55 SUMMER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
� Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a &
One-or Ttra-Fomt, e!ling tf�
This tc-tion or Of c I Use Only
Building Permit mbec Date pplied:
Signature: /l"- �IL31 Pei
Building Commi ner inspector f)BflqiW Date
SECT 1:SITE INFORMATION
1.1 Propertdddrress: 1.2 Assessors Map& Parcel Numbers
1.1 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(R) .
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40;4 54) 1.7 Flood Zone information: 1.8 Sewage Disposal System:
Zone: Outside F1004;One?
Public Private❑ T Check if es Municipal) On site disposal system 13
SECTION 2: PROPERTY OWNERSHIP'
Ownerl
or Itejorch
ft J`,.Tt4' !YI Tt '� t ( Gc
Name(Pri t) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(cheek all that apply)
New Construction O Existing Building 9 1 Owner-Occupied fd I Repairs(s) Id I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brieescriptton of Pro ed Wor r:
�r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ ? -- 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
Q Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S .r (J„ ^ O Paid in Full ❑Outstanding Balance Due:
c� '2
f
SECTIONS: CONSTRUCTION SERVICES
5.11 Licensed Construction Supervisor(CSL) CS O 7,elZ�—a
CT<Cr/QC�Ct G�it Q License Number / 7 Expiration Date
N;(mc ol�r ('
�ni Je / (1 t List CSL Type(see below)
Addrel ( T Descri lion
U Unrestricted u to 35,000 Cu. Ft.)
Signawrc R Restricted I&2 FamilyDwelling
97cY ?7/ cZo� M Mason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Btunin A fiance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration 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 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:OWNERt OR AUTHORIZED AGENT DECLARATION
I, i-�+ U ,as Owner or Authorized Agent hereby declare
that the statements nd information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
I ll�c Vel
Print N e
3 ZvD
Signature of Owner Ir Authorized Agent Date
(Sign d 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 IfLR6 and 110.115,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 ofheating 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
,l( 7 PUBLIC PROPRERTY
DEPART'.MENT
I I I''I'8 �J 4.'R• + • I �C 'i�`L'J:' .i J
Construction Debris Disposal .affidavit
(required Ibr all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 C'MR section I 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will lieettransported by:
/C J4�c�1 �`cP/13'Je/ JfetG�,
(name ul hauler)
I he debris will be disposed of in
17 .c < Sffi��
(name tit laallty)
fd sij��,jA_
laddress ur tacilltYl
ate"
� twc o pe��lt appheant
dale
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,1vr.N'1l' INhI•'ll
12^ WAIHIM.1,^5131.1,T • 5ntI M.M.bl.\\ nl it 1 1\31977
IIA. 778-713-9i'+5 is f\.e 978-.'40'1346
%Vorkers' Compensation Insurance 11,117ida0t: Builders/Contractors/Electricians/Plumbers
itimucant Information Please Print Lepibly
V:11T1t tau.111%sy1)rpanlr.uiorvinJl\ntuall: \} C4 �'4Q Cmc-l«� RtK �r'J fl,•f�/s Gt,C�AI�
1I.Idross: 70 te
City'stare.Rip: \79�ci1/l 0. 0/ p7<3 Phonei! � �(�' ? �l'��a�
Are)uu an employer'!Check the appropriate bus: 'I)pe of project(required):
4 ;un a general contractor and
). El I am a employer with ❑ I 6. ❑ New construction
employee%(full anld'ur port-time).• haec hire!the 'uh-contractors
2.2!;,11 line a sole proprietor or partner- listed on the anachcd.sheet. 7. ❑ Remodeling
ship and have no e+nployces These sub-contractors have g. ❑ Demolition
%%orking for me in any capacity.acity. \%orkers' comp. insurance. 9. Building addition
I Nn workers'comp. insurance 5. ❑ We are:it corporation and its
I required.] officers have exercised their 10.[] Electrical repairs or additions
7.❑ 1 ant a homeowner doing all work right of exemption per MCL I LQ Plumbing repairs or additions
myself.(No\%nrkcrs'comp. c. 152. ¢1(4),and we have no 12.❑ Ruul'repairs
insurance required) r cmpluyces. (No worker' 13 0Other C QC 3
comp. insurance required) 4 -Y -e i
•%u, .,pphwul a Wt cleccks boa al muss also tit u,u the wcnou twluw>huwmv thou wurkui cumpumasion twhcy nuiu siuu.
' I Iumuuwncn who mbnlif this anlJavif indicating shut are doing all work mW lien hire uusslde ewuraclon muse.uhmit a new aIr.davil{ndieabnil such.
4••nsrxnrn flim\heck this box miss$a/lwhnl.m addlliunal short.howmV aw omw of taw sub�ontrxwrs and their wurken'comp.policy mliermannn
/arta un cu+pluyer that is pro riding$vurkers'cowrpe+$salian in.rurnnce fur uty earpluyeer. Belw$v is rhe pu/icy m+d job rile
infunnurion.
Imurancc Company Vane:C ,r _ ^,i):. --
I'uli;;y A or Sclf--ins. Lic. t': �' /- 7t�r�4ftN6 ._ ___ Expiration Date:
Job Site Address: L L \/Ge�lit/✓� C✓` P City;SwtuZlp: /✓CQ. ��91�
Attach it copy of lite workers' cumpunsatiun policy declaration page(showing the policy nluaber and expiration date).
halluie to secure cu\erage as required under Section 25A ul'>lOL c. 152 eau lead to the imposition ofchininal penalties of a
tint op to.11.5110.00 and/or one-year imprisonment,as\%ell as cis it pcna111es in the furan of a STOP WORK ORDER and a fine
Of up u\ 52'50.00 a day agahut the violator. Inc advl.+cd that a copy of du%,latcinent may be tun%arded to the Office of
I❑\ial Pjallnlla ul ;hc DLA :or imw.i:ce un crags \cr ilic.icon.
/Ju herrby r..rtifr wider dm pains and penalliev of perjury their the infonnudon provided above is true uud correct.
;i•"i,pui ...as-.�-'�-- --- DSI -3'09
F1. 11i,ard
l rue urdy. Da not!aril!in dri.e arra,Iu he rwnylrlyd by,ity ur torso a/�iria/.
filen: _ lacrmiul.iccnsc 4.\ulhurity (circle nuc):
of 11%.dth 1. Il ildin;; Mpartorcnl 1. Cit).-funis Clerk J. Electrical luspcclor i• Plumbing In\pcclor
rl l'l'rfull; .. .- Phone it:
Information and Instructions
N I.us.lchusoli General Laws chapter I i2 nrquires all eugrloycrs to provide workers' compensation for their employees.
I'Ilr.u.un ro this,tatute,an empfuree Is defined as- .e+cry pctsoil in the service of another under.iny contract of hit-,
e Rpre,s Jr Implicit, oral Or m itten.
An emplop,r N domed as"an Individual,purlrterlhlp,association,torpor tion or Other legal entity,or ally two or Inure
.It the lorewIII g engaged In a joint cnicrpnse, and including the ;coal representatives of a deceased cmpiu}cr,or the
reserver or trustee of.ui individual,painicrship,association or other legal c inty,employing employees. However the
owner of a dwelling house having not Inure than three apartments and who resides therein, or the occupant of the
,fwOhng house of another who employs persons to do maintenance,cun.uuction or repau'work on such dwelling boost
or on the.groundc or building appurtenant thereto shall not because of such employment be deemed to be an employer."
1MGL chapter 152. §25C(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 who has not produced acceptable evidence of cumpliance with the insurance coverage required."
.kdditionally, MGL chapter 152, 425C(7)states"Neither the commonwealth not any of its political subdivisions shall
enter into any contract for the performance of puhlic work until acceptable cvideoce 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 ilia boxes that apply to your situation and,if
necessary,supply sub•contracior(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
cmployces,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Xecidents for confirmation of insuranco coverage. Also be sure losign and date the affidavit. The allitlavit should
he ictumed 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 it 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.
Pity or Town Ofnciab
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 his to contact you regarding the applicant.
I'l.rase be sure to till in the pctiniltlicense number which will be used as Is reference number. In addition,an applicant
that must submit multiple pennitllicensc applications in any given year,need only subtmt one affidavit indicating current
policy information(if necessary)and under-Job Site Address"the applicant should write"ail 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 tilled out each
year, where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
I i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I h; I)Ince of hisestlgation) would Ilne N thank you in adYance far your cooperation and should you have :my questions,
plea,e do not hesitate to give us a call.
fhc Mpamncnt's address,telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
011ce of investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mass.gov/dia