4 SILVER ST - BUILDING INSPECTION t
The Commonwealth of Massachusetts
° Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition Budding Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
IY.\ Signature: 9 6�
Building Commissioner!I spector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
r4 5tivev
L 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1ert of Record:
a,f 1 oYa S } 511ye, Sit- SAe i 1•`h V-�
Name(Print) Address for Service:
`)8i cS-S \S35
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ` n
` W
l�'v,p FxrSh•-+� qz v G ifal..r t...e.-.w 'Gin
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ `'— 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S e-
4. Mechanical (HVAC) $ List: \L
5. Mechanical (Fire $
Su ression Total All Fees:$
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: $ �j ) 0 paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ,76—a (�8`\
'" � LJ �`S , y, License Number Expiration Date
A �^S
Name f CS - Oder List CSL Type(see below) V
)Ud
Address T Description
-� U Unrestricted up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
,=�n P, &S 3� I a RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 gtstered Home Im rovem nt Contractpr(HIC) b
is4cliz c, 1 �c VLA r3�tl 1�3
HIC Co pany Name or HIC Re istrant N ne Registration Number
on L-8-l6
--'1 I
CA Expiration Date
Signalitre- Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , 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 ORRAAUTHORIZED AGENT DECLARATION
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.
Print Name
Signature of Owner or Authorized gent Date
(Signed under the pain,and enalties of r'u
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 1 IO.RS,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.) 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"
I
•'''" CITY OF SALEM
PUBLIC PROPRERTY
DEPART'.MENT
I U \��I II\i...'J:1:311 r � S.V I V, \L\a U :. .. I .•.I'I
I I I.V'$ '4, ♦ 1 \S-.'i'X '4: 1h4,.
Construction Debris Disposal .affidavit
(rcyuired li)r all demolition and renovation work)
In accordance % ith the sixth edition of the Slate Building Code, 780 C NIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 0 is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
ac CC_V_N_\"
(name of hauler) b
I he debris will be disposed of in :
pJ CZv-�6 e a L
(name ut lanlity)
- IadJres. ul'lacllitVl
\Iplawlc Ott prnnrt .y\phcant
date
CITY OF SALEM
PUBLIC I ROPRERTY
a
DEPARTMENT
,1ur.• 11 .IMh(,-Il
t!: WASI11\G 1,^)131.1,1 a 5,%11,%4. 111 it I I s�I')1,',
11%I. ')78-713-9Y+50 1:%s Y7x-7vC'txt6
Workers' Compensation Insurance %fftda�it: BuilderVContractors/Electricians/Plurnbers
Itunlicant Information `t Please Print Leeibly
Naineilio%uwvsit)rgamauina'Indrs
VIdlc.is:
Cily,Stara7ip SG`e Thune '':
Are lou an clnplayer!Check the appropriate box: l}pe of project(required):
4 I am a general contractor and
1.�lam a employer with - ❑ h. ❑ New construction
enq)lu)ces(full indiur part-time) hues hired the sub-contractors
. ❑ 1 ,un a sole proprietor ar panncr-
listed on the attached sheet. 7- ❑ Remodeling
ship;mJ have no empluyeus These iub-contractors have S. ❑ Demolition
working for me in any capacity, %workers' comp. insurance. 9. ❑ Building addition
5. ❑ We area ens ration and its
1Cq iTud.workers'comp, insurance a 10.❑ Electrical repairs or additions
I required.] officer have exercised their
J.❑ 1 am it homeowner doing all work right of exemption per MCL I I.❑ Plumbing repairs or additions
myself. [No workers'comp. c. 152, j 1(3),and we have no 12.❑ Roof repairs
insurance required.) r employees. IKo%workers' 1 J.❑ Other
comp. insurance required.]
No, yph[m11hst thccks box nl n1ust AI]Y IIII WII Ihw cocoon Wow showing rhuar wurkas cunipunauian%whey ndlnmariuu
' I Iamuuarwn alio au6mil this affidavit indicating They ore doing all vod mW Own hire uutude cmurnaon most sutnnif a new alGdavil indirdmg wch.
-(,mrrwWn that check this Iwo most aoxhcd an jedoianal Acca,hawing Ila aame of Ih:nubKonlrxwrs and their auded comp.policy mfurmanun
I aura on employer that ft pro riding workers'coanpen wiuion insurance for ray employees. Below is rhe policy and/ob.life
information. _
ln,urancc Company Name: �� __M v�S.� w�S• �au_.----._--
11olicy a or Sclf-ins. Lic.,,r': F•\ < . Expiration Date:
-\dl
Job Site
uress: A 5,Ii_ — -- SI-' City:SlatuZlp: SQ�-e.c.., V\A
A itach it copy of the workers'compensation policy declaration page (showingthe policy number and expiration date).
Failure to secure cuserage as required undo Section 25A ul'.%IGL c. 152 can lead to the imposition of criminal penalties of
tine up to S1.500.00 andlur use-)ear imprisonincnt, as%vcll as ci%II penalties in the furfn of a STOP WORK ORDER and a fine
of up un 5250.00 a Jay .Igainst the violator He advt.cd that a copy of this statement may be furwardod to the 011ice of
D1%an,aunro u '.IIc UTA :br imw.lrcc ,,.%sage %eI ilic.d:on.
Ida herchy r crtifv as •r rhe pain%and penulticv pfperju that dre infurnutlon pruvided above is true and correct.
Official rue only. /)a not write in ddc arra, to be craupleted by airy ur town ufjiciaZ j
City ur fawn: __.. _ Pcrmit/Liccnie p
I„uing.\ulhurily (circle nnc): i
I. I{a.aru of Ilcalth L nudJiny 1)cparuncnt 1. /:it�.'I'unn C'lerlt J. Ucctrieal lnip,cror i• Plumbing hupcclor
6. 011ier
Cinitacl Vvrluo: _. ._ Phone q:
'L
Information and Instructions
1.us.idlusetu Ccncral laws chillier I52 rcyuires all onplo)ers to provide workers' compensation rbr their employees.
Ptir,u.ult to this,nature,an empfutee is coined as ' esery poison in file service of another under any contract of hire,
e%press it Implied, oral or written."
\n ,fnployer is derined as-in Individual,partnership, associanou,corporation or other legal entity, or any two or mare
'r the I"reeulr,g engaged In a Joint enterprise, and including the!cgal representatives of a deceased cnlplu)cr, or the
i'Ccelver or trustee of .rm individual,partucnhip,association or other legal conty,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
d.vcllulg house of ancrher who employs persons to do maintenance,construction or repair work on such dwelling house
or on the..rounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer."
\IGL chapter 152, �25C(6)also slates 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."
\ddinunally, \IGL chapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of puhlic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
ploase rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)nume(s), address(es)and phone number(s)along with their certifecale(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
.Nccidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The alf idavit should
the reltimed 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 Ofllcials
Please be sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom
Of the affidavit fur you to fill out in the event the Office of investigations has to contact you regarding the applicant.
Pl.ase be sure to rill in the permit/license number which will be used is a reference number. In addition,an applicant
that must submit multiple permit;license 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)." l, copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant a proor that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
vear. Where a home owner or citizen is obtaining a license or permit nol related to any business or commercial venture
(i.e. it dug license or permit to but leaves etc.)said person is NOT required to complete this atftdavit.
I llJ I)Ince of Inveitlgallans%%uuld Ilii to dlank )-ou In advance for your cooperation and should you ]lave:Iny questions,
please do not hesitate to give us a call.
rho Dcp.unnent's address,telephone and fax number'
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdradons
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