12 MUNROE RD - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
' % Board of Building Regulations and Standards
t !a' Massachusetts State Building Code, 780 CMR, 7'"edition Building Dep
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tera-FumiliDuvelling doom
This Se ici`nFor Offkial Use Only
Building Permit Numb ate Applied: q
Signature: - I VA&/ l
Building Commisswrie nspector of Hit Date
SECTI : SITE INFORMATION
1.1 Pr erty ress: 1.2 Assessors Map& Parcel Numbers
YAyx
eoe
1.1 a Is this an accepted street'?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
r Lot Area(s R Frontage R
Zoning District Proposed Use q ) g ( )
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.(.i.L C.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal E3 On site disposal system 13Public❑ Private❑ Check if es❑ P
2.1 9!� SECTION 2: PROPERTY OWNERSHIP'
2.1 O of'ecor1 , y r
.�D S cT
Name(Print)
r' Address for Service:
�� .'2 6 y
Signature Telep one
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
i
EDescriptitoEnof
Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offtclal Use Only
Item Labor and Matenals
I. Building E "a `�L' 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical e ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
wi Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S �D 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Su ervisor(CSL) eSOTg6 Dq
�•�/t�`J�j4.Gyt 4 / i7i4 License Number G Expuau n Date •�-
Ngmc of CSL tipl r
crkA7� ���� List CSL Type Isco below)
s+ GTS
Address Type Description
U I Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 FamilyDwelling
Signatyr, p M Masonry Only
RC Residential Roofing Covering
Tclep one WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 @ sred�H4el pp6xgmVVnntn or(HI�) ��� ��
V "7iLS' r Q
HIC ompany N co 11 Registrant Name Registration Number
l t/��,,, .k 57 � D9Ed
Addrcs 't-��j �[ 3—/J) bo
/6 .T>5o�c1d� Exprr ha on Date
Signature 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 to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNERr OR AUTHORIZED AGENT DECLARATION
1, TSm /✓/ 4�<4 L ,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 Name
Signature of Owner or Authorized Agent Date r (7
(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 10.115, 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 ofcooling system Enclosed Open
3. "Total Project Square Footage"may be.substituted for 'Total Project Cost'
.y CITY OF SALEM
PUBLIC PROPRERTY
` DEPAR'T'MENT
Construction Debris Disposal Affidavit
(icyuired I'm all demolition and renovation work)
r In accordance %%ith the sixth edition of the State Building Code, 780 C NIR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit >t is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal I'acility as defined by MGL c
I 11. S 150A.
The debris will betransportedby:
/
(name of hander)
I lie debris will be disposed of in
_ / �rry•��hi� �Y��"!
(name of facility)
. (address of rac:litv)
,:p:atwc of pcnnu apphcanl
,late
CITY OF SALEM
x. ,J) PUBLIC PROPRERTY
DEPARTMENT
!!^ Wn,IHM,ION SCt LLT • 5A11 M. MANNAw In ,f I In 3I97-
ILA. 178-7113.9393 • 1:wx 978-74c rxur
)iVorkers' Compensation Insurance %fftduxit: Builders/Contractors/Electricians/Plumbers
', 1 ylicant Information Please Print Le ihly
V illmd lllu.nl.sl)r/;]mralinrV lndn�dual l: ���� L
Ciry'slate.%ip �� NC 1911'&2 1'honr ,!:
.%re)uu an employer'! Chuck the appropriate box: f)pe of project(required):
'
1.❑ 1 ;un a employer with 6. ❑ I am a gcncral coutractor and 1 6. New construction
employees(full 4ntt/ur part-woe). have hired the suh-contricturs
2. ❑ I ans a sole proprietor or pinna- listed on the anachctl sheet. 7. ❑ Remodeling
,hip;mJ have no clnployces These subcontractors have S. ❑ Demolition
,lurking for me in any capacity. workers' comp. Insurance. g. C] Building addition
I No workers'comp. insurance 5.Q�J_We are it corporation and its
I rcyuircJ.]
officers have exercised their 10.❑ Electrical repairs or additions
3. ❑ I ons a homeowner doing JII work right of exemption per h1GL I I.❑ Plumbing repairs or additinins
myself tKo wvorkers'comp. C. 152, g 1(3),and we have no 12.❑ RWI repairs
insurance required.] r employees. (Ka workers' 13.0 011ier
comp. insurance rucluired.J
•wm .yphcmrl cwt checks box 01 must alsu fill out the wq,uu Wow showing Ihuu wurkus'cumpensatiw,twlicy utlirtrtutiva.
' I lumcuwmts who lubmil this affidavit indic.oing Ihay um Juing 411 work arta ower him outside contractors must ouhmil a new ulGdavil mJirrlmg.ach.
d',.nlrxuNv thus whack this box mOsr JII]chcl.m udJrfimal,ha-el.hawing the nano of the sub-contractors and rhea wurkeri comp,pricy mfie madan
l am un employer that it pruviding workers'compel wi ion insurance jar uty enrpluye0.r. Below is rhe pulfry und/ub.till,
ittiforulatiars.
Ir.ulrancc Company Vame:��_--,,,���Sss
Policv 4 or Sclf--ins. Lic. d: Expiration Date:
Job Site -lddress: 1 /'�,///��/4 —6710- SQL. `-moi Clty;Slate/zip:
Attach a copy of the workers'computnatiun policy declaration page(showing the policy number and expiratiun date).
1'Jdurc to,ccurc cuwerage as required under Swiun 25A ul'>lGL c. 152 can lead to the imposition of criminal penalties of
tine op to S 1.51101)JmL'ur one-year imprisonment. Js well Js ci%d punul4cs in the I•uon of a STOP WORK ORDER and a fine
,*f up to 5250 00 a d,ly.Igainsl the viohior. Be advl.0 d that a copy of this,iateinctil may be fur%JrJcd io the Office of
III\<?II'.(J 11411]ul Ills DIA :or Iii,tuarcc c,,%atgc wci rtic.n;on.
/Ju hereby r:rri/V under die prrinc unr/prnuhier u�pr'//��//tt ry/but 1100 infunnulan provided above is true and correct.
5c((,
Dire
Fr _
qtly. Do nal write in ilii, area. 1u hr cuurp/rlyd by city•ur lorvn ra//iciu/. I
n: Per miul.icvnwe 0
l ify (circle Due):
lle.tlth L Molding Mpartutcat 1. til)."I'uan Clerk J. Electrical Iu,pcctor 5. Plumbing Impcolor
Cnutacl Tenon: Phone tt:
Information and Instructions
�t.usodmsetts(icncral Laws chapter 152 requires all emplo)ers to provide workers' compensation lir their employees.
11uno.mt to rhis +tatule, an empluree is defined as" .e,cry person in the service of anuther under.lny connacgyf hire,
%press or implied. oral or carmen."
\n rreplurer is defined as"an individual, partnership,.issociallou. corporation or other legal entity,or any two or more
t cnie rise, and including the !cgal representatives of a deceased empluycr,or the
,.r the h,regJuig engaged m aynn rp g wevcr the
rccenm alu
er or trustee of. Individual,piurahlp,association or usher legal entity,employing cmplo)nes. He
owner of a dwelling house having not more than three apartmens and who resides therein,or the occupant of the
,lwcll,ilg lluu,e of another who employs persons to do maintenance,construction or repair work on such dwelling house
all not because of such employment be deemed to be an employer
or „r. the grounds or building appurtenant thereto sh ."
NIGL chapter 152. �N 25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal urn license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of cumpliance with the insurance coverage required."
.k,ldiuunully, MGL chapter 152, §25C(7),rates"Neither the commonwealth nor any of its political subdivisions shall ;
enter into any contract for the perfomlance uf'puhlic work until acceptable evidence of cumpliance with the insurance
requirements of this chapter have been presented to the contracting authority." r
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) namc(s), address(es)and phone nunibef(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 worker' 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
xecidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The allidavit should
be returned to the city or town that the application for the permitor license is being requested, not the Department of
I nduslrial 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'rown OfOcials
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.
ill:ase be sure to till in the pcnnil/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitlicelse 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 Tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.,:. a dog license or permit to bun leaves etc.)said person is NOT required to complete this affidavit.
I ole ()I Ileo II losestigatnUn, would line IU thank)'Ju in adviillce fur your cooperation and should)'Uhl lase:rny questions,
please do nut hesitate to give us a call.
rhe Ucparnncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investizatlons
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia