95-97 PROCTOR - BUILDING INSPECTION "7 -7 CK (,?q zq
'rhe Commonwealth of Massachusetts �T
Board of Building Regulations and Standards � $Ai Oki/�
Massachusetts State Building Code, 780 CMR TJ Revise dlairiZOl1
Building Permit Application To Construct, Repair, Renovate Or Demoli5t��dtW"r`,i'I.
N One-or Two-Family Dwelling v.3 f � S `
This Section For Of(icia!Use Onl
Building Permit Numbeir Oate.Appl d
-DuilJins Official(Print Name). Srgttaturo '. Date
t SECTION 1 SITE INFORi1tATIOW
1.1 proper A res : 1.2 Assessors Map&Parcel Numbers
f a
L la is this an accepted streetl ycs no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dlmerisions: `
Zoning District - Proposed Use Lot Arca(sit R) Frontage{R) -
1.5 Building Setbacks(R)
Front Yard' Side Yards Rau Yard
Required Provided Requbed Provided. RequitedProvided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone information: 1.8 Sewage Disposal System.
Zone.* Outside Flood Zone? fsystem Q .
Public Q Private n — Municipal!Q On site d"s1�8
. . Chedt if �n .
SECTION 2:r PROPER'CYOIYNER$HIP!
2.1 Owner 1
C' 7iJ /t's"r�/tr�
e(Pant) City,Sucre,ZIP "
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Constmction Q Ettsting BuOdi Owuer•Occupied Q Repairs(s) Q Atteration(s) 17 Addition n
Demolition Q 1 Accessory Bldg,d-1 Number of Units Other Q Specify:
Brief Description of Proposed Work.
00
, x
SECTION 4:ESTIMATED CONSTRUCTION COSTS
ttem Estimated Costs: Offietal Use Only
Labor and ltateriats
L DuilJing S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical g Q Standard Cityagwn Application Fee"
Q Total Project Cost'([tem 6)x multiplier x "
3. Plumbing 's Qther Fera: S
4.Mechanical (}:VAC) S List: f
S.ltce:hanird {Fire 3
Su ression) Total All Fees:S
/ Check No. Check Amount: Cash Amount:
G.'fntat Project Cost: S / Q,� 0 Paid in Full ❑Outstanding Balance Due:
+ 060(-7T�
SECTION 5: CONS'rRUCT1UN SERVICES
5.1 Cru ion Supervi or Llccnse(CSL) `�6,,07 License Number Expiration ate
Naige of CSL Ffot r
(1 (^ List CSL'Type(see below)
y�
Type. Description
No.and Street .
7/� U Unrestricted(Buildingstip-to 35,000 cu. tt.
(J R Restricted 1&2 Famil Dwellin
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidinst
S I Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D I Demolition
5.2 Rcg B .19
ret Ime a provement Cont actor(H IC) a
C __ H C Registration Number pi on Date
HIC Cumpan N e or HIC Registran nine // / / C,
G' /'/9T/.�/G t iD%S� T 'l4 � «its
No.and Street ) ! Email address
7
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION 1NSURAiVCE AFFIDAVIT(M.G?Lc.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 permi
Signed Affidavit Attached? Yes ..........O No... .
SECTION 7a.OWNER AUTHORIZATION TO BS.COMPLETED.WHEN,
OWNER'S AGENT OR CONTRACTOR/APPLIES FOR BUILDING.PERMIT
I,as Owner ofsub' t erty,hereby authorize J�G 4,
t9 act o �ybe f tters relative to work authorized by this building permit application.
Prin tuner s N clronic Signolure) Pfite
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain d in this application is true and accurate to the best of my knowledge and understanding.
not Owner's or Authorized Agent's Nume(Electronic Signalurc) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
registered in the Home Improvement Contractor(HIC)Program);will have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important mformnfto`n on the FTIC Program can a tounti3t -
www.m:tss.eoWoc t Information on the Construction Supervisor License can be round at www.ntas�
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) (including garage,finished basementlattics,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
.1. "rota) Project Square Footage"may be substiuued for"Total Project Cost"
CITY OF SALEA MASSAaA SE TTS
Bu7DiwDErAR7mxr
120 WASIANG71ONS7REET,3"FiOOR
110.(978)745.9595.
FAX(978)740.9846
%IIvJBERLEYDRISQ7I.L
MAYOR DKWAS STYMME
DmcrcacFpLs,ucpxommlBuEEDRcomeamoN=
Construction Debris Disposa/Affidavit
(required for-all demolition and,.renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL coo, S 54; Building Permit 8 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris willpe disposed of in:
(name of facility)
41,1211
L�
(address of facility)
Signatu a of applicant
Date
The Commonwe. &h ofMassachuset/s
Deparanerst oflndustrutlAcc idents
I CongressSftw4 Suite IN
Boston,AM 01114.1017
www.masRgov/dla
WiWairhers,Compensation Insurame Affidavit BuilderslCantractorsMieeblcianVPJnmbers.
TO BE FUID WITH G AUTHORITY.
a a
Name{nusinas/Orguxation9ar4»ituai}:
Address: f (7ti'!'v"`''`"'`
city/statejZMP: vPhone#: ? !1 J
Are yna an empto ?Cheek the appreprHtc bos: Type of prof eat(rey0tred):
l.❑Jam a=?
with .empbyees(full awaypan-t®e).e - 7. ❑New coo shucti_on
a sok pmpiielmaparmaship Mohave no empbyeea wodaaag forma m 8. ❑jjCntpdeling
upaciry.jHo wdekeia''comp.inawoee reguaedJ-
3.❑t am a homeow,tcdoing all work myaeN:[No workcs'oowp.insmaoxxaryved.j 9. ❑Demolition.
4.❑Ism a homeow,«r�t win behirmg caadractms to conduct all work onmy Faopaw. ]will 10❑Building addition.
came that all coffia to s ei8terhave workers'compeasaom:insurance a are sole 11. Electrical
❑ rapers or additions
with
I2: Plumbin oradrlititins
g
5.❑lam a general rentractor and i have hued on anliKont name bated on the attached sheat. 13.[]Roafrepairs.
7treae sub�cantrscamhave+mpmyeecaoa7rave wmkga'eomp.insutaocer
ti.❑Wemeaaorpmationmdits officersbove,merchadthairrgbaofevemwtimperMGL c. 14.[]Other .
152,11(4).and we have no employees.jNo workers'alMnop-IDetoanoetequhedj
-AnyMilitand out c}o1a,has,Sl must also 511 out the actin below ak`ewkrgtb�vagataas'e nae poSeyfs tion. - ..
t Homeowacs who s4bmit das affidawitindicetmg they are doing all work and a"ice outside eomwisas must subaa anew affidavit indicating such.
rCanpacmn that check this box must attarLed an'addi6ansl shea4showingthe same ofthe su and sonewkedisa Mt flow Waiths have .
employees. Uthe sub-tenhsctwa have employ-.they Wowide tt- wolm,eemp Policym®ba.
I am an expkyer 0Wk prVWAWg Workers'Fo for rreY F1RYeea Below is thepallgandjab ails
tnforynallon. j_
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date;.
Job Site Address: City/Stat&Zip:
Attach a copy of the workers'compensation policy declaration page(showingflie policy tundr and expiration date).
Failure to scare coverage as required under MGL c. 152,§25A is a cahninW violation punishable by a fine up to$1,500.00
and/or one-yew imprisomnent,as well as penalties in the farm ofa STOP WORK ORDER and a lino of up to$250.00 a
day against the violator., a t may be forwarded to the Office oflnveatigations of the DIA for insurance
coverage verification. py
I sfo hereby cerrrjy rhe and skies ofperJnry tkattbe infomrarion provided '.due srrrerL
silmature: Dow- /m
Ofliciael ase only. Do nee'wrbe in this area,to be conViered by city ortosvri o fickI
City or Town: PermiULieeuae#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CHyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
,y
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 writtep"
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 spartnents 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 corrmtonweabli 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 511 out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their cer i5cate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships 012)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 aomopriate Ire.
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
pplicantPlease 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 pemtiNicense applications in any given year,need only submit one affidavit indicating curr®t
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 frilled out each
year.Where a home owner or citizen is obtaining a license or perat not*elated 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
I Congress Street, Suite 100
Boston,MA 02114-2017,
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia