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10 NORMAN ST - BUILDING INSPECTION (002) / 11/ 11 /vcu� ��Mar�yiV ( / Thee Commonwealth of Massachusetts \� 9 Town of � Board of Building Regulations and Standards � t Massachusetts State Building Code, 780 CMR, 7"edition Building Dept \ `k Building Permit Application To Construct, Repair Renovate Or Demolis a One- or Tuo-Famill, wellin This Section r Official Us 0 y Building Permit Number: Date lie Signature: - Building Commissioner/Inspector of Bu Idings Date SECTI N 1:SIT FORMATION 1.1 Property Addr ss: U 1.2 Assessors Map& Parcel Numbers I.la Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distnct Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Wager Supply:(M.G.L c.40,g54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: .C91 Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Public Private❑ Check if es[3 SECTION 2: PROPERTY OWNERSHIP' Name(Print) AddreA for Service: On Q 90 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORKr(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other 13 Specify: Brief Description of Proposed Work: SECTION 4: ESTIMATED CONSTRUCTION COSTS W stimated Costs: OMclal Use Only Labor and Materialsng 5 1 Q©� '— I. Building Permit Fee: E Indicate how fee is determined: -❑Standard City/Town Application Fee cal S ❑Total Project Cost'(Item 6)x multiplier x ing 5 J�l ^ 2. Other Fees: Snical (HVAC) S List: nical (Fire S Total All Fees:bionCheck No. Check Amount: Cash Amount:Project Cost: E 1 �d ❑ Paid in Full 0 Outstanding Balance Due: r SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) tR � �� Numbcr E.rpirau\oon ate Ngmc of CSL-Hpld � �O 5�1�( �Q) `�� 11 Type(uc below) AJ cs Description h/v'"'� 1 ♦ `^ - Unrestricted u to 35,000 Cu. Ft.) Signatu Restricted 1&2 FamilDwellinNia onry Only RC Residential Roofing Covering Telephone ^ IF Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation v D I Residential Demolition �G�HI5.2 RegistilredoHogte Imp a hent Con ractor(HI ) :!E C C a� Name or��Rrisu nt slam tion- ulmber Address '�'� , ation ate Si�gnaturt:J Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6)) rS orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide is affidavit will result in the denial of the Issuance of the building permit. gned Affidavit Attached? Yes.......... ❑ No........... ❑ ECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. as Owner of the subject property hereby authorize to act on my behalf,in ail matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION 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 (Signed under the pains and penalties of r'u 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 110.116 and 110.115,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 Tv pe 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" t CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT ,11.1 K 1'.,Kilt,41 L: W,+.ru.,u,,.)crl.1,l • )AI 1 11,M.\s\\1111 N I Is 31`/7- l i.l. 'Irt-7/3.93'13 • 1:%x 478-:'< 1846 IaYorkers' Compensation Insurance :%iftdaxit: Buil ers/Contractors/Electricians/Plumbers %ooncant Information Please Print Le ibly VdlTll lBuwa s ()rgonl r.uimV l ndls afoul l: �Jdrass: (��., Cily,Smw Zip Thune i': on dU �V b��� Are ou an employer?Check the appropriate box: I')pe or project(required): 1.C3'1 inn a employer with 4. ❑ I.am a general cuulraetor and 1 6. ❑ new construction unplopcaa(full .rntL'ur part-unit).• have hired the sub-contracturs 7.�aRcmodeling 2 1 .1111 a sole pmprictor or Panner- listed on the anachcd sheet. ihiP:uIJ have no employees These subcontractors have g. ❑ Demolition working for me in any capacity. workers' comp. Insurance. q, ❑ Building addition 5. ❑ we are a corporation and its Kn workers'comp. insurance 1'O 10.❑ Electrical repairs or additions I rcquircJ.] officers have axerciscJ (heir r3. ht of exrnl uon a MGL, 1 I.❑ Plumbing repairs or additions 3,E31 and a homeowner Join�all work B P P' myself. tKo workers' comp. C. 152, ¢1(4),and we have no 12.❑ Ruuf repairs insurance required.] cmploycce. [Ko workers' 13.❑Other comp. insurance required.] •%m .pphcm,t that checks bolt al mustalso Till call Iha¢mmil I,cluw;huwmal 1he1r w'urkw,i eun,panraiw,lwlicy ndurmaliun. +I Iumuuwrwrs who xu6mit this aOldavit indiu,ina Ihey am doing all work mal Ihen him use ilde coni,.cion mail.uhmit anew+lydavil indi"ma.n.h. -C..nimua,I that thvck this tax m,al atachsd.m additional.baa.hawing taw nm,a of IM nib:onoxtoasand their wurkun'ctanp.gx,hcy mftmnanun /um un eropluyrr that 3..r prurfdinq workers'eutnpenention in.wruuc•r jar ury rnrpluyrecr. Below is rhe puliey and job site ' iujunnmion. Ir...urancc Company Name:__--- - 1'olicv aur Sclf-ins. Lice R: ___ .. . _ -_— Expirauon Date:- job Site Address: _-_. City;Slate/Z1p. .\each At copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Palluic to xcurc coserage as require oder Scctiun 25A ul'.\IGL c. 152 can lead to the imposition of criminal penalties of a rine up to SI.SnQr>n an ser une-pear opt',. j1lncnt• at \Yell as CHIT pe1W111cs III the form of a STOP WORK ORDER and a fine nl up m i250.g0 a Jay ub -nit the viol.Lor. 11t�advLacd that a copy of this slatcmenl may be furca arJeJ to the 011ice of Im..m,a uous ul the DIA : r 11111 .ureaos saau tcrilitauon. Ido,herrhy tcrtify surlier the tins rd p Jrie'ujprr%nry that the injunnution provided ubu a is trait1 11001 correct. I I)/Jiriul tut only. /)a ons n•rite in this arra, to he runrp/rlyd by 'it),or 1011`11a//ilio/. I ('ilv ser Ibwn: _... _ - Pelton/License y. Issuing.\ullnurily (circle one): 1. IloarJ of IIc.JUI 2. Iiuddin; imocol 1. Cily.'I'unn(1111 J. L•'leclrical luspaclor i, Plumbing; Inspcclor 6. OCIIer _ 0,11ucl 1'cnmt: .. -. Phone a: Information and Instructions >1.usaihusens Gcncral Laws chapter 152 icyuires all employers to provide workers' compensation for their employees. Purnu-mt to mss ,t atute, an emplor'ee is dctined-is" .wary pcison in the service of another under any contract of hire, c%prees or itnphed, oral or wrnten." \n employer Is defined as"in individual, partnership, .issocianou, corporation or other legal entity, or any two or more .n the hrtegon;g engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the (cleaver or trustee ul •ur Individual, paltnctshlp,association or other legal cnnty,employing rnlplo)ccs. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the ,IwelLng house of another who employs persons to do maintenance,construction or repuir work on such dwelling house or nal rhe around¢or building appurtenant thereto shall not because of such employment be deemed to be in employer." MGL chapter 152. $%25C(6)also states that "every state or local licensing agency%ban withhold the issuance or renewal of it license or permit to operate a business or to construct buildings in the communweullb for any applicant who has not produced acceptable evidence of cumpllance with the insurance coverage required." \ddiuunally. MG1-chapter 152, a25C(7)stades"Neither the commonwealth nor any of its political subdivisions shall anter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements ofthis 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 nunrber(s)along with their certificate(s)of insm'ancc. Limited Liability Compania(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 con fimlation of insurance coverage. Also be sure to sign and dale the affidavit. The allidavit should he reamled 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 u 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. ('fly or'rown Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of die affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pl:;ue be sure to fill in the pennitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple ponnio'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 proof(flat 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 dug license or permit to burn leaves ctc.)said person is NOT required to complete this affidavit. I jl: t)I licc tit for e5(rgations would ltne to diank you in advance for your Cooperation and should you have.any questions, pleise du not hesitate to give us a call. fhc D.parnncnt's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of lnvesdgationtf . . 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax p 617-727-7749 -'u.05 www.mass.gov/dia �� """r617-451-6491 ��(� 266 Sommer Street / Boston,MA 02210 So ® Fax:617-451-0601 / E-mail:graphics@sirspeedy6119.com PRINTING•COPYING•DIGITAL NETWORK www.sirspeedy8ll9.com WEB BASED DOCUMENT MANAGEMENT SOLUTIONS CITY OF SALEM l � PUBLIC PROPRERTY = .�� ` DEPARTMENT , nr. ..,r:}� I I r � �.�11 si. 11.1"x, .. I _I• _ II I- 'J'3 '; 1; • 1 1o '/'S V=v.i L, Construction Debris Disposal .al'lidavit (rcquired for all dcmulition and renovation work) In accordance w ith the sixth edition of the State Building Code, 780 CMR section 111.5 Dcbris, and the provisions of MGL c 40, S 54; Building Permit At is issued with the condition that the debris resultin- from this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c I11. S 150A. The debris will be tran >ortcd by: Iname of hailer) I he debris will be disposed of in : (name of facility) (address of lacilily) 'ignatu. �[ apphcam Y J V daw