1 RIVERBANK RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Town of
oBoard of Building Regulations and Standards
a� Massachusetts State Building Code, 780 CMR, 7"edition Building
Building Permit Application To Construct, Repair, Renovate Or Demolish a �
One- or Tuo-Fmnrh Du ellrng
'S ction For Official Use Only
!Signature:
ilding Permit Number: Date Applied:
Vl �. a�
Building
r--
Building Commi sioner/ ctor of dings Date
V ECTION 1:SITE INFORMATION
I.1 rop ?y,Address"•y' / 1 1.2 Assessors Map& Parcel Numbers
_S /!1 7 i�PY J 4�1{� V -
I.I a Is this an accepted street?yes no. Map Number Parcel Number
1.1 Zoning Information: 1.4 Property Dimensions: -
Zoning District Proposed Use Lot Area(sq B) Frontage(B)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L C.40,954) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system 13Public❑ Private❑ Check if yesO
/�" SECTION 2: PROPERTY OWNERSHIP' l
2.11/'7deXof ordefit/o^LtiL
NN' imAddress for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Aiteration(s) ❑ 1 Addition ❑
Demolition - ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
OOlyl L4?P O r/lA v 'P k
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ejand
Costs: Official Use Only
Item LabMaterialsI. Building S OD1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee2. Electrical SO . ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S � �, 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S Check Amount: W�
Suppression)
Check No.� J& Cash Amount:
6. Total Project Cost: S /0—SQ491 0 Paid in Full 0 Outstanding Balance Due:
r
SECTION S: CONSTRUCTION SERVICES
5.1 is nsed Construction Superviso (CSL) Iq<1
-� �r � , License Number Ex alto Date
N4mcfCS - I1pIJ r ���
S List CSL Type Isco below) LI
Ad •ss T' Descn tion
U Unrestricted(u2 to 35,000 Cu. Ft.)
Si at r R Restricted 1&2 FamilyDwelling
M Masonry Only
—JO OC RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residemial Demolition
5.2 Registered Home Improvement Contractor(HIC) �,�b
HI o NYO ame �C Re �npnt Na s Registration Number
A drc s v/a/4
,a/
�7�'_ p?. Ellpirarflon Date
Signatur ep one
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 .......... O No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, U ) / as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative rk authorized by this building permit application.
v
Signature of Owner k Date
SE TION 7b: OWNER! OR AUTHORIZED AGENT DECLARATION
1, ,as:aaisss8 o uthorized Agent ereby declare
that the statements and information on the foregoing application are true and accurate, o o my knowledge and
behalf. /
I CI .
Print N
Signature of�yor Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 IO.R6 and I I O.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. R.) (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"
l
\
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1/671 i'IS•l5 • I ] 979-.'1: M46
IlYurkers' Cumpensation Insurunce %1'ftda\it: lfuilders/Contracturs/Electricians/Plumbers
\ 1 tlicant hirorinution Pleaa Print Leizihfr
V i11nC llhnll lc,Y t)r�an✓.UunelnJl,�,l/uall:
P l -VA-VACI d
\Jdlrss: l,J !7��rI�,`CY/a'P 7 p •
City,stare.%ip- _<c;1 // 44440, I"/(� ` Thune d: "/ 7Y- 2y7/,_12 0�
.-in an employer?Check the appropriate boa: I*)PC of project(requir
eve ged):
i 6 ❑ I on a general contractor and 1 6. ❑ Ncw construction
IC] inn. 1 . a employer with
employ Ccs(full jernVur part-time).' have hired the dub-contractors
2 1 am sole prnprienlr or partner- listed on rhe.machcd sheet. • C] Remodeling
ship and have no mnpluyees These subcontracmn have 8. ❑ Demolition
working lily me m any capacity, workers' comp. insurance. g. ❑ Oudding addition
Nn worltcrs'cum tosurdnce 5. ❑ We arc a ccoporation and its
I P officers have examixed their 10.0 Electrical repairs or additions
required.]. 11. plumbing le airs or additions
5.❑ 1 :un a hnmcowncr doing all work right of exemption per hIGL b 'P'
myself. lNo workers' comp. C. 132, ¢1(4),and we have na 12.0 Ruuf repairs
insurance requited.] / unploycvs. (No workers' 13.❑Other
entrap. Insurance miluncd-1 _
• ,n. .,grLaud IhN:Ewka Ent AI moxa alai rill uul the,e.Uou Iwluw Ywwmy IAeu wwtaai cumpunvdiwa Iwhcy udium+aiaM.
' I6rmaur on who,IlEnail this affidavit indle+ana Ihe)+re Juiny dl work cold Ihcn Mm uuWde canuracton must.uhmit+new mr.,laril lnJiu my.oche
4,Mlcwn.n Ihut•heck IhY Dox mare ntwhad.m aeduiun+l JE Vl,Aurins llw rnnw of the IuEtonlraclOra and their wukun'sump.pu6cy mfilmmianon
/aur ml a9nployer deur fs pruriding workers'eu/nprnauion in.rurnner jur/ray eurpluprrx. Behar is the policy aped job Ade
iajunnuriun.
Ir,\urancc Company Name: _._ -- -
I'olicv Y ur Sclf-ins. Lice it:--- . .. -_— Expiration Date:
luU Site -\tlJress: —--
City,StataZlp:
.\trach it copy of the workers' compensation pulley declaration page(showing the policy nwuber and expiration date).
I•allurc or secure co\einge as required uodcr Section 25A ul'>IGL c. 152 can lead to rale imposition of criminal perealries of a
time op ro i1.5410.00 an Vur Unc,ycar,npriN.,o.mnt• at %%ell as Q\II rivoiltics in the I•urm of a STOP WOR K ORDER and a fine
of up w 1230 0(1 a Jay .Igauut ate violator. He advLacd that a Copy of thu slutclncnt may be lorw arded to the Ullice ad
In,;al¢+uou, til '.hc l)L\ :or msw.u•.ee e,ner,t,c act Ui.aLun. -
/du ha•rrhy a.'rrijv un.favIl peon lJ eery /irx r'Y/, lint I/�e in //nY/lOA prYY1J@J Y/rYa'e is/rY YYJ roarer.
�L3�a-
tl(/iciu/use wily. /)o nil Imre in rhir Yrru, ru beeu//rylrrrd by airy Yr/OIVe NW/rlY/.
( i1r nr linen:
I\suing .\uthui ome (circle noe):
il�IIc.JIIt !. Ili Jdin� Dep.lrlurc all 1. (.it%Aclu ,o Clerk J. Clectric.J hisli"lor i. plumbing Impeelor
6. Oilier
('Int tact Phone h:
r
Information and Instructions
%I.0 o.i,hu+ens Genesi Laws dtapter I i2 icquires all empIo)ers to provide workers' compensation for their cn iployees.
I'u rnu.mt totaus .I,t ute, an e,npluree is dclmcd as - e)cry pcison in rhe servi.e ul another miler.uhy cunlract of hire,
c spree, or implied. ural or w nten."
\n :mpluprr i, defined as "an individual, paftner,hip, .Is>oclaljou, corporation or other legal cnhry, or any two or more
.0 tte L,rcgou:g engaged In a)nim emerpr.se. and Including the !egai representatives of a decea.ed cmpluiter, or the
rc,nver or Irustce of .uh individual, painicrship,assocuuon or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides thereto, or the occupant of the
,Iwo Ihng hou,e of another who employs persons to do maintenance,cunstrueiion or repau work on ouch dwelling house
or on he--rounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer "
StGL 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 "too has not produced acceptable evidence of cumplianee with the insurance coverage required"
kadlllunally, WGL chapter 152, 425C(7)orates "Neither the commonwealth nor any of its political subdivisions shall
inter into any contract for the performance uf'public work until acceptable ev idence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
.applicants
Phase fill out the workers' compensation affidavit completely,by checking the boxes that apply to yuur situation and,if
necessary, supply sub-contractor(s) name(s), addresses)and phone numbef(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 confimtatiun of insurance coverage. Also be sure to sign and date the afndavit. The affitlavit should
he Whittled to rhe city or town that the application for the permit ur license is being requested, not the Uepanment of
Industrial Accidents. Should ynu have any questions regarding the law or if you are required to obtain workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
scIf.insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Deparrment has provided a space ut the bottom
ilf the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
vlI a c be <urc to till in the pcnniulieense number which will be u,ed as a reference number. In addition,an applicant
diA must submit multiple penninlicense 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
veru. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
1 toe. a dug license or permit to bum leaves etc.)said person is NOT required to complete This affidavit.
I h; ,h ticc ,n Inve,n--atiuna wuuld li.e to dhank ynu in adv:uice for your cooperation and should you have any questions,
I)lea,e du not hesitate to give us a call.
fhc Dcparuncot's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lovesdradons
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617.727-7749
t.•. :,.d �.7u.ui
www.mass.gov/die
t
CITY OF SALEM
j PUBLIC PROPRERTY
DEPAIZTLIENT
Construction Debris Disposal .-affidavit
(required lbr all demolition and l'en0Y:It1011 work)
In accordance %%ith the sixth edition ol'the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c
I11. S 150A.
The debris will be tra
nsported by:
Qp�r c'4aA�Y
1 name of hauler)
the debris will be disposed oof""in
I name uY lacllny) -..�
-5
1: res, a lacllay)
H L'IWIW I' of prnurt.yq>Ilunt