211 NORTH ST - BUILDING INSPECTION 1
3� GK 3 oL�
3
The Commonwealth of lvla� flwsQt�� NAL SERVICES CITY OF
r Board of Building Regulations and Standards SALEM
Massachusetts State Building Co578Q I�q ReviseJ.Nur 2011
61Z tl, c
Building Permit Application To Construct, Repair, Renovate OrDert561i9tt�a
(� One-or Tivo-Family Dwelling
Lo This Section For Official Use Only
cli Building Permit Number: Date Ap ied:
('n -Building 011icial(Print Name) Signatureate
t SECTION 1:SITE INFORtNIATfON`
4
I.I roper Address LZ Assessors Map St Parcel Numbers
6It �AO.'i�ka71—• i
L 1 a Is this an acce ted street?yes no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(R) ..
1.5 Building Setbacks(R)
_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 Informatlosi 1.5 Sewhge Disposal System:'
Public❑ Private❑. Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check 1f yesE3..
SECTION Z: PROPERTYOWNERSHI0"
2. s� S of,I}ecor�l'S��
to V
.� a Prin - City;Slate,ZIP -
No.and Strcet Telephone Email Addrn .
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply),
New Construction❑ Existing BuildingrR Owner-Occupied CK Repairs(s) � Alteration(s) 17 Addition 13
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorV:
SECTION a:ESTIDIATED CONSTRUCTION COSTS
Item Estimated Costs: Of11cirl Use Only
Labor and Materials
I. Building S 5 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost?(Item 6)x multiplier x -
3.Plumbing S I!'Qther Fees: S
4.Mcchanical (HVAC) S List: L �
5.Mechanical (Fire S total All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost .S 5 wp, DD ❑Paid in Full ❑Outstanding Balance Due:
��12-0
SECTION 5: CONSTRUCTION SERVICES I
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Numc of CSL Holder List CSL Type(see below)
Type :. ..`: - Description .
No.and Street _restr-
U Unicted(Buildings tip-to 35,000 cu. It.)
R Restricted 1&2 FamilY Dwelling
City/Town,State,ZIP M Masonry -
RC Roolin Covcnn
WS 1Vindow and Sidin
SF Solid Fuel Bruning Appliances
I Insulation
Tcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
BIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /f own State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.152.§2$C(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 Isivance of the building permit.
Signed Affidavit Attached? Yes..........0 No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED)WHEN•
OWNER'S AGENTOR CONTRACTOR APPLIESFOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
tg act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nance(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
mering my name below,l hereby attest under the pains and penalties of perjury that all of the information
co 't t in this application is true and accurate to the best of my knowledge and understanding.
Print tier's o Authorized Agent's Nannc(Electronic Signnature) Date
NOTES:
1. (k�gyviier 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 LLai have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other tmportnniimfotm5fion on the HIC Program can e-Coun at
www m:us. ov'oca Information on the Construction Supervisor License can be found at www.mass�
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basemendattics,decks or porch)
Gross living area(sq. 11.) 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
j. "total Project Square Footage'may be substituted tar"Fatal Project Cost"
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTME�
120 WASHINGTONSTREET,3 FLOOR
r TEL. (978)745-9595
FAX(978)740-9846
KIIvIBERIJE Y DRIS COI.t
MAYOR TYiOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BLBLDING COMMISSIONER
a
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date ) I• )9 ' )� Q
Job location 3 1 ( �_10n �,1� *�T
Home Owner Address q()t7jt—\-�– J j^
Present Mailing Address K[D C_v�
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one=or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPE TOR
The Commonwealth of Massachusetts
Department oflndustrialAceidents
I Congress Street;Suite 100
B.ostop,MA02-Im-2017
www.massgov/dill
WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Elecilicians/Plumbers.
TO BE FUYD WITH THE PWdMING AUTHORITY.
AurilleautInformation Ple t Udbkv
Name(Bosmess/Oigemz?tion/lndividual):
Address:
City/State/Zip: Phone#:
Are you memployer?Check theapprepr(ate box: Type of project(rljni
erep:
1.Q I am a employer-a .caployees(toll eallorwrt- )' _ 7. ❑New consultation
2.Qlameaok prtipreforor➢arloanlup®dLsve uo empbyeea wo7l[ing formero S. QRAMO&IMS .
RiY eepaciry•[No wakens'rte•iostaaoce requvedJ 9. llemolition'
3.�I am a home !doing all work mynah[No worker'camp.iasoanaregamed.]t _
4.n I am a homeowner and wis be hhios e®hactm to corhat ell work m my property. ]will 10 Q Building adtlition.
emtae that all coffiaaeas either have weaker'compmmfon insmaax ea are sole l I.❑Electrical repairs or additions
ptoprielma wide m employxa• 12.0 Plumbimgrepaits or additiOnis
5.❑lam a general coaumam and l have lured the mb-bomxtwE listed on the attached sheet i1l]Roofyepairs.�
Mwe sabconemctoahave employees and have wQtkaro'comp.mium o t
6.❑We area corporation and its offic have e5 miwd t iciri gbt of exemption per MGI.e. 14.Q Other .
157,§1(4),and we beve m employees.[No worker•camp tasmaoce r j -
-Any applicant that checks boa:Mmust dso'ba out section 6ebw ehoamg theawoikeia policy m6oimetion.
t Homeowner who submit ttiis affidavit indicating they ere doing ail worn thea true outride ebffiaaers must submit a new affidavit indicating Rich'.
1Convaetur that check this boa mast attached in additional shedmhowing do nameofaa Rib-contreama and state whets o not thme amities have .
employees. tithe au6-conhaCmr have employer;?hey mast pamxdetbeu-wmkaa�mmp.policy—daw :.. ..
I am an empbyer thatisprovidmg workers'compensation fnnnancefor my empfgpees Below is thepaliey and/ob s!!e
lnforinasiom
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date: _
Job Site Address: City/State0p:
Attach a copy of the workers'compensation poll ry declaration page(showing the policy number and expiration date).
Failure to sellae coverage sa'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 oflnvestigations of the DIA for insurance
coverage v cation.
I do hereby cert45ZWAder Mepaws and penaflies ofperj'ury that the information provided above i r doe sad mneeL
signal=: Date:
Phone M
Ojlieial use only. Do not write in this area,to be coniplered by city or town o,89eial
City or Town: PerudMeense#
Issuing Authority(circle one):
1.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 apartments 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 urdi]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 numbers)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other then 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-insuredcompanies should enter their
self-insurancelicense 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"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 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 dqg 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