19 OLIVER ST - BUILDING INSPECTION (2) ✓ ►� �,00a
The Commonwealth of Massachusetts
W ��t Board of Building Regulations and Standards CITY
r OF SALEM
Massachusetts State Building Code, 730 CMR, 7ih edition
�r r Revise[/Junuurp
Building Permit Application 'ro Construct, Repair, Renovate Or,Demolish a 1. :OI1R
One-or To•o-Family Dtcelling
This Seoiqp For Official Use y
Building Permit Nu ber. 4 D to App ' d:
Signature: I )) q/ f l
Building ommissionerl lifspector of B6400LDate
SECTI I SITE INFORMATION
1.1 Property Address:. 1.2 Assessors Map& Parcel Numbers
/9 D,L" 57 �r>Lr-7LI
I.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) Frontage(Il)
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 13Check if yes❑ Municipal❑ On site disposal system C3
SECTION 2: PROPERTY OWNER SHIP'
2.1 Owner'of Record:_
N m (Print) Address for Service:
sc ,wl?c 979- 7f-s= s�
Signature 'felephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apWAddition
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) AlterationDemolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:Brief Description of Proposed Work': / 7C,4Cb11 �7R6 ECel / g hoc�i� S�Pporcr Gof77
T ry rt oe-ox/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S °'= I. Building Permit Fee: S Indicate how fee 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
4. Mechanical (IiVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: 5
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: Syar—
❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor(CSL) �l L(
License Numher lispirut' n Uat
N:uneot CSI.- iu
3� er List C'SL-I)'Pelxe helow)--ZZ-
TY - Descri tion
res Il Unrestricted(tip to 35,000 Cu.Ft.)
It Restricted 1&2 Family Dwellinit
. ignaturc M \lassoo Only
�7S SJ/- eo RC Residential Routing Cowrinit
telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance installation
D Residential Demolition
5.2 R istered Home Irgprove ent Contractor(It1IC)
Z E7v Z Ou I l`D✓�I7IZ(rc 7n o
1ICCmany Name or till'Registrant Name Registration Number
—
Gvpiru ion Dat
Signaturs e Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, /% 17/G }'Of1 , as Owner of the subject property hereby ;
authorize 2ft ZZZZENcoONto act on my behalf,in all matters
relative to work authorized by this building permit application.
Ste' .ter�P� moi' T L - Z/2 L o
Signature of Owner Dat-
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
.��j r
/2-- eey j ,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 N
ig um )wner or Authorized Age Date
.
(Signed under the pains and penalti 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(IIIc)Program),will nor have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Fl.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Fl.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half%balhs
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"
44/ " '"""' �f� CMIu/✓
Vie"`
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.14a::N:1'y UMMI:nI I.
\1.ss`its Ili WnquM;ION S I RELT • SAII!M,MAShACI II %I is A97Z
Tn1.:WS."15-9375 • Psx. 979-74,1-')446
1'Vbrkers' Compensation Insurunce Affidavit: Builders/Contractors/Electricians/Plumbers
%pnlicant information Please Print Leeibiv
NalncI lluciiH ss 1)r aniratinNln llvnluul): 1/ U��6�
City,Stalci Zip' n lalllynC i ��� `J SI�t7C �i
Are), ate eatployer! Check the appropriate box: 'Typo urproject(required):
1. 1 ant a cmplu ilh 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees fu and/ur part-unto).' have hired the soh-contractors
_.❑ 1 :un a sole proprietor or partner-
listed on the attached sheet. : �- Remodeling
ship and have no cmpluyces These sub-contractors have S. ❑ Demolition
working for 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.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.(Ko workers'camp. c. 152,§1(4),and we have no 12.❑ Roofrcpulrs
insurance required.] r employees. [Ko workers' 13.0 011ier
comp. insurance required.]
•!sny up phamlt 11141 checks box dl must:llno till WI the section Wow i1WWllla Iheir MWfkWY cumpensmion policy informutiun.
s tlomeuwra:n who 4udlmif this affidavit indicating they are doing all work and nhcn hire outside eaurmton must.uhmil Anew alr.dawl indicwing ctich.
('aNnwtlMt dmf cheek this box must allached on additional shcel..hawing the uatlte of tho sutaSontractorsand their wurkers'comp.policy infurmadun.
/am mf employer that Is providin,K workers'c•ontpen.sadon insurance jar my employees, Below is the policy war/tub.rite
infonnution.
Insurance Company Name: Z .���-n.
Policy 4 or Self-ins.Lice d: _ Bl Expiration Dater Z—
Job Site Address:�Z7 1"51 L./V Yt �- Cayistate/Zip: �5
Attach a copy of file workers'cmnpensalfun policy declaration page(showini;the policy number and expiration date).
Failure Lo secure coverage as required undo Section 25A vi'MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,5110.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5230.00 it day against the violator. He advised thus a copy of this slatcmcnl may be lurwarded to the 011ice of
Invcmigaimns ufthe DIA loot insurance coverage tcrilicaltun.
/do hereby rtijy u e rhe Ind srhe ur��fpenul 'es 'rrsylmt she i'e.c�ns7drut rhe injurmudon provided ubuve is rate nd correct.
tii :cw e'
U It��o �2 Z1
Ph.,,:•:v
Official use only. Do not irrire in thix area,to be completed by city or tonva official.
i
Ci Iv or'fown: Pcnnit/License 4_ _
Issuing;Amhurily(circle nuc):
t. Board of Ilculth 2. Building Department .1.Cilyi town Clerk 4. Llectrical Inspecsor 5. Plumbing Inspector �
6. 01 her
Contact I'snuu; Phone 4:
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this.natute,an empluree is defined as"...every person in the service of another under:my contract of hire,
clpress or implied, oral or written."
An einpluyer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
d the tbm.oing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
feCCiver or trustee ul lei individual,pa mership,association or other legal cnnty,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
,Iwclling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the.rounds 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,btGL chapter 152, v§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 nunnber(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 dale the affidavit. The atiidavit shoulJ
he retuned tothecity 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 of you are required to obtain a workers' f
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 Ofnclals
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 pennitllicense number which will be used as a reference number. In addition,an applicant
than must submit multiple penniUliceiise 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lie office tit Inve5ti.ations would mile to drank you in advance fur your cooperation and Should you have any questions,
please do nut hesitate to give us a call
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgadons
600 Washington Street
Boston, MA 02111
"fel. It 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
itcvi.ed 5-'_taus
www.mass.gov/dia
b CITY OF SAt.E.Nl, l�L-kss kcH1USETTS
BI;ILDLYG DEPARTMENT
' 130 W.A.iml:NGTON STREET, 3"FLOaR
TEL (978)745-9595
FAx(978) 740-9846
Kl%®ERLEY DRISCOLL
THOMAS ST.PIF�tRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING 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 I 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 defined by MGL c
I 11, S 150A.
The debris will be transported by:
2�ZOw r �' -rn tl 720Z
(name of hauler)
The debris will be disposed of in
�/t7 f777/-sie7tr �i1yC
(name of facility)
(address of facility)
Zsignarureof—permjtapplian—t —
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Z. //d
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