2 1/2 ROPES ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of I)uilding Regulations and Standards CITY
J( !, Massachusetts State Building Code, 730 CMR, 7"edition OF SALEM
Retired Ja ur„rt•
Building Permit Ap n To Construct, Repair, Rcno4te Or Demolish a 1. 2008
One-)or Tnvr-Fumdv Dwellin
This Section For 011ici se Only
Building Permit Nu er: I D Applied:
Signature:
Buil&4comrm done do of ildings Date
CTION 1:SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map& Parcel Numbers
i e
1.]a Is this an accepted street?yes__ no Mar Number Parcel Numb r
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(R)
1.5 Building Setbacks(fq
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 M Private C! Zone:
if yes❑ Municipal❑ Onsite disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
!r'//P/� S/irrn5on Z—//,l
SPP f Sr
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building e Owner-Occupied Fri Repairs(s) El Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work'-: ;1 Oo ek / c
�G�!iesr. V /iaAT s
/ o T rr cd l T ,aTi r au ho o V
v a fro
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S 3500, 0=, 1. Building Permit Fee:S Indicate how Ice is determined:
❑Standard City/Town Application Fee
2. Electrical S 2-5-0-0 , 0, ❑Total Project Coil'(Item ).r multiplier x
3. Plumbing S /Lap p,t 2. Other Fees: S
4. Mechanical (H !VAC) S List,
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S 7200s 00 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) it)
3 e./
���Qt ber Expiration Date
N;,4nc otCSL-I IulJrr -7
pe(See t+elaw) (..�Descri lion
Address /fL� nrestricteJ u to 35,000 C'u.Ft.�OT estricted 1&2 Famil Dwellinason Onlesidential Rootin C'owrinephone esidential Window and Sidin/1 (/3� esidential Solid Fuel Oumin A liance Installation
/(g' 'O j .1 � �� / 1 esiJemial Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company It nt IIIC Registrant Name Registration Numb:r
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... V Nu...........❑
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
1, 6,00r-it- -/ N r S '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. �w'
T V P
Print Name C/
Signature of ner t razed Agent Date
Si med er the ' 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. I42A.Other important information on the FIIC Program and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations I I0.116 and I I O.R5, 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.) Ilabitable 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 he substituted for"Total Project Cost"
CITY OF SALEM
=(„ ;;�, p PUBLIC PROPRERTY
:7..-rsgo
DEPARTMENT
,nu::N:1'1':1NK4UI 1.
\I TUN
12C WA\Ill\G I ON 5'I S ELl' • SAI F.M.M.WSAC I II SI.'I l S 0197.".
978-;45-'1575 • P.tx.979-7447.146
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
kpitlicant Information //_ Please Print Leeihly
Nalnd l0ucilkss�f^t)r�amrulinNlndlv,dua4: t YP art Q �y (IjQ�f rya? f
Address: Tc' fr, top
V4—, �7 p p
City,State,Zip: r.5�lyCl 117 (214 1`1 1'huncif':� � d ' 91 S YY 2 '1
you an employer!Check the appropriate box: 'rype or project(required):
1.❑ 1 am a employer with 4. 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or part-tmtc).• have hired the suh-contractors
.❑ 1 ant a sole proprietor or partner-
listed on the attached sheet. : 7. ❑ Remodeling;
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑ Building addition
1 No workers'comp. insurance 5. ❑ We are a corporation and its
required.] otltccrs have exercised their 10.C] Electrical repairs or additions
3.❑ 1 ant a homeowner doing all work light of exemption per MGL 11.0 Plumbing repairs or additions
myself.(Ko workers' comp. c. 152,q1(4),and we have no 12.❑ Roof repairs
insurance required.] r - employees. (Ko workers' 13.0 Other
comp. insurance required.]
-Any apphcaul that checks bust Ml mustalso till out the w:citon Wow ehuwina(heir wurkuy compensation policy intiaeuti,m.
't lumcuwmn who s,dtmir this anWavit in heanng They ate cluing all work and then him outside courxtors must ouhmit anew al'fdavlt indicating such.
�r'oatMI'Ws that chuck this box mml anxhuvl an additional sheet showing ale,,ante of iho sub.onirmson and(heir,t'urkers'comp.policy infum,ation.
I not on employer thatch providing workers'compensation insurance fur my employees. Below is the policy and job site
injanouriun.
Insurance Company Name:__ ...
Policy is or Sclf-ins. Lic.0: _._ Expimuon Date:
Job Site Address: City;Stats/Zip:
Attach it copy of Ilse workers' compensation policy declaration page(showing;the policy number and expiration date).
Iailurc to secure coverage as required under Section 25A of JIGL c. 152 can lead to.the imposition of criminal penalties of a
tine up to 51.5110.00 and/or one-year imprisonment,as well as civil penalties in the furm of a STOP \VORK ORDER and a fine
of up to 4250.00 it day against the violator. lie advised that a copy of this statement may be forwarded to the 011ice of
Incul'dtc DIA for insurance coverage teriticnion.
/du hereby certify and the pains d pe/rnUies ufperjury that the infurinallon provided above is true and correct.
Date,
s,
Official use only. Do not sprite in this area,to he cuorpleled by city or lmvn ofjiciaL i
i
Cily or'I'own: Perinit/License s._
issuing.\ulhorily(circle one):
1. Iluard of licalth 2. Building Mpartineut .1.C.itri fonu Clerk 4. L•'lectricul Inspector 5, Plumbing luspeetor
6. 011ier
Cuatact Vchua; ._ Phone Y:
Information and Instructions
>lass.tchuscns General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employed is defined as"...every person in the service of another under anpcuntraot of hire,
evpress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
d The Ibregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,piumership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work an 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, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract fbi the performance of public work until acceptable evidence of cunnpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill 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(LCC)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 date the affidavit. The affidavit should
he 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 appropriate line.
City or Town Officials
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.
Please 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 pennitilicese applications in any given year,need only submit one affidavit indicating current
policy information t 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 cite 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 bur leaves etc.)said person is NOT required to complete this affidavit.
I lie or hce It Investigations would like to drunk you in advance fur your cooperation and should you have sly questions,
please du not hesitate to give us a call.
rhe Dcparnncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
iscil i-26-05
www.mass.gov/dia
CITY OF S�U.E.NvI, NLxSSACH1USETTS
13LILDLNG DEPARTNWNT
130 W.ISHLNGTON STREET, 3"FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
Kl.%C3RAr FY DRLSCOLL
MAYORTHO.�L1.4$T.P[ERRH
DIRECTOR OF FCBLIC PROPERTY/BUMMLNG 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 t 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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
si re of permit applicant
L/ i
date
Jcbnvlf J.e: