29 RAVENA AVE - BUILDING INSPECTION CI( #t D3 �y
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
r�
` J Building Permit Application To Construct, Repair, Renovate Or Demolish a "111-
AlmoL
One- or Tiro-Fmnily Dtve!ling
This Section For Official Use Only
Building Permit Nu �er:,�^ Date Applied: T s
Signature: ✓ J /O
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro erty�y Address: 1.2 Assessors Map At Parcel Numbers
e2 hAV P.n R Au—A�
I.1a Is this an accepted street?yeses no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal tlrOn site disposal system ❑
Public PI Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: 21 RAA PA/Vd Ay-e,
Name( int) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) PT Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed WorkZ: e +� P .h er1P x
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building E /0 U 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
E3.
El S �U O 13 Total Project Cost(Item 6) <multiplier s
g E �Uv• 2. Other Fees: E
4. Mechanical (HVAC) 5 List:
5. Mechanical (Fire E Total All Fees:S
Su ression
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S 9 UCX) 0 Paid in Full 0 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervi94J,
r���..�GLicense Number Expiration Date
t
N,gmc of CSL- Hplder��(�..L77�r.i l S)"- List CSL Typr(xe Ixluw)Address T Descn tion
U Unrestricted u to)5,000 Cu. Ft.)R Restricted 1&2 FamilD%cllinM Mason OnlRC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered HomelmprovementContractor(HIC) 13 r ' I a
�Tc�I'xe.5 �rV f/i Cr'} �il5trc./Gfid✓�
HIC Company Name or HIr7�Registrant Name/J / / /yam q Registration Number
s `7 C-C�il'�ry4-( .$t Yecr00J 9 I
Address t? 3 / I 1 ( d
W7 /3fr'3Qav / 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 ........ No........... 17
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, Gf}T�J� C sry/`sC 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.
�0 3
✓ Print Name
S-S-oy
Signature of Owner or Authorized Agent Date
(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 I O.R6 and I I O.RS, respectively.
2. When substantial work is planned,provide the information below-
Total Iloors 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"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,Ito'. M'I l' INhI .'II
\I 11.NI I2.^. W,tull.\t:I.JN$CALL I' # ),H I']f, M.\U.\t III III iS3197:.
Il'.I. v71-7/3-e5'l5 • l lx 978-740J.146
1Yorkers' Compensation Insurunce %friiduvit: Builders/Contractors/Electricians/Plumbers
itmoicaut Information Please Print Le¢ihly
V:IITIC IItu.11kvvchganlr.UinNInJlt nluol): Gi+f-�C7) C -rw^-1G
AddrCss: s '7 Ge j7L,- l s�
City,.5tata%ip PC�etb�/y � �(V` Thune it- 97�_ - 335 3 01
/
rc)tau all employer'!Check the appropriate box:
'1')pe of project(required):
4 1 am a general couractor and 1 -
1.❑ I and a employer with - ❑ fi. C3 New cunstrucuun
�plo)".s(full in1L'ur port-tame).• have hired the sub-cuntracturs
2 1 .un a tole prnprictor or partner- luted Oil the Ilttachcd sheet. 7• ❑ Remodeling
%hip and have no empluyeus These subcontractors have B. ❑ Detnolitiun
corking lir me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
No workers'coin insurance 5. ❑ We area eniparution and its
I P 10.❑ Electrical repairs or additions
I required.] oflieerx have exercised their
J.❑ 1 ;un a homeowner doing all work right of exemption per MCL 11.❑ Plumbing repairs or additions
myself. (No workers'comp. c. 152, ¢1(4),and we have no 12.❑ Rout repairs
insurance required.) / .anployces. LNG corkers' 13.0 Other
comp. insurance required.)
•k... ...gsli,taw awl ahccks box 01 mu it Aw 1111 wi the wcIIi11 iwjww SIIUwing,hJlr wwkws cvnipgnsuliwl Iwllcy nd6rmal:un.
' I lumeuwrcn.vhu e.almir chis atfliavil indicA,ing me)act doing ill work cold Ibcn him WI$Ide cwuroeton musk allbMil a new atrdav:l indirmny.oah. -
C'..ncmvton Thal ahcck this box mun atbched.m aedaimil nhv'xt'huwiny Ilm name of tho subsonitNion and their wurkerx'comprmdccy mfi ninadun
/am un employer that is pruvidine workers'conipenvalion insurance fur Juy rmplayees. Belo is the pu/iry and job 0e,
iajarnlutiun.
Ir..,urancc Cunlpauy Name:___ - . -- - -------.---
I'nli:v 4 or Sclf-ins. Lic. rt: __.. . . .. ._ Expirauun Date:
Job Site -Address: ___. Cuy:Stauvzjp.
.\each it copy of lite workers' cmnpenxathln policy declaration page(showing the policy nusubcr and expiration date).
Failure to secure euseruye as required under Scctiun 25:\ ol':•1GL c. 152 call lead to the imposition of criminal penalties ofd
rine up ro.S1.500.i4)and/or elle-year I111pl'1MIllmcnt. aY%%eII as;lull pcllalllcs Ill the furan of a STOP WORK ORDER and a fine
of up ill i_150.00 a Jay .Igainst the violator. Be advi.t d that a copy of this ntalcmcut may be forwarded to the Office of
Im;al•,au„m of '•he DIA :or lo,ul trcc a'nur�e vcriticalmn.
/do herrhy c lrtifv nrl./rr the
[/.Mini mrd ppeno/tiev of perjury that the urJnuNon provided above is true aand correct.
O�/iciu/rue an/y. Do not Ivrirr in fhi.l craw to he rump/;red by tvfy or folvn a//ii ill/. I
( itv ur Foca: ... _ - Pel'Ininl.ieensc
Issuing .\uthurity (circle nuc):
1. Board of Ilc.lhh 2. 111111'161' ncpartlncnl 1. (JI.s.'Ibcn Clerk J. Electrical lu,pcctor i. Plumbing Inspector
6. OIIler _
Contact Pcnua; -. _ Phone tl:
Y
Information and Instructions
\1.h>s.4chuscts Gcncral Laws chapter 1 i2 requires all employers to provide workers' compensation tier their cnhployees.
1'unu.un to alis ,litule, an empluree is dcfined as " .etcry person in the iervice of another under any Conflict of hire,
e%pre,s or implied. oral or %vnmen."
\n ehnplayer is defined as "an individual, partnership, association,corporation or other legal entity,or any two or more
.r [he hrreeou;g engaged it a joint cntcrprue, and including the legal representatives of a deceased cmplu)cr,or the
receiver Or trustee of .ul I11dividual, paitlicf,hhp,ass"latnOn Or Ocher legal ennty,employing employees. However the
owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant of the
d\ve111ng iluu5e if another who employs persons to do maintenance,construction or repair work On ,tach dwelling house
or ,m the grounds or budding appurtenant thereto,hall not because of such employment be deemed to be an employer."
NIGL chapter 152, §25C(6)also states that "every slate or local licensing agency shalt withhold the issuance or
renewal urn 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."
\ddirhunally, \IGL chapter 152. 425C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ufpublic work until acceptable evidence ofcompliance 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) nanlc(s), address(es)and phone nullbef(s) ailing with their cerllflcate(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 confimtation of insurance rnvcrage. Also be sure to sign and date the affidavit. The affidavit should
bu refilmed 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
)r-insurance license number on the appropriate line.
City or Town Ofriclals
Please he 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.
ri ::se be sure to fill in the penni /license number which will be used as a reference number. In addition,an applicant
that must submit multiple perniniice[vse 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 affiduvll is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a hume owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I ho [)[lice ul IIIV Csti gallon, would Ilse to diank ),)u In advance fur your cooperation and should you have sly questions,
please do not hcsirate to give us a call.
fhe D,:p.unncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. 11617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
( d "' www.mass.gov/dia
v
CITY OF SALEM
PUBLIC PRc)PRERTY
DEPARTMENT
I_'� U ,d II'a.. ':l;,tl 1 f � 1.\I I \I, �(\ "\I :. •. I .I'I _
III /';6 V4.1i45 ♦ I \\: 'i'Xi '4:'"4,.
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance % ith the sixth edition of the State Building Code, 780 C NIR section 11 1.5
Debris, and the provisions of MGL c 40, S 54;
Qui Wing Permit tt is issued with the condition that the debris resulting from
this work shall be disposed of in it properly licensed waste disposal lacility as defined by MGL c
I11. S 150A.
The debris will be transported by:
(name of hauler)
I fie debris will be disposed of in
(,naine u((facility) _
(adJre . ul'19nlilVl
aguatwc of p:arta .y,phcdnt
dale