190 OCEAN AVE W - BUILDING INSPECTION The Commonwealth of Massachusetts � -ITY OF
Board of Building Regulations and Stand Ids v Will, SALEM
Massachusetts State Building Code,780 CIviR Revised OF
2011
Building Permit Application To Construct,Repair,Renovalt P*V6rTVShp. ZW
One-or Two-Family Dwelling 11➢➢11
This SpotonFor O Itcial Use only
Building *' mft Number: Date Ap
Cel s �f�
Ifuiiding OtSciel(Fria[Name) Sigasnne s
SECTION l:$ITE INFORMATION "
1, Pro erty ress: 11 Assessors Map&Parcel Numbers
ryn' 8c�AddRuti. w4�.s 1'
Lin Is this an accepted street?yes_ no_ Map Nwnber Parcel Naber
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District 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 Water Supply: (M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal 13 On site disposal system 13Public 13 Private 13 Check if yes❑
SECTI0N2 PROPERTVOWNERSHTPt
2.1 Owneriof ord•
rOD 7C6m' OLIrS
Nam
e(Print)
City,State,ZIP
/
7b
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK"(¢heck all that apply)
New Construction ElExisting Building 13Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Wore:
SECTION 4:EST1114ATED CONSTRUCTION COSTS
Estimated Costs: O )al Use Only
item (Labor and Materials
1.Building $ ") 1. Buildf ag Permit Pee:$ indicate how fee is determined`,
t3 E3 Standard Cityfrown,Application Fee
2.Electrical $ p Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ 5- OLb List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
Cheek No. Cheek Amount: Cash Amount:
6.Total Project Cost: $ ol� E3 Paid ut Full ❑outstanding Balance Dues ..
q' 2, CJ:( YUUtE 0 j M--ALi--� 1vo ca.t;
SECTION 5: CONSTRUCTION$ERVICES
5.1 Construction Supervisor License(CSL)
,f�✓L./AK� iYB�I License Number Date
Name of CSL Holder` ;l
List CSL Type(see below) t,
: Fr -or"W 11 s'f
No.and Street Deacription
r. II Unrestricted(Buildings up to 35,000 cu.ft.
Restricted M2 Family Dwelling
City/ToOni,State,ZIP M
r-�-� RC Roofing Covering
c V/ WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number n Date
HIC Company Name or HIC Registrant Name
�i✓4 41'No.and
"�`rwdrK
6Atree[ Email address
10
Ci /town State ZIP Telephone
SECTION 6.,WOREEP.8'COMPENSA"ITON MURANCE AFMAVIT(M.G.L.t 152.§ 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 .......... Cl No...........❑
SECTION Tae OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR ING 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.
Print Owner's Name(Electronic Signature) Date
SECTION 76t OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and acqu3te to the best of my knowledge and understanding.
'ZO-4"-oc/ %�riyaK D /d
Print Owner's or Authorized Agent's Name(Electronic Si ) Date
NOU
1. 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 can be found at
xnnv.ntMLggv(oca Information on the Construction Supervisor License can be found at mm .mass.00v/dos
2. When substantial work is planned,provide the information below:
Total floor 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 be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Let>ibly
Name(Bnsiaess/organiTation/Indiv;dnal): t&m K l pyiJc,yDi'(
Address: 5.11 C411AC)/I C-
City/State/Zip:_ Ci�/1 AW 4� y_17) Phone#: .S / 3a Yl
Are you an employer?Check the appropriate box:
re
project(required):
l.❑I am a employer with employees(full and/or part-time).* ew construCtlon
2.�J am a sole proprietor or partnership and have no employees working forme in Remodeling
any capacity.[No workers'comp.insurance required.] g
3. I am a homeowner doing all work emolition
❑ 8 myself[No workers'comp.insurance required.]t4.❑I am a homeowner and will be hiring conVactors to wnduct all work on m o ilding additiony p perry. I willensure that all contractors either have workers'compemation insurance or are sole ectrical repairs or additionsproprietors with no employees.
mbing repairs or additions
5.❑I am a general conimctor and I have hired the subcontractors listed on the attached sheet.These subcontractors have employees and have workers'comp.insurances of repairs
6.❑We are a coryomtion and its officers have exercised thew right of exemption per MGL c. ef
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
•Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
lam an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 1'.vS•
Policy#or Self-ins.Lic.#: f/'d1lC t<,D/dy �D/ Expiration Date-_0 y /
PF
Job Site Address: City/State/Zip:. O a/I`� —.7i O/7
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as 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 of Investigations of the DIA for insurance
coverage verification.
I do hereby cerci r the pains and enahies ofperjury that the information provided above isrue an correct
Si ature: 'z /
Date: 3v .fj
Phone#:
OKIcial use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
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 then 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 until 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 number(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 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 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 pemilt/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 dog 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-NIASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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�e Vam��rrurruoea�i a��aauecLumelrq
Office of Consumer Affairs&Business Regulation
RE0
E IMPROVEMENT CONTRACTOR
etrtiongis135896 Type:
xpiration 5/17/2'0181 Individual
EDWARD JAMES TRAINOR III
EDWARD TRAINOR� --E1"€
58 CARROLL ST. `
CHELSEA, MA 02150 Undersecretary
_ Massachusetts Department of Public Safety
® Board of Building Regulations and Standards
License: CS-077231
Construction Supervisor -
EDWARD J TRAINOR
58 CARROLL STREET `
CHELSEA MA 02150
r Expiration:
Commissioner 02113/2018
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Construction Debris Disposa/Affidavit
(required forall demolition andrenoviition work)
In acmr&m with the sixth edition of the State Building Cade, 780 CMR, SectW 111.5 Debris,
and the proMsIons of MGL o4Q S 54; Building Permit i1 - Is Issued with the
condition that the debris resulting from this work shall be disposed of in a'properiy licensed
waste deposit facility as defined by MGL c ill,S 156A.
The debris will be transported by:
-S S L-
(name of haul r)
The debris will be disposed of in:
(n me of facility)
(address of facility)
Signatur of applicant
C/.->d/6
Date
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