24 PURITAN RD - BUILDING INSPECTION <1 fit. The Commonwealth of Massachusetts Town of
I Board of Building Regulations and Standards
11 � Massachusetts State Building Code. 780 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a �
One-or Fmnih Dwelling
This Sectio For Oficial Use Only
BFPrope
it N tuber: ate Applied:
S
ing Commis r/I spector f dings Date
TION is SITE INFORMATION
1. ddrefs: 1.2 Assessors Map& Parcel Numbers
-• /G,�,., 'L
1.1 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 R) Frontage(R)
1.5 Building Setbacks(ft)
From 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: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal prOn site disposal system 13Public Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1,Dwner'of Record:
;�$J�
i // zY iPr.r J`
Name(Print) Address forService:',
`12t 71/'l o fi- 2 2
Signorine Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(-) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Numb r of Units_ Other ❑ Specify:
Brief Dgsg Iption of Proposed Work':
�rJ
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMclal Use Only
Item Labor and Materials
I. Building 5 I. Building Permit Fee: 5 Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $ Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 2 /�'S�v ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ^
5.1 Licensed Construction Supervisor(CSL)
/ QWSResidential
sus2S er Expiiration Date
Gm/ der. (tie below)
Address Descri tion
estricted u to 35,000 Cu. Ft.)
tricted 1&2 FamilDwellinSi ture son Onl
7Y S�didential Roofin CoverTelephone idential Window and Sidin
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Rggistere Home Impovem/gnt Contractor ^HI
HIC Company Name or HI grstr t Nam ' Registration Number
ei�i ��..5_2= *t l� l
Address
Z/ 8' Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 .......... �0 No........... ❑
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. ISI
Signature of Owner Date
SECTION 7b:OWNEW ORR�AU/THORIZED AGENT DECLARATION
1, // ,, e� `�S.HL-r�a , 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
97igna'MYE—of Owner or AuthoriW Agent Date
Si ned under the pains and penalties of perjury)
NOTES:
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, 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"maybe substituted for"Total Project Cosi'
CITY OF SALEM
ty ` .
( ,,�; PUBLIC PROPRERTY
DEPARTMENT
Constrtiction Debris Disposal Aliidavit
(required liir all demolition and renovation \Volk)
In accordance with the sixth edition of the Statc Building Code, 780 CNIR section If 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
11 1, S 150A.
The dehris will be transported by:
I name of hauler)
I he debris will be disposed of'in
(name ur ISulrty)
laddre..of ldc JilV1 /-
r
.Icnalwc If prnnu .yglhcanl
I"_41 Z_'59
li
CITY OF SALEM
1; PUBLIC PROPRERTY
o.
DEPARTMENT
/\SIALLi is S.%I 1'U, kf.,»,I Iit u 11,507:
J7t-71>•r3'+5 e I tv 97M-.'1,: Ix16
Workers' Cumpensation Insurunce \fftdllxit: Builders/Contractors/Electricians/Plumbers
\ l diLant Inforinrlion Please Print Leeihly
VdInC lllu.uha,y1�rpanv.hnnnInJi,!.luall: J
"' f I
C ay.State.lip Thune # 7 Y 5 r Y
.\re yatt at employer?Cheek the appropriate bol: I')PC or project (required):
I.E 1 an%a employer with a Q I :un a general couhraclor and 1 6. Q New construction
hate
caytloyccs(full and'or Put-time).' hired the soh-convacwrs 7. 0 Remodeling
2.❑ 1 ,all a sole prnprictnr air partner- listed on rhe anachal sheet. :
,lisp antl have no employees These sub-contractors have It. ❑ Demolition
working fair me In any capacity. ,corkers' cornp. Insurance. q, ❑ Building addition
nn workers' cum . insurance 5. ❑ Weare a corporation and its
officers have exeniseJ their
P 10.0 Electrical repairs or additions
rcyuired.J
ri ht of r MGL
11.0 Plumbing repairs or additions
1.El am m
u hoeowner ailing all work g cxent tiPon per
lno wn cumP
Jnself. rkers' . c. 152.j 1(3),anJ we have nn 12.0 Ruul'mpairs
y
insurance rcyuired.J t anployccs. iKn work ers' 13.0 Other
-
comp. in.wrancc rcyuired.J
•,m .pphcaut ilidl1 hE cka boa OI mush+110 Jill out the r`o'an I»luw Jwwuts Ilteu wufkw cumpen,Wiwl lwhey udbrhlWliaML
' I L,meownn whir udlnhil this affidavit indicauns ilwf am Joins WI work and then him witide cahuraenba must.ulvnk a nn.lirda.It mJiutms..mh.
-f.wn.u.n that ahoea this boa Mimi nlxhnl an uJniwwl,I+eet Jwwms tate lues:of taw subrontracton and their wurkun'tulip:rsdwy Mfurhnadon
/run un cosi/uyrr that le prorating rvorkers'rurnprnrntiou in.mrancr jar urs enrp/uprrs. Be/nly is the pit/icy and jub.,ife
irrjurmatiun
1'1)li.v 4,)r Sclf-ins. Lic. n:--- - /� J . _ -__ Eapiratlun Date:
Job 1ne -\ddresv: „ `" C1ly:5Wler[Jp:
, eclaratlun page(showing the policy ntuober and expiration date).
VtacA n copy of the workers' cumpensatlon policy d
Pulurc to,ccur,co,'rage as required under Sct-tion ?5:\til'\IGL c. 152 can lead to the imposition of criminal penalties o(2
6110 till Io 51.5no,of)antkor une-year imp6s.nuncnt, as n cll is ci,d Pcnullics in the fain of a STOP WORK ORDER and a fine
of up u+ S250 M)a J.ry .Igamst the violator. Re adv,.cd that a copy of this,wtcmcnl may be Iurwarded to the 011ice.1'
I.t, nga I,,%,ul :he UI.\ :br ut,w.ICC: a!,7.I�e ,al Ilia shun.
/Ju herchy I%rllfv 1./I r lb r,a, rnu/ria•t of rrjnry shut sir injurrnutlon provided above is true ud correct.
L
Fil
+e mdy. no normittin/hit arca, ru beown:ulhurity (circle enc): I
If IIc.JtbIhpartulcrd L Chh.Tunn Clerk J. Lleclric.d In,pccror ?. Plumbing la,paclor
c nue:
Information and Instructions
�L1>,.1.hu,nta Gcncral Laws chapter 1 52 1cqulres j I I cis piu)crs to provide workers' compensation tier theeI cnhpluyces.
Punu.utt 10 1:119 .t atule, all emyluree is do li l led.hs " eh cry pc,son 1n the wrvlve of anuhher under .my cunwwt of hire.
�\pre>t Jr ilnpl,CJ. ofal or %taten."
\n :mpluper is Joined as "an individual, partnership, .isaociatiW, Corporation or )(her legal entnry, or any two or inure
.It 1t•c hrtcgolcg engaged it a joint enlerpnse. and mcuding the !cgal rcpreseuunves or a deceaseJ cmpiu)cr, or the
rcvaver or rude.ul .ui maliviJu il, parurenhip,association or other Icgal ennry,employing emplo)ees. However the
owner of a dwelling house having not snore than three apartments and who resides therein, or the occupant of the
.hv:Ilu1g Iwuse of another who employs persons w Jo maintenance•cunNtruction or repair work on such dwelling house
or.111 the.rounds or budding appurtenant thereto shall not because of such employment b< deemed to be an cmplo)er "
MGL chapter 152. 525C(6)also states that "every state or local licensing igency shall withhold the issuance or
renewal of a license or permit to uperate 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."
\ddit anally• NIGL chapter 152, 425CM states"Neither the commonwealth nor any of 1u political subdivisions shall
enter into any cumract for the performance of public work until acceptable ev idcnce ui cunhpliance 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 emplayucs 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 al'lidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Ikpartment 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 he sure that the affidavit is complete emd printed legibly. The Department has provided a space at the bottom
of die aRidava for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
IHcusc be sure to till in the permit/license number which will be used is a ret'erenec number. In addition,an applicant
that must submit multiple pennitJlicetuc 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 lucatiuns in Icily or
town)." A copy of the affidavit that has been officially stamped or niarked 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 tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(1.c. a dug license or permit to bion leaves etc.)said person is NOT required to complete this atfidavit.
I h; ,)Bice of Imevti.atiuns would Is" to dhaiik )ou in adtilnce fur your Cooperation and shuuld guts have .tny queahuus,
please Ju our hesitate to give us a call.
fhc Department's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. 0 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
1j 11i www.mas3.gov/din
�p 4S
it .` �'/re �oorromamu `7'�(�aaoar�euaell6 , �tt
Board of Bu1Mlu6 Regalatiooe and Stasdarda
t Consttuctlon Sup etvl W Ucans .
Ucsny:4 M it 97788-
Exp mtkm 212412011TA 97788-
Rsstrlctlan ' i'
O �`
CHRIS Yl
I 44 BROOl IDE
tCommlaaloner li
pAWVER3 MA 01923
Board Bio"d lg Re^i� eco-(Is end rds'
HOME IMPROVEMENT CONTRACTOR
Registration: 153299
Expiration: 11/14/2010 Trill 276829
Type:.Private Corporation
PRIDE CONSTRUCTIOf9 AND DEVELOPMENT INC
CHRISTOPHER YOCUM
471 HIGHLAND AVE
SALEM, MA 01970 - - •-�.
al"llstrator
OSHA
001428219
U.S.Department oI:Landr M
Occupational Safety and Healtn AdOlinistlation
CHRIS YOCUM
has 3UCce9afullY camplete0 a lecc
t"Occupational Safety,and Health
h N
n9 Course in - )
Construgton&e_ty a Health
-. Jay Fitzpatrick 9/20/07 '
maaler)
__. ... ..
(Date)