr .: CITY OF
Massachusetts State Building Code,780 CMR SALEM
i� �evrsed Mar 2Q11
Building Permit Application To Construct,Repair,RerA*tQ*H�toAh
00 One-or Two-Family Dwelling
Was For qT2LtAse .'
Buddtag P lt.Ahattbea . Date Appliod-
Sailing 0ific�t(Prat kite) Sigeabnc
j SEC']IOIu I:SITE IN1rOR147ATION
1.1 Propkrty�Address: nn 12 Assessors Map&Parcel Numbers
Lla Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) - Frontage(S)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
I.6 Water 5gpply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Pub] Private O Tkme: _ Outside Flood Zone?
Check if esO Municipal G'�On site disposal system ❑
S7C1TON2i PR4PERTYOFYi!1&RSIi#i't
2.1 Owner of Record:
�. l Sm.4 er' S111, 144 d 1 rt -7 4:7-
N
N e(1Rint) pp f] City,State,ZIP'I
l�tLr�.d<,r'7�"�ti.rN �9?��7`'l l�r�`?.3Z Jr`'"."1�'� ✓ric w�sri,o}'
No.and Streeter Telephone Email Addre
SECTION 3:DESCRIPTION;OF PROPOSED WORK'(eheek an that apply)
New Construction❑ I Existing Building 91 Owner-Occupied ❑ Repairs(s) Alteration(s) 13Addition 03JDemolition O 1 Accessory Bldg.❑ 1 Number of Units_ Other O Specify:
Brief Description of Proposed Work': D lac d- oxw ;zf tN o t*
.a- � t/t[ 1s 410 J CLeJ .. ��
rAtAlote: K, 1:N s-t` fes- `i-tek Se, tm2 dhlfa o
SEC17`1YN 4: Id CONMUCTIQN COSTS
Estimated Costs:
Item Estimated Use Only .
(Labor and Materials
i.Building $ Kaoo, 1. Buik#iug Ponnit Fee:$ Indicate how fee is determined,
El Standard City/Town Application Fee
2.Electrical $ Cl Total Pr*d Lost'{Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Zook No. Cheek Amount Cash Atnotmt:
6.Total Project Cost: $ 17 Paid in Pull O Outstanding Balance Duo
i
a�critnv�: cx�vuc t��ry s�c�c�s
FConstruction Supervisor License{CSL) C, S` 03„]5
'J c '{y/t[..F$d'O Limse Number / irabon Date
L Holder _.� _w�7JIr
List CSL Type(see below)etrfl j'44d- �R d (1Q -] U Unrestricted din u toM Dcu.ft.
ZIP R Restricted 1&2F Dwelling
M I masonry RC Roofin CoveringWS window and Siding 7 Zell fj'. GL a�c.S e d�Gc�t Nie. SF Solid Frcel BuriagAppliancesInsulation
Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
9664rit--F. bil-)or on /a on
HIC Registration Number Expiration mgDate
de
aoy N _ or H gistr�ut Name 1 t
No.and gStr et �q� If . u r i iS r D G�toriCkjf R! '
cJ U� -f'ia 0— pld� a/(t ?4 l 740-FV R1 Email address
Ci /Town Sfate.ZIP Te] hone
SEMON 6:WORKEW COMPE111SAUON B+iSII11RANCEAF'MAV 7r OLGJ..c.1S2 25C(ti))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit
Signed Affidavit Attached? Yes.......... No...........O
SECi'tOl+lIn:OWNERAU 1 MA 7bB COWILMb WaK
1,as Owner of the subject property,hereby authorize )eALCI CK �plyi i o
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SEt::TTON Tb:OWNEW OR AUT RORIM AGENT DECLARATION
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 accur the t ofr ledge and understandin/gg..
on �g
Pent Owner's or Authorized Agent's Name(Electronic Signature) Date
Nf)TES: :
1. 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(IHC)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
wlvw.mass, op vioca Information on the Construction Supervisor License can be found at www,.masss.gov/dys
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 haWbaths
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
I
The Commonwealth of Massachusetts
Department oflndustrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgovldia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE PILED WITH THE PERMITTING AUTHORITY.
AonlicantInformation / Please Print Leeibly
Name(Business/Organiution/Individuaall)})..: y7�� /C��,Fh-LhtJ C v/Lf alay;4 M,¢t !i?.0i'LU1 6 a.,z'
AiidI'eSS: Zs
City/State/Zip: ojO 0/f6.-),_ Phone#: ' Wj Ste!'` —333
Are you an employer?Ch k the appropriate box:
Type of project(required):
1.®'1 am a employer with .�employees(full and/or pan-time).- 7. 0 New construction
2.01 am a sole proprietor or partnership mid have no employ=working forme in g, f—I Remodeling
any capacity.[No workers'comp.insurance required.]
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.)t 9. n Demolition
10 n Building addition
4.0 7 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the amched sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurances yt�
6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14"�Other dirt'
157,§1(4),and we have no employees.(No workers'comp.insurance required.) +tepiace S ,C1 f a.-si 1713S
'Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing an work and then him outside contractors must submit a new affidavit indicating such.
lCommemrs that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. if the sub:connactors have employees,they must provide their workers'comp.policy number.
1 asst an employer that isproviding workers'compensation insurance far my emplayees. Below is thepolicy andjob site
information. yy��
Insurance Company Name: phi
Policy#or Self-ins.Lia#: yy G t� 5 d Y SS.+2()/� Expiration Date: ^ 3'"a2 Ul7
Job Site Address: 4-0Y17"4 ho-Ci City/State/Zip: ,A
Attach a copy of the workers'compensatiob policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify
Fu ,r/he�pains and p of jury that the information provided above is true and correct.
Sienature y�? i �f/ - Date
Phone#
Oficial use only. Do not write in this area,to he completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
2.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 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
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 aparbnents 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)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
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 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-insured companies 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"lob 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.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. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 02-23.15 www.mass.gov/dia
ROBERT E DILISIO INC
AKAR DILISIO CO INC
CONTRACTORS
113 Fayette St.
Lynn, MA. 01902
Tel/fax (781) 599-3332
r.dilisiokcomcast.net
August 08, 2016
City of Salem
Public Property Dept.
120 Washington St.
Salem, MA. 01970
(978) 619-5643
INSURANCEAFFIDAVIT
Please be advised that Robert E DiLisio inc also doing business as R DiLisio Co Inc are
currently insured With Workers compensation insurance with ASIC, 54 Third Ave. Burlington
MA. 01803. Policy number WCC5005014755-2016A.
Si ely,
Robert E DiLisio
President
PT=7777
Office of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR -
t egistration: 181008 Type: 1
piration: 2117/2017 - Corporation
.ROBERT E.61LISIO.INC.
-
i
• � RUBERT DILISIO
L 4050 HUMPHREY ST g
a< SWAMPSCOT-r MA 01907 - —�
Undersecretary
L...
e artment of �ubety
ulatlons: rds
Massachusetts D p
Buildln9 Reg
Board of
License: CS-035792
Construction Supervisor z
05 14UMP14 TREET
01 0
SWAMPSCOTT MAA
Expiration:
1210212017
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Construction Debris Disposa/Affidevit
(required forall demolition andrenovation workj
In sewrdance with the sixth edition of the State Building Code,780 CMR, Semon 111.5 Debris,
and the provisions of MGL c40.S 54: BuiMine Permit A is Issued with the
condition that the debris resultfrxg from this work sha8 be disposed of In a property rkensed
waste deposit faculty as defined by MGL c 111,S 150A.
The debris will be transported by.-
(name
y:(name of hauler)
The debris will be disposed of in:
(name of bdi�
(address of facility)
Signature of applicant
L �`-
Date