3 MASON ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
(� Board of Building Regulations and Standards
v ` Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
�l. B P
Building Permit Application To Construct, Repair, Renovate Or Demolishlish a
One-or Two-Fawil}'D,velling
This Section For Official Use Only
Building Perml
umber: Date Applied: /
Signature: \ Vq
Building Commi loner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 iroperty Address: 1.2 Assessors Map& Parcel Numbers
�I asO�t
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Res
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici On site disposal system ❑
Public Private 13 Zone: Check if yes❑ P y
SECTION 2: PROPERTY OWNERSHIP'
Owne ' f Recprd: ]�) m�c 4 5 C
1�t�
Name(Print Address for Service:
Gt� - �� -
e ep
zn
Tel
hone
SECTION 3: RIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) I� Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': V m 10 m L6
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S o OCA 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S top ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ 2. Other Fees: 5
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: S
Suppression)
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S `�� ❑paid in Full ❑Outstanding Balance Due:
dhsy Lf7 �
11r, Ile
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
(597795s
- -9/ 141,5 OGU Yrt License Number . Ex irauon Date
Namc of CSL-Helder
L H Fl 13•�k r .,A List CSL Type(sec below) tJ
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.)
Signature R Restricted 1&2 Family Dwelling
617f J,Sy M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Rey,Ie�re�d H�Irr1Pro;meenut
HIC Compan Name or H C R gistrant Name Registration Number
Address ��
_l R Zg"�)—VZ /g Exp ration Date
SiVnature 6 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property hereby
authorize U to act on my behalf,in all matters
relative to work ai.uhhp4zedy this building it application. Li 07
Si o Ow rDafe
SECTION 7b: WNER AUTHORIZED AGENT DE ARATION
o C ,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. /
Print Nam
Signature of Owner or Au orized Agent
(Signed under the pains and penalties ofperjury)
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 I IO.R6 and I I O.RS, respectively.
2. When substantial work is planned,provide the information below:
Total foors 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 Syuare Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
.y ? PUBLIC PROPRERTY
DEPAR'T'MENT
I'; \\ r•i II\i..,`J:1: I r • �.\I I \I, I . .I'I _
')'4 '4; ia5 1 \Y: 'i';L'J:'ai Jai
Construction Debris Disposal Al'lidavit
(required I'or all demolition and renovation work)
In accordance \kith the sixth edition offhe State Building Code, 780 CMR section 111.5
Debris, and the provisions of'v1GL c 40, S 54;
Building Permit 1t is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
T((((h��e debris will be transported by:
9'2a r t e rC) lii <-�� S -\-/4 I
' // (name of hauler)
`YUa.jed axua,Y
Ilie debris will be disposed of'in
(namr ut IScility)
tnddres<uf lacllilvl. - .
�Iguatule of p"rilut appkillt
late
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Kl' IK hl•91
\IIaM 12- W,Ntll.\t,I.I.)Ct LL 1' • SAI I'M. ?tSAI III N I INJI`/7�
I IA. ')71.715.95,15 9 1'Ix 973.7< IYIh
Workers' Compensation Insurunce 'ifftdavit: Builders/Contractors/Electricians/Plumbers
\uplicant Information Qn Please Print LLeaibl
(JCj1 y
V;IInC 11111.nks1)r;;an/l,.min/n�l/ndl,caluau: Pr i
�ddr�ix: X17/ {1"JI/0-
/
Cily,srua/ip sal �/1/< U1970 Ate-
Moneg: 17't 6VZ 1?5K8'
its an employer?Check the appropriate bus: Type of project(required):
4. 1 am a general contractor and 1
I.� I :un a employer with� ❑_ 6. ❑ New construction
anpluyecs(full anll/ur part-aloe) have hired the suh-contractors
2. ❑ I aro a sole pmprieux or partner-
listed on the:coached sheet. C] RmnoJeling
ship and have n t employee. These sub-contractors have S. ❑ Demolition
working rix me in any capacity, workers' comp. insurance. q. ❑ Building addition
INo workers'comp. insurance 5. ❑ lit entporation and its
I repaired.)
officers have exciviscd their 10.0 Electrical repairs or additions
).❑ 1 amu homeowner doing all work right ofcmenlption per NICL 1 I.❑ Plumbing repairs or additions
myself. (No waxkm' comp. C. 152, g 1(4),and we have no 12.0 Ruuf repairs
insurance required.) r employees. (No workers' I).❑ Other
comp. insurance required.]
• u. .yphamd mal checks bus nl mus:dao till um the.emits twduw:hawing their wurkui cunlpena ion Iwlmy mdtmrutiva
1 I Llmeuwmn,who s,4tmit this alr lavit indicating they ax Joins all work mid Oben him"tilde cwurmlen mail auhmil a new alridavil indica ing uich.
-f\.nlrxwn that Ikck this box most mmhcd.m addaiunal..het.hawing the manic of this sub<onlrxtun and their wurkorr'comp.pahcy roar m:ahm.
/am an employer that is pro riding Ivurkers'cmnpentlatimr insurance for trey employees. Below is dire po/iey and job site
ujunnurimn �D
Imuraucc Company Vame: u �211X�" - —/i[5_ Zvi
I'ulicv a or Sclf-ins. Lic. if: // _-.. .. . .. ___ Expiralliion Datc: /
tub lire -\ddress: 3 Maso-,, S oc — City;SlataZlp. 544y /"�/l 01Y
.\trach it copy of the workers'eumpcotatlun policy declaration page(showhlu the policy nmuber and expiration date),
failure to secure cuserage as required under Section 25:\cal'.MGL c. 152 can lead to the imposition ofcriminal penalties of a
rine tip to SL5o0,()n and/ur une-year imprisonment, a well JS cisd penalties in the furor of a STOP WORK ORDER and a fine
ni up In i?i0.00 a d,ry against the violator.
Its: advi.icd that a copy of this stalcincnt may be lurwarded to the Mica of
Im:.m,a u,nn of:hc UI,\ :or m,w.u•xc ancraw aeti tic aUon.
:da her,b2,,rfifv r lerdpd prat •r of perja us she in/unnrulon provided abo e is true nod correct.
—_ Dil,;__�L ss o
tiul ase only. Do not n'rirt in N�i.c urea, to be cumrpla•!rd by city car/o rvn ulliciu/.
( itv or fnw'n: PcrmifiLiccnsc 0
I..uing.\uihurily (circle one):
I. 1loarJ of IIvaItIt ?. Ituddiay 141)artatcn1 1. t.Il)Aiiiiif Clerit 4. L•'lecIfric.d Impactor 5. Plumbing Inspector
6. Other
Contact I'cnuo: _, ._ Phone 4:
Information and Instructions
lussadmsens Genl'fal Laws chapter 192 requires all cnq)Io)ers to provide workers' compensation for their employees.
Ptir+uant to(lis ,tatule,an empluree is dctined as" .etcry person in the service of another under any contract of hire,
vpress or tin pled. oral or avruten..'
\n employer is dctined as "an individual, partnership, Issoclanou.corporation or tither legal entity,or any two or more
,,t the toregmog engaged m a lolot cnlerpnse, and including the legal representatives of a deceased employer, or the
rel:eaver or trubice of .W Individual, pal"W1111p, association or other legal :only,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
j vs:11ulg house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or 011 the grounds or building appurtenant thereto shall not because of such employment be deemed to be an emplo)er."
NIGL chapter 152. §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal arts Ikcnse or permit to operate a business or to construct buildings in the commonwealth for any
applicant "Ito has not produced acceptable evidence of compliance with the insurance coverage required."
\ddiuonally, \IGL chapter I52, §25C(7),rates"Neither the commonwealth nor any of is political subdivisions shall
enter into any contract for the perforruance of puhlic work until acceptable evidence ul'cunlpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicmrts
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
insurancc. 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 docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confimtation of insurance coverage. Also be sure to sign and date the affidavit. The af)idavit should
he rewmed to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you Ila"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'rown Officials
Please he sure that the affidavit is complete and printed legibly. The Department has 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.
111atuc be sure to fill in the pennit/license number which will be used ,as a reference number. In addition,an applicant
ilwt must submit multiple pennit: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"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 permits or licenses. A new affidavit must be tilled out each
vcur. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
111,; 1 It Iii:of Investigations would line to thank )ou in advnllce fur your cooperation alnd slnuuld you ]live luny questions,
please do not hesitate to give us a call.
fhe Dcparonent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfAce of Invesdradons
600 Washington Street
Boston, MA 02111
Tel. 111617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mass.gov/dia