4-4A ROPES ST UNIT 1, 3 - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7"edition Budding Dept
Building Permit Application To Construct, Repair. Renovate Or Demolish a
\� This Section For Oficial Use Only
\� Building Permit Number: Date Applied: A�r���d
\� Signature:
Building'Commissioner/Inspector of But ldings Date
SECTION 1: SITE INFORMATION
1.1 Property Ad ess: L2 Assessors Map& Parcel Numbers
y �f�I nrira sf 'i
1.I 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 It) Frontage(ft)
1.5 Building Setbacks(ft)
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? Municipal eOn site disposal system ❑
Public I� Private 13 Check if yesO
SECTION 2: PROPERTY OWNERSHIP'' 1 /
2.1 Owner'of Record:, y x.71 LJ�Lr y'VhLAo/t c '1T ,,�j�y�l' / '3
;Nam�e( int) Address for Seryce:
ure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Cr Alteration(s) 2r Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other CO Specify:
Brief Description of roposed Work': / _
,C k�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
7 Estimated Costs: Official Use Only
jItem Labor and Materials '
-�. 1. Building b 301 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S /1r OtTiJ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 10/lF7J 2. Other Fees: E
4. Mechanical (HVAC) b /0,orn) List:
5. Mechanical (Fire S 7i M Total All Fees: E
Su ression
_ c Check No. _Check Amount: Cash Amount:
b.Total Project Cost: S 6 a f�j0 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) q� y.� t
Cxz 1�4 Liccnsr NumJbrr Etpirauon Datc
Nmc of CSL-Hpldcr List CSL Type(see below)
Address T Descn tion
tLcs+ rv` 'S S 02LLZZ U Unresvictrd u to 35,H10 Cu. Ft.)
R Restricted I&2 Fared Dwellin
Signatur�Q — ^ y1 Mason Onl
-) RC Rcsidcntial Roofin Cavenn
Telephone - WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home iImprovement Cogr[ractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Add ss
�pf -Z - pira ionion 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........... 0
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT
/OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Z?;� L Q.GLt , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work a 11horized b is building permit application.
11/2,f/0
Si nature of er Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby declare
that the stateme and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
xf
_ - ignal of r or Authorized Agent Date
(Signed under the pains and penalties of riu
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 floors area(Sq. Ft.) -CO C)'.F (including garage, finished basement/apics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count (p
Number of fireplaces 0 Number of bedrooms y
Number of bathrooms a Number of half/baths b
Type of heating system fe 69S Number of decks/porches
Type of cooling system GEIS Enclosed Open V
3. "Total Project Square Footage"may he substituted for"Total Projcct Cost'
l
Crowley Construction
Renovations Additions
Consulting
617-282-9282
Edward Crowley CS # 050391
36 Parkman St. HIC # 162235
Dorchester,MA. 02122
April 30,2009
4 Ropes Street LLC
CIO Mr. My Lam
44A Ropes St
Salem Mass. 01970
Crowley construction will perform the renovations of 44A Ropes St as drawn on the
plans by T Design 27 Prospect Ave. Randolph Mass. 02368 for the sum of$104,000.00
(One hundred and four thousand dollars)
Payments as follows
25%at signing of contract
25%at rough inspections
25%after drywall finished
25% at completion of work
Any extra work beyond the contract will be through a signed change order prior to the
work being started.
Si �
Edward Crowley dba rowley ConstruCtio
36 Parkman St
Dorchester MA 02122
Accepted
am
44A Ropes LLC
4-4A Ropes St
Salem Mass. 01970
104-
L
Lv If ,
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CITY OF SALEM
PUBLIC I)ROPRERTY
DEPARTMENT
,inn'.K'IS iMhl ,41
12' W,\It InN,,,I,^S l su:T a SAE l'f1, th1.v♦S.%I I It III IN 3I97-�
I i,1. •p1-,'Iy1343 s 1'1.r 971'1346
workers' Compensation Insurunce ,liffddavit: Builders/Contractors/Electricians/Plumbers
ltpplicant Information Please Print Leeibiv
Name
Ciry,Sttta%ip� >t�s -LE-Phone "l: Ld\7- 7S6Z e'x'7A
Arv)uu All employer?Check the appropriate but: I')pe of project(required):
d. 0 I :un a guncral contractor and 1
I.� I .,in a employer with fi. C3 New construction
e olpluyce%(full und,'ur part-tins).' have hired the sub-contracture
2 am a sole proprietor or partner- listed on the attached sheet. 7. [�]'7tmnoJeling
?Pshipand have no tmphiytxs
These sub-contractors have S. 0 Demolition
working Airint in any capacity. workers' comp. Insurance. I) 0 pudding addition
1 Ko workers' comp. insurance 5. 0 We are a cnrparation and its
I required.) ottieen have exercised their 10.C3 Electrical repairs or additions
3. 0 1 ;m)a hnmcuwner doing all work right of exemption per NMI. 11.Q Iumbing repairs or additions
myself. (Ko workers' comp. c. 152, j 1(3),and we have no 12.0 Ruuf repairs
insurance required.) r cmpluyces. [No workers' 13.0 Other
comp. insurance required.]
-\,r) n�tldlranl IIWI checks bJA nI mufl:list,IIII Wa the wction iniaw showinv iheir wvrkwsk cuniprnuaion lwl icy ndirtrtuiiva
' I I.,mctj%mm who wmmil mis affidavit indic.iiiny lhcy.ire doing all work aid then him uuwide cuiuraetan mush.uhmil a new a)rdavil mdi",ny.u.h.
-f,micwhrn rhul dicck Ihrr box mem mmhpl an adddiunal..hatll chuwiny Ih.name of IM subSYntrac4Nx and(heir wurken'comp.lrnhcy information
/um
,it eul/duyer thus i.r pruvidhng wurkers'runrpenvnBan lnsurauce jar ury employees. Below is the pu/iay and jub.vlfr
i"furnwrium
Ir...uranu•Cunlpanly Varve: --- - -- - --___.----
Policv a or Sclf-ins. Lic. 0: _-_ .. . .. __ Expiration Datt:
Job Site Address: Cuy:Slate/ZIp:
.\[tach is copy of the workers' cumpenxallon pudic) declaration pale (showing the policy nutuber and expiration date).
1'allu(C n)♦ccurc cacerage as required under SClltun 25A uI :•IOL C. 152 cart lead to file innposltion of cnininal penalise]of a '
tine up (o 11.500.00 and/ur une-)'tar imprisalnncat, as w'cll as Cnall fictlallics in the farm of a STOP WORK ORDER and a fine
If tip u) 5250.00 is Jay .igainsl the violator. lie advised that a copy of tills swicinew may be forwarded to the 011ict of
laa:nngau,ns arsine DIA :br in.ot.uxc arvcra4i; act ilical;un.
/du hereby a.rfify wider I�lse puinv and penahiev of periisfy that the iu/bnnttlfon proviiid_eedu�bxuve istrue andcorrect.
ZfY�2-'G2cjfL-
IJ//iriu!use un/y. Do nit n'rite in this arra, tube,wuplered by airy ur town u//iciul 1
( ilv or finen: _.. __. Per mitll Avrise p.
Ivvuing Aulhurity (circle nue):
L noanl ..f IIc.JIh ?. ISudJin:; Ikpunulc•nt 1, 1.il).'Ibwu Clerk 1, Electrical In,peclor i- Plot bion; Invpec for
6. Olher _
C,rntact 1'cnuw; .. _. Phone tJ:
9
Information and Instructions
N Ia.s.tdiu,ctts Gcncnl Laws chapter 152 requires all enplo)crs to provide workers' compensation for their employees.
I'urou.ult w Ynis statute, an empluree is deduct as " esery peison in die service of another under any contract of hire,
a apress or unplied. oral or wruten...
.\n :rnpjvprr is defined as"an Individual, partnership, association, corporation or tither legal entlry,or ally two or more
.( It:c t„recou;g engaged m a joint enterprise. and including the :cgai representatives of a deceased emplu)cr, or the
recti%cr Or uuDlce ul.at mclividual, pwtncr�hip,association or Other legal cnnty,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
.Ivvclhng house of another who employs persons to do maintenance,construction or repair work on such dwelling house
Ji- on the grounds or budding appurtenant thereto shall not because of such employment b.' deemed to be an employer."
\IGL chapter 152, i25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of u license or permit to operate a business or to construct buildings in the commonwealth for any
applicant wbo has not produced acceptable evidence of compliance with the insurance coverage required.-
kddiuunally. MGL chapter 152, 425C(7)states 'Neilhei the conunonwcalth nor any of its political subdivisions shall
enter into any contract for the performance ul'puhlic work until acceptable evidence of cumpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
vv -
Please fill out the workers' compensation atfidavit 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 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 dale the affidavit. The affidavit should
be retiarimcd 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 11 you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Sclf-insured companies should enter their
self-insurance license number on the appropriate line
City or'rown Official
please he sure that the affidavit is complete :md printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to till nut in the event the Office of Investigations has to contact you regarding the applicant.
Please be Sure to till in the pennittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitaicetse 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 luuatiuns in laity or
town)." �\ 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 tilled out each
year. Where a Koine owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
Ut Itiveltlgatiun! wuuld like to thank )flu in ativalicc fur your cooperation and should You lase sly gUeDt1011i,
please du nut hesitate to give us a call.
rhe Dcpartinent's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofllce of invesdgadons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mass.gov/dia
i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I_ \1 ��I II\,,,,'\\6411-r \.11I M. \L\
111: v'8-'J;.�;h � l��s: 'i'X-V:•�.i Jig
Construction Debris Disposal Affidavit
(re(luired tier all demolition and renovation work)
In accordance \010 the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of"NIGL c 40, S 54;
Building Permit tt is issued with the condition that the debris resulting front
this work shall he disposed of fit a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
7 A tA)±:x
(name of haul&)
Ilie debris
will be disposed of in
(name offCaac�illiity)
(address of facility) - -
' Jturc of permit applicant
yX2,&/ g
,late