28 SHORE AVE - BUILDING INSPECTION SGT
The commonwealth of Massachusetts RECEIVED CITY
4 / Board of Building Regulations and 9fe6aidsi ITiAL SERVI ES SALEM
Massachusetts State Building Code, 780 CMR Revised,Nar101!
Building Permit Application To Construct Repair, Rej$hl M PalMo iRh 47- q
One-or Tivo-Family Dwelling
This Section For Official Use On[
Building Permit Number.° Date Apph
I Building Otiicial(Print Name). - - Signature: '. ate
SECTION If SITE INFORMATION
1.1 Property Addresse 1.2 Assessors Map Su Parcel Numbers
Y�) 1.1a Is this an acce ted street?yes no krap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
G Zoning District Proposed Use Lot Area(sit R) Frontage(R)
1.5 Building Setbacks(it) .
Front Yard - Side Yards Rear Yard
ReyuireJ Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information! 1.8 Sewage Dbposal System:' '
Public 0 Private O. Zone: _ Outside Flood Zone? Municipal O On site disposal system O
SECTION 2: PROPERTY;OWNERSHIPt
2.1 Owner'of
cord: /� /�� . e19 0
K* a(Print) City,State,ZIP
98- bdlp,L-c 19ve— $ 0?
No.and Slrcct - Telephone Email Address
SECTION 3:DESCRIPTJGK OF PROPOSED WORKS(check that apply)`
New Construction O Existing Building Owner-Occupied O Repairs(s) Alterotion(s) l] Addition 0
Demolition 0 Accessory Bldg.0 Number of Units Other O Specify:
Brief Description of Proposed Work-' r r
rte- lrt.e S /
SECTION a:ESTIMATED CONSTRUCTION COSTS
EOfficial Use Only
Itcm La
1. Building Silding Permit Fee:S Indicate how fee is determined:
ndard Citylrown Application Fee
2.Electrical Stal Project Cose(item 6)x multiplier x
3. Plumbing SherFees: S
d.blecittmical (FIVAC) ISMO
5.\lechanical (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
6.Toted Project Cost: S �� 0 Paid in Full ❑Outstanding Balance Due:
6f--A L—t—P—ID 1=0
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Liccnse(CSL) CS 13537 0 6
V A tom. � K"—ve'y! License Number Er ra_tio/n trate
Name of CSL Holder List CSL'rype(see below) y
3Q A &J?D 11 e S�e TYpa . _ - Description
.
No.and Street
�I U Unrestricted(Buildings up to 35,000 cu. Il.
log ��� d R Restricted 1&2Famil Dwelling
City/Town,Slate,ZIP, M Masonry
RC Roaring Covering
WS Window and Siding
SF Solid Fuel Bruning Appliances
1 I Insulation
Tele hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) /9,3/99' �y
� y C WLA"fLy`4iy HIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
'719 14 r ie S Tit GT -77-C M1 IrL t® YMAb 0_ GOd"
No.mid AStreet w [hL lA O (Ci7 d�7 � L/;DG`lr/ Emui address
Ci town State ZIP Telephone
SECTION 6:WORKERS,COMPENSATION INSVRApICE AFFIDAVIT(M.G.L ec 152.§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 Witancef the building permit.
Signed Affidavit Attached? Yes.......... No...........17
SECTION 7n:OWNER AUTHQRIZATIUN:TQBE.COMPLETED.WHEN' ;'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEIe OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 uu have access to the arbitration
--- -
program or guaranty fund under M.G.L.c. 142A.Other impor—tant informatioon onl rf a HICVrobr.tm—can be-founttaT —
www incus eov:'oca inrormation on the Construction Supervisor License can be.found at wvaw.nrass. ov;dns
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. ft.) '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 or heating system Number of decks/porches
"type of cooling system Enclosed Open
J. '"rolal Project Square Footage"may be substituted ror,,rotal Project Cost"
i
a'
The Commonweclt/i ofMassachuseta
Deparbnent ofbMWstrib[Accidents
1 Congress SOM4 suite Joe
Boston,M4 02114-1017
www.massgov/dia
Workers'Compensation Insurance Affidavit Builders/Coatractors/Electriclaas&iunkbers.
TO BE FH"WITH THE PERh1171ING AUTHORITY.
s
Name(Bosiuess/0�ti3Ondividae0: �.J Oh w
Address: 30 dl �rQ Ov S
City)State/Zip: S (tit^^- 04M 01.4'70 Mone#. V r . yad 6YyeG
Are you an empkywr Cleek the awropalate box:
P 1 . fregry�►ed):
1.OIam ]oyer w eiupkyees(full aoNorpart t®e).' 7. New cour"on
2 a.sok propsiewrwpamerahip aoQhere no exWloy,. wo7,M for- S. Remodeling
tatyeapaeky.INo M,1A, 'eotap.&066ct re4uire6) _
3.p,ama6omeo madomg all wodk myself.No r•e0011).msmmPIC mVim&l 9. .ODamblltibu .
4.Dlamsbomeowmermd M'gbel>�Bmmaetorato�daBwm;kmmyP�Y. twill to psln]aiug
co m:that all enNmdom ea"bare ambers'eompemetian msmavee mare sok 11.p Electrical mpaus or additions
> w+�m •
12.01`luiv* g epms t r add;titms
S.O famagemsl ecawtlaaane l have hiked the anbkonft"I i ruled on tbeaftachedaheet: 13.ORoofrepsits._ .
iblx.sub-samtraWm6mrcampkyxsaod love noilcge'.�p.mup��t
6.Ej We M,cotpomrl®and its officers here eYeicised Ihmrigltt ofeaeatptimpehiQ,a
14.QOther ..
151,41(4),and w Nawab employawJMR lamim'dat*�aanarega'sed.] . . .
met eheelu boa gl moa also�ovt the eecamhetov ahoiving theh wadrtis - .
*An _ . moo pobry Ghon•
tHomeowms who suhmit tLieaBdavit mei giheY aia dokg a0 wodia�ffiedbve oubrde toabBitiab must sobniaaa. afadwithAeedngsucd
$Cootactma that checkthidtivianvo attached a nkaddiGonalnhxtaid as bave :.
employees,iftsub- mbactmhwcamployW40eymnstla jtlbea-w-Javv?.eonp WbcYm - . .
I an+qa ewp/ayec thatiaproviding workers'eamperaatlon Jnsaraacefor my ea+P1Ryeea Below fs thePoNryaad/ob oke_
tajoiantitloa
Insurance Company Name:
Policy#or Self-ins.Uc.#: Rspiration Daft:
Job Site Address: CityAtatelzip:
Attach a copy of the vrorkers'compensation policy declaration page(showing the policy number and expintlion daft).
Failure to geque coverage as iequired under MGL c. 152,§25A is a tamiina]violation ptmishable by a fine up to$1,500.00
and/or nue year' as well as civil penalties m the form of a STOP WORK ORDER cad a fine of up to$250.00 a
n copy oft his atateiiimt may be forwarded to the Office of Investigations of the.DIA for innuance
day &thc yjcoverage Boit.
I do hereby e ' s aadpenaities.oJ' .. Irrry thatthe&for aadon provided abs ...is a a�Leorreet
Phone M
QB'ichd use only. am write in this area,-to be campided by dly or town o,Blcial.
City or Town: PerndtMkense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of anotber under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of in individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than tbree apartments and who resides therein,or the oceupe nt of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employmuat 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,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance 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 end,if
necessary,supply sub-contactor(s)nanic(s),addresa(es)and phone number(s)along with their certificates)of
insurance. 1=ted 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 date the affidavit The affidavit should
be 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-mamed'cpmpanies should enter their
self-insurance license number on the appropriate Tare.
City or Town Officials
Please be 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 permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple poarrntAiemse applications in any given year,need only submit one affidavit indicating current
policy information(if neceaaary)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 proofthat 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.a dQg license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
The Departnmt's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017.
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dis