3 OAK ST - BUILDING INSPECTION c 1
i
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 730 CMR, 7ih edition
,�. Revisee January
Building Permit Application'I'o Construct,Repair, Renovate Or Demolish a 1. 'OUR
One-or 71vo-Fomily Dwelling
This Section For is Us Only
Building Permit Number: 7e Date Appy' d:
Signature:
Building Commissioner/Inspecrn ('Buildings Date /
SECTION 1:SIM INFORMATION
1.1 Property Address: ? / d, 1.2 Assessors Map& Parcel Numbers
1.[a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) Frontage(11)
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?
Public❑ Private 13Zone:
if yes❑ Municipal❑ Onsite disposal system 13
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owpq{t of ecor
� cD (� 1 Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessary Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Desc ' tion of Proposed Work': e
L1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how Ice is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S e- 1
i
4. Mechanical (HVAC) S List: ` �� e C44
5. Mechanical (Fire S
Total All Fees:S
Suppression)
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 Supervisor(CSL) _ ,
md ejy-Z I.cense Number Expiration I ate
Name of CSI.-I]older
List CSL Type(see below)
Tv PC Description
Address U Unrestricted(up to 35,000 Cu. Ft.
/G li Restricted 18r2 Family Dwellin
Signature, M Mason Ont
(�(I RC Residential RootingCovering
-felepho e / Residential Window and Siding
v 5^ SF Residential Solid Fuel Burnina Appliuncc Installation
U Residential Demolition
5,2 Repjsye�t�d-FipmelmpeQverr�entC troctor(HIC) 150617
MIC Cumf5r Nam r HIC Registrant me Registration Num
/L //9
J ssI Expiration Date
gnature Telephone
rii
e
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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...........O
SECTION 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 all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, ,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.
J7v J
m e
? GVo ✓ /�
Signat eof w �n Authorize)Wgent Dale
(Signed under the pains and penalties of perjury
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 1 IO.RS,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 of cooling system Enclosed Open
3. "Total Project Square Footage-may he substituted for"Total Project Cost"
CITY OF SALEM
ni;`2011it PUBLIC PROPRERTY
DEPARTMENT
.Ml::K:1'Y LNIA:,-I I.
I?C Wd`it11M.IU?STXECT • SdII:A MASSAta 11 shru u197^�
WS-745-9595 • F.sx.97x•74 7546
NYorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
r rlicant Information Please Print Le ibiv
Velent:InudnesslOrgannmioNlndlvutuulJ: N �
:Address:
City,
State;/.ip Phone
—��
Are you art employer!Cheek the appropriate box: 'Type of project(required):
1.❑ 1 :un a employer with ;2= 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or part-tine).` have hired thesub-contractors
_.❑ 1 um a sole proprietor or partner- listed on the attached sheet. : �• E] Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working (or me in any capacity. workers' comp. insurance. 9, ❑ Building addition
I No workers'comp. insurance 5. ❑ We are a corporation and its 10.C]Electrical repairs or additions
required.] officers have exercised their .
3.❑ 1 ant a homeowner doing all work right of exemption per NIGL I I.[] Plumbing repairs or additions
myself.(Ko workers'comp. c. 152,41(4),and we have no 12.❑ Ruufrepairs
insurance required.] t employees. [Ko workers' 13. OthcrC t ,e re,0 a
comp. insurance required.]
-Airy.,pphcanl that chucks boa BI muYl:dao all wl the wctiou b0ow d uwin&j their woikms cumpcm;,tiw pulicy inrinmaJua
't rumwwrwrs who salmis this aMdavit indicating they are doing all wurk arKl then him uutside cwunuton must.uhmit a new Aridavil indicating%ooh.
-(',wtncwn That chuck this box mom mlxhud en additional..hatl1 ehuwiny the name of the tub<oniracron and(heir wurken'comp.policy mrormadon.
/ant mr eerp(oyer!/rut&pruriding rvurkrrs'r•atnpeusn!/on iaeurnnce fur cry emplaprer. Below is rhe policy and fob.rife
injonnation.
InsuranccCompany Name: Pear.-LArtt'_._.
Policy is or Sclf-ins.Lic.t+: -_.. .... __ Expiration Date: �,,
Job Site :Address: �Q �C Cityrstate(Zip:SO.IP-wl
Attach it copy of the workers'compcasation policy declarution page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ul'}IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/or one-year imprisonment,as well as civil penallics in the form of a STOP WORK ORDER and a fine
of till to 5250.00 a day ugainbi the violator. De advised that a copy ofthis smtemunt may be lurwarded to the Office of
lnvrsngauons ul the DIA for in,urarse coverage scrificacon.
/Ja hereby r• under thr pairnenol pata�lr�c1 of_ppeerj'"rry that the information provided above is t(r�u/e7 run!correct..
P- A--b 4 Date. ,-�2 /bo
-
official use only. Do not write in this area,to be completed by city or town official.
i
City or Town: Pcrnit/License I._.
Issuing.%ulhorily(circle one):
I. Board of Ilcalth 2. Building Ilcpartincul .l. Citf✓fown Clerk J. Llectrical Inspector 5• Plumbing Inspector
6. Other
0,14(act Peron: _ ._ Phone Y:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eniployees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
etpress or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
I the Ibrceoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ofan individual,paimership,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,cunstruction 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."
`IGL 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. NIGL chapter 152, y25C(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 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 certificatc(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,arc 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-insured companies should enter their
self-insurance license 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
please be sure to till in the pennitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitiliceisc 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 die 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 dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he Offs"of Investigations would like to thank you in advance for your cooperation and should you have:my questions,
please do not hesitate to give us a call.
rhe Dcparuncnt's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
011ce of Invesdgadons
600 Washington Street
Boston, MA 02111
Tel. It 617-7274900 ext 406 or 1-877-MASSAFE
Fax H 617-727-7749
ifeui,cd -'6-us www.mass.gov/(ha
CITY OF & .E.NI, NLxSSACHUSETTS
13LWL`IG DEPART%L&NT
•
130 WA SHLYGTON STREET,3'°FLOOR
�* TSL (978)745-9595
FAX(978) 740-9846
KiJtBEFLEY DRLSCOLL
.MAYOR THo.+us ST.Pw-m
DIRECTOR OF PCBLIC PROPERTY/BunmLNG COMMISSIONER
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 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c
111, S 150A,
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility) --
b�
(address of facility)
—49gnature of permit applicant
Z6 L
date
en��,trd,k