Loading...
112 LORING AVE - BUILDING INSPECTION �- One or Two-Family Dwellinu The Commonwealth of Massachusetts * Board of Building Regulations and Standards Massachusetts State Building Code 780 CMR, 7"Edition Application to construct,alter,renovate repair or demolish �� ThirSE` on Foi3Officral iJse0ii1 Building Permit Number: �• Date application: Signature: ? Buildin Commissioner/Local In ecto Date t , �F��ON i ' S`I3`E T1Vi~�IiMAT�1QN � ' 1.1 Property ddr ss: 1.2 Assessors Map&Parcel Numbers t -o —�— 1.1a Is this an accepted street? Yes V No ❑ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(feet) Front Yard Side Yard Rear Yard Required Provided Required Provided Required Provided 1.6 WaterrSSypply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public; Private❑ Zone: Outside Flood Zone? Check if yes ❑ Municipal❑ On site disposal system ❑ 1.9 ZBA Special Permit 1.10 Old &Historic Commission 1.11 Conservation Commission Date filed N/A❑ Date filed N/A❑ Number 40- N/A❑ 2.1�OwnerofRecor s � e(Print) Address for Service 2' —�& S' oi el 1 � f 1e Owner �(E-�4E Te1�ln��1 } New Construction❑ Exist ng Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify: SECTION 4;.;. EST IMATE.D CONSTRUCTION COSTS :BUILDRVG P.-V FEE Item Estimated Costs (labor and materials) This Section For Official Use Only 1.Building $ J�7760 0 Building: $10/$1000 2.Electrical $ /v ��� Building+Plumbing:$12/$1000 Building+Electrical: $13/$1000 Building+Electrical+Plumbing combined: $15/$1000 3.Plumbing $ Tota]project cost(labor and materials)$ 4.Mechanical (HVAC) $ Fee multiplier from above$ /$1000 5.Fire Suppression $ 56d0 \ 6. Total Project Cost $ Permit Fee$ Receipt Number SECTION 5: ,;;CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) r�,� � ��f6 M*- / License Expiration Date 3X13-/! Name fes=:CSL ' -� �F'/V Type Description Va • �-�/! U Unrestricted(u to 35,000 Cu.Ft.) Add ski s`— R Restricted 1&2 Family Dwelling 1W. M Masonry Only Signare RC Residential Roofing Covering WS Residential Window and Sidin Te eph e SF Residential Solid Fuel Burning Appliance D Residential Demolition 5.2 ome Improvement Contractor Registration(HIC) ��f!/ Registration Expiration Date/L-/YJ- ;g HIC Company+ ame or AIC Regi trant e A es �. 1�w 4V Tel p--� ✓"�-�----p- SE�STI�N 6 > r1�'Q12'�R'$C'QIkSP�NSA�IO�T�INSU�tP,NCE AFPTDA�3'(14I°G L.c I52 '§�ESC(b�� �' "tet, � , Worker's Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide an insurance affidavit may result in the denial of a building permit. Signed affidavit attached? Yes No ❑ x��r r w 'les�`?cr R .✓ r.' T"z Ys}ti,_ � _£ t 3 r m. r �EC�I0N'`3a OWN'�,R�`[I3'H0I�Ze�TI01�T�'O,�EC"�OIVS��.�<LED�'1�L+N'AI?1'�T�R'SA�UEN7'0$ ,„«*� ''fi - r C0I�IRAGTR APPIESdOR BUILI� C�P � } s r 4 F s * ,A �. (vim ,f€t, tile «maw... -sx.,rn Ys-n trm .✓.8.. k.1 ,.3ry xbR ,`➢'-.n+fli.A 'K m.�o . >aM���•,:*.R I, as Owner of the subject property,hereby authorize ��L�t•��t & ��� to act on my behalf in all matters relevant to work au rtz this oil mg permit application. SiEnaturor0wAer Date ECTIO)\71fdx_OR�ER`0 Alli IORIZED,A.Q 1 I DECLARAT3(91a, w I, ezaog as Oumor-or Authorized Agent,hereby declare that the stat n and n ation on the foregoing application are true and accurate,to the best of my knowledge and belief. e 11 Si torer r u orized Agent Date (Signed der the pains and penalties of perju ) NOTES 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 1 IO.R6 and 1 I O.RS. When substantial work is planned,provide the following information: Total floors area(Sq.Ft.) (including garage, finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Number enclosed of decks/porches Habitable room count Number open of decks/porches Number of bedrooms Number of fireplaces Number of bathrooms Type of heating system Number of half'baths Type of cooling system CITY OF SALEM PUBLIC PROPRERTY ''"? `"` n*,fg� DEPARTMENT 111 tlt 120 WA.il ll.Xl.;(1.V SrIICrT # 5.\I r\t, `t.\tiiAl l It iI Ii JI`i". G1:9'8-'43.9;95 • FAX:978.740-9846 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 111.5 Debris,_and.the.provisions.of:MGL c-40,S_54;___, Building Permit Ik _ is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c 111. S 150A. The � til debris will be transported by: p �A ••" (name of haadq&) / The debris will be disposed of in ( larne of facility) (address of facility) r -t gna ore f(erinit applicant date 40111' 11 due CITY OF SALEM ; . ft PUBLIC PROPRERTY -,�� DEPARTMENT \INNt 4% I 2C�WA\hll\G IU\SI'SEkI'O SAL Ii N,M.\11.\CIII 9I-IsOl97.^ fh.f.;WS-715-9593 • T.,x.97y1-74C--)346 %Vorkers' Compensation insurance Affidavit: Builders/ContractursiElectricians!Plumbers \nnlicant Information Please Print Leflihly V it lTll' l0u<nkss/OrgmlivatioNlndlviduull:��0,���������` Address: t /ri Ciry'slarci%ip: /I r T Phone i%:q7 :\rc you an employer° Check the appropriate box: 'Type of project(required): 1.❑ I any a employer with 4. un a general cautractot and I G. ❑ New construction employees(full and/or part-time).` have hired the sub-contractors _.❑ I am a colt proprietor or partner- listed on the anaclecd sheet. t �• em elite - ship and have no cinpluyccs These subcontractors have 8. emolirion working for me in any capacity. workers' comp, insurance. 9, ❑ Buil o g addition I No workers'cattle. insurance 5. ❑ We are it corporation and its ra uired.] o. iccrs have exercised their 10. lee icor!repairs or additions 3.❑ I ant a homeowner doing all work right of exemption per NIGL I I. numbing repairs or additions myselff, ho workers'comp. c. 152,§1(4),and we have no 12.[�2iwf repairs insurance required.1 t employees. iNo workers' 13.❑Other comp. insurance required.] 'Ally enp6cwa Iha checks box 1#1 must also fill out the sco,un it fuw showing ihcir workuti cumpenwliwt Fwlicy infornutiun 'l lumcowners who uihmif This affidavit indicating IN)am doing all worliand men hire outside cot mactors must•uhmir anew aftdavie:ndicuing mach. -C,mlrxWn Iha1 shuck this box mime anxhcd an addieimal.sheet showing the nmtm of thti sub<untrxfm and their workers'comp.prdicy infurmariun, l one un enrptoyer dial/r pruvidi"workers'c•ontpen.enlinn insurance jar toy entployeev. Below is the policy and job.Vile itijurntution. Insurance Company Name:-_.... --- --- Policy 4 or Self--ins. Lic.Ti: .. ....__ Expiration Date: Job Sitc Address: jl�4( 09l[(/GI GCapstale/Zip: Attach n copy of lite workers'compensation policy declaration pate(showlng the policy number and expiration date). Failure to secure coverage as required under Section 25A of'.'IGL c. 152 can lead to the imposition of criminal penalties of a find up to 51.500.00 and/or one-year imprisomncret,as well as civil penalties in the 1'unn of a STOP WORK ORDER and a fine of up as )'_50.00 it day against Ilse violator, nc advised shut a copy of this watcmcnt may be-I'urwarded to the Office of Inv,sogjttmu ul'thc DIA for insurance envcragu \ciificaliun. I do her chy rcrtify under theins mid pet t tics ufperjury that the in/brinalleen provided above is free*and correct. tii�r:vuure: �72 Date, I'hurc + Official use only. Do tint Ive-he fn this area,to he conspleled by city or town n/JPrial. City or'fown: Pcnnidl.icente d.__ __ Issuing Aulhorily (circle one): I. Board of lic;dth 2. Building Department J. Cit).Iotso Clerk 4. Electrical luspecror i• Plumbing Inspector I 6. Of her Contact I'cnuu: __ Phone 'l: Information and Instructions %I:Issachusetts GCncral Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an empluree is defined as"...every person in the service of another under any tonlmct of hire, express or implied,oral or written." An empluyer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more ,f the lbregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,prumership,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 shad 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. NlGL 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 till 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 Qin number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. - City or Town Officials Please he sure that the affidavit is complete and printed legibly. The Department has provided u 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. I'luase be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pennitllicense 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 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he 01,icc of Investigations would like to thank you in advance fur your cooperation and should you have any questions, please do not hesitate to give us a call. The Dcparnncnt's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Offlee of Investlgatlons 600 Washington Street Boston, MA 02111 Te1. 11617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 R,%i%cd i-26-05 www.mass.gov/lila go1w,Ce O C W ff r TL✓RI /YCGO(ifif0 ug 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Registration Reglst t Contractor omelm ro H improvement e istration: 161666 R9 Type: LLC' _ Expiration: 11/14/2012 TO 206474 RGN COMNSTRUCTION & REM© GN _ - _ 1 OI -- ROGER NSEUX 68 B LORING AVE. SALEM, MA 01970 �- (\,` g- fsNp(late Address and return card.Mark reason forLost Card .. �. ,Y ❑ Address 0 Renewal Employment DPS-CA1 0 60M-04/04-G101216 Valid for individul use only Offi�h +a �axkvw� before the expiration date. If found return to: -- HOME IMPROVEMENT CONTRACTOR Type Office of Consumer Affairs and Business Regulation Registration 161666 10 Park Plaza-Suite 5170 Ezpuatlon �11114I2012 LLC Boston,MA 02116 COMNSTRUGTION-WREMODELING CO LLC t ROGER NOISEUX, ; `1 68 B CORING o li wi t 1 r SALEM.MA 01970 Z'' .+% Undersecretary - r Massachusetts- Department of Public Safe,,. Board of Building Regulations and Standards ��SSII Construction Supervisor License License: cS 66533 . Restricted to: 00 JAMES F NELI PO BOX 8191If SALEM MAU1970 "Ex iration? ('umatiesiuner p 3/23/2011 Tr#: 11945 .. Restricted to: 00 00- Unrestricted 1G-1 2 Family Homes Failure to possess a current edition of tht Massachusetts State Building Code is cause for revocation of this license. Referto: WWW-Mass.Gov/DPS s