5 SUTTON AVE - BUILDING INSPECTION 4
Y
UI The Commonwealth of Massachusetts U Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
Revi.vedJunu,tn•
Building Permit Application To Construct, Repair, •novate Or Demolish a
a` One-or Two-Family Dwe! rrg
This ' ction For Otlii !al Use Only
J
Building Permit Nu erD� Applied:
Signature: `G`AA / Wl?/10
Building Commissioner nspnctor of 3 Date
SEC 1 N I:SITE INFORMATION
I.l Property Address: 1.2 Assessors Map& Parcel Numbers
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 11) Frontage(It)
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 EK Private❑ Check ifyesQ3 Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record:
LaMIZ �v�zA✓a 5 — $Jr��.o A✓f IkeCl r 1W c//tea
No Print) Address for Service: -
Ie-vvw/ 9-79- 7s6- oyi�
Si6natl re Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition Cl Accessory Bldg.Cl 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': ic.444
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offleial Use Only
(Labor and Materials
I. Building I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6).x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
6.Total Project Cost: S 'Z
Check No._Check Amount: Cash Amount:
��`
0 Paid in Full ❑Outstanding Balance Due:
I Y
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) (�� i,
��p raj- /�✓J/N El License NumM:r/r --/ Expiration Date
Name ol'C.SI:Ifolder List CSL 1'y pe(see!+clow)
/g S�T7'i.ty XIC, l�ij+ /W. n/°77c p
Tv Description
Address �'�--'�.P
1 Unrestricted a to 35,000 Cu.Ft.)
It Restricted INe2 Family Uwcllin
Signature M Mason Only
97g- 703'3 65-9 RC Residential Routing Coverin
I'elcphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) I S{ 33
!l��et C:�ivr2e4�ri>/G //V2 Ri
I fIC Company Name or IIIC Registrant N me Registration Number
I vi � LEiy/ �A• �'/22��1J//
Ad es � 3LI, Fp
Gs imtion Date
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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Lo KRA I N Q Co Rr}y os as Owner of the subject property hereby
authorize le,-, t'-144z!!,F-4 L to act on my behalf, in all matters
relative work authorized by this building permit application.
Si I Libre of owner Date
�' SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
I, /-7 �L ,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.
IZs16gr AvwJ.
Print a
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
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 10.116 and I 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 hal0baths
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"
CITY OF S.U.E.NI, �rLxSS.kCHUSETTS
a
9t:ILDLNG DEPART%EENT
120 W.kSHLNGTON STREET, 3'°FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KlJ03ERLEY DRISCOLL
MAYOR THomAs ST.PtEaRs
DIRECTOR OF PUBLIC PROPERTY/BUMD12NG COMMISSIONER
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 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
slate
•lcbnvlf.J•a
CITY OF SALEM
=C
, ,r PUBLIC PROPRERTY
>.
DEPARTMENT
M:1'Y:lxH(:w 41.
Usr`xr 12C WAiHIN6IONS1XELT• S,urst,MMLSACI11 xlrru007'.
11a.:WS-743-9575 • P.ss. 97X-74C-9346
Yorkers' Compensation Insurance :V171davit: Builders/Contractors/Electricians/Plumbers
\imiicant Information Please Print Leeihly
Vi31Tlt:lliuuuessi Qr�amrminNlnddvuluull: y?%7�'r"�i/ GCi�/I/l�i�C'7iN(u �f�'L. _
Address:
City;Start;/sip �/l /s/ N14, &77D I'huner:: X78 7%5- 3652
:arc you all m
employer?Check the appropriate box: Typo of project(required):
L❑ 1 :un a with employer 4. [1m 1 aa gencral contractor and 1
. have hired the sub-contractors 7. ❑ Newdolng construction
employees(lull antl/ur part-time). 7. ❑ Remodeling
2.❑ I ani a sole proprietor or partner- listed on the artachcd sheet. :
ship and have no employees These subcontractors have S. ❑ Demolition
working tier me in any capacity, ers' comp. insurance. q, ❑ Building addition
No workers'comp. insurance 5. We are a corporation and its 10.❑ Electrical repairs or additions
required.] oBiccrs have exercised their .
3.❑ 1 ant a homeowner doing all work right of exemption per MGL ll.[] Plumbing repairs or additions
myself. (No workers'ctnnp, c. 152,¢1(4),and we have no 12.0 Ruut'repairs
insurance required.) t ❑nployces. [No workers' 13.0 011ier
'( comp. insurance required.]
•nary applicant shat chucks box til must alba rill out rho section Witt,showing dhcir wurkws'cumpcnsaliwt policy m6wrioltiun
r I tumcowncn who submit this affidavit indicating rhcy are doing all work and duan hire outside cutnra calors must auhmil a now alRdavil indicating aich.
C',mdrnh,n Ihut check this box mull mtxh(d an additional..b rat showing the%auto of ilia sub-comracwn and their warken'comp.gndicy infurmanun.
/ton rot uoy�luytr that Lt pruridinX rvorktrs'(•mnpcnsntinn inxurancr jar ury enrp/oyter. Below is the policy and job.rife
/nrjurmuri,nn.
Insurance Company Naine: ___. .. _...._.--_.----_---
Policy 4 or Self-ins. Lic.n: _ ._ ..._ Expiration Date:
Job Site Address: C'ityl5latcizip:
Attach it copy of Ilia workers'cumpensattun policy declaration page(showing the policy number and expiration date).
I'ailuru insecure coverage as required under Suction 25A ul'`lGL c. 152 can lead to the imposition of criminal penalties of a
tine up t.)51.500.00 and/or une-year imprismuncnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine
orup to 5250.00 a Jay against Ilia violator. Ile adviud that a copy ufthis smtemuni may be forwarded to the Office of
lnvrsngauons of the OfA for insurance covcragc %ed icahun.
I do hereby certify tinder rl lien•and penalliev of perjury that the/njonnulion provided above is/rut and correct.
:4/ —e– Datc' �z6�10
11I1r-:i
Official tut only. Do tint avfre in this area, to be completed by city or lown of Bial.
i
City or Town: _ Permit/License X_
Issuing Authority (circle nut:):
I. Hoird of Ilealth 2. Building Dcpartincul .3. Cil)i Town Clerk J. Llectrical Inspector 5. Plumbing; Inspector
6. Other
Contact l'cnon: .. Phone 4:
Information and Instructions
\I1ss.IcllU;elu General Laws chapter 152 requires all employers t0 provide workers' compensation fix their employees.
Pursuant to this statute, an emplc ree is defined as-...every person in the service of another under any contract of hire,
evpre»or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
o[ the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or 1ruYlee of at individual,patmership,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
,lwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
pant thereto shall not because of such employment be deemed to be an em layer."
or on the grounds or building appurtenant P
.%tGL 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, hIGL chapter 151, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit 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 date the affidavit. The atIldrivit 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. Sclf-insured companies should enter their
self-insurance license number on the appropriate tine.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennidlicense applications in any given year,need only submit one affidavit indicating current
policy information lif 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 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.e.is dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I sic t)t ncc of love.srigations would like to thank you in advance fur your cooperation and should you have any quehtrons,
please do nut hesitate to give us a call
rhe DeparmcriCs address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel, #617-727-4900 ext 406 or 1-877-MASSAFE
itcviscd ;-'r,-us
Fax N 617-727-7749
www.mass.gov/dia