8 SUNSET RD - BUILDING INSPECTION G+
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7"'edition OF SALEM
O
Hevtv
. JumturBuilding Permit Application Too Construct, Repair, Renovate Or Demolish a 1.1. '011B
One-or Two-Family Dwelling
This Section For ficial Use Only
Building Permit Number: Da Applied:
Signature: ('i>ZPobo
Building Commissioner/Inspector df Buildings Date
SECTION 1: 1 E INFORMATION
LI Pr erty Address* 1.2 Assessors Map& Parcel Numbers
L la[s 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 Il) Frontage(11)
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?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Oner'of Record:
Ntime(Priory ddress for Service:
Signaturep Irelephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: 1
0 Paid in Ful( 0 Outstanding Balance Due:
I
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constr tion Supervisor(CSL) )
p f.ice_ i.tt' n Date
e YCSL I of er� ,
fist C'SL T.vpe(see behrw)
� ((�L f Description
Ilestr ctieted a to 35ADQ Cu.
R Restricted 1&2 Pamil Dwelling
Signa u M Masonry only
l,.lephone j RC Residential Roofing Covering
WS Residential Window and Siding
SF Residential Solid Fuel Burning A liance Installation
U Residemiul Demolition
5.2 Registered Home 1 ov ment ntrac or(HIC) r f j f
c—€ -_
HIC bmpany Nan or HI - eg'str t arae Rfcgistmtion Nu be
's�
v� ,, spimti Uate -
Signature '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...........O
SECTION 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNEWS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Viedbyv
as Owner of the subject property herebyauthorize �yc" to act on my behalf,in all mattersrelative to worlding permit application.
Si+nature of Ow
Bate
CTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
Z? (2k2 A"'VI=—`'� ,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.
f
Print Name'
Signature of w e Authorized Agent Date
(Si med under the pains and penalties ofperjury)
NOTES:
1. An Owner who obtains a building permit to do his/her awn work,or an owner who hires an unregistered contractor
(not registered in the[tome Improvement Contractor(111C)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 I I O.RS, respectively.
2. When substantial work is planned,provide the information befow:
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 halt7baths
Type of heating system— Number of decks/parches
Type of Gaoling system Fnclosed Open
f 3. "Total Project Square Footage"may be substituted for-Total Project Cost"
I
CITY OF SiU.ENI, ,NL LksSACHUSETrS
BUILDMG DEPAR'M&NT
e 120 WASHL�IGTON STREET,3tD FLOOR
TEL (978) 745-9595
F.C.Y(978) 7.7044
KIN
iBERL!~Y DRISCOLL
MAYORTHOI W ST.PtERRs
DIRECTOR OF PUSLIC PROPERTY/8t:nZING CONNISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Alitalicant information Please Print Legibly
Nafnc iousiiw.s Organi:atiomindividual):
Address:
CitylStatclZip:� jQ �l�f Phano if: F2
Are you an employer?Check t/(e appropriate tax: Type of project(required)/:
1. 1 am a employer with / 4• ❑ 1 am a general contractor and 1 6. Fl New construction
antployees(fidI aadJorpart-time}.* have hired the sub s ontraciors1
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet,t 7. 91 Remodeling
ship and have no employees These subcontractors have g. CI Demolition
working for me in any capacity. workers'comp.insurance, % D Building addition
[No workers'comp.insurance S. ❑ We are a corporation and in
required.) officers have exercised their 10.[]Electrical repairs or additions
3•❑ 1 am a homeowner doing all work right of exemption per MGL I I.E3 Plumbing repairs or additions
myself[,No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees.LNo workers'
camp.insurance required.} 13.❑Other
•Any opplirun our ducks box rl must also rill out 1h,=aim hit ow showing thou workers'compenudon policy inlinmaion.
s I hsnxuwa�s who submit this affidavit indicating they aro doing sit work and then hire moside contractors must submit assess arfdavit indicting such.
Comractors that chak this box most atlachod an additimul shots showing the name of the nlbcunuutort and their workers'camp.policy information.
I am ant employer that is provfdiag workers'compensadon htsurance for my employers Below is the policy undJvb site
itrfolmaliaiL r
Insurance Company Name: /' (�45L A1_1_
Policy N or Sclf-ins• Liv.N:_lav ' - Sr) ? fes- Expiration Date:
Job Site Address: City/state/Zip:.. "adv
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to wcurc coverage as required under Section 25A ot•MGL c. 132 can lead to the imposition of criminal penalties of a
tint up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
orup m 5250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the 0111ce of
investigations of the DIA for insurance coverage verification.
/elo hereby certify wider rho pules un ambles p dint the h jarmadon provided above ..6I a as td CorreCL
pho / !
Official use only. Do not write in this ureas„to be completed by city or town ajjklaL
City or'ruwnt __. . ._
Insuing Authority(circle one):
1. Board of licalth 2.Building;Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact I'crsun: _ ,__. .,. Phone tl:
at
i
Information and Instructions
Massachusetts General Laws eliapter 152 requires all employers to provide workers' compensation Gu their employees.
hursowit to this m:n ite,an employee is defined as"...every person in the service of another under any contract of hire, _
c%press or unplicdroral ur written."
\n employer is defined as"an individual,partnership,association.corporation or other legal entity,or any two or more
a the torewwg engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee uI in individual,pumcrship,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 on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
'vIGL chapter 152. §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of it license(or permit to uperate 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. a25C(7)states 'Neither the commonwealth not any of its political subdivisions shall
enter into any contract for the performance ufpublic work until acceptable evidence of conipliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workcrs' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)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 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. Scif-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Official
Please he sure that the affidavit is complete;rad 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.
I'Icase be.cure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit'licen se 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)."A copy of the affidavit that has been officially stamped or marked by die city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits of 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 i.e.;r Jog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he 0I lice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please Ju nut hesitate to give us a call.
rhe Mparunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Depament of Industrial Accidents
OfIIce of Investigations
600 Washington Street
Boston, MA 02111
Tel. N 617-727.4900 ext 406 or 1-877-MASSAFE
R:ci.eJ ?-_'G-IIS
Fax 0 617-727-7749
www.mass.gov/dia
CITY OF S'U E.N1, IL-kSSACHUSETTS
BUILDLYG DEP.%Rnt&NT
130 W.I..SHLNGTON STRM, P FLOOR
TtL (978)745-9595
FAX(978) 740-9846
Kl.%jBEnEY DRISCOLL
T
MAYOR Ho.+usST.PIERRs
DIRECTOR OF mauc PROPERTY/BUIEDLNG CONNISSIONER
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 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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
ya�
(name of6.ty)
(address of facility)
44igna re o p rmit a scan
ate
Jcbnvlf Jew: