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0018 THORNDIKE STREET - BUILD NEW SINGLE FAMILY HOME cK l� � l The Commonwealth of Massachusetts %`) ' .lt` OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code,780 CMR Nit SEP — I eVe@aar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a bo One-or Ttvo-Family Dwelling ThisS P©rOt .Use 1 r Building Parmk hFumber . Date elppliad:, f Btiilchng O�oial(Priid . e� Sigma SECTIOAT 1i Sit1T i3!iI ORIMIAnON 1.1 Prope Address: 01 ECQ 1.2 Assessors Map&Parcel Numbers l.la Is this an accepted street9 yesLO'_ no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water upply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Di/syasal System: Zone: Outside Flood Municipal�Un s,te disposal system ❑ Public Private❑ Check if es SECIION2: PROPERTYO�yAIERSIIIP' 2.1 Owner'ofRecord LLL (�tl�K► T A^k OfrJZ3 Name(Print) (y, � � City,State,ZIP l dM�erSlCtra�GAtA;(- W1/07 Brrdstr .9�C� gog-96Z Wg _Q< WA and Street Telephone Email Address SECTION 3t DESCRIPTION OF PROPOSED WORK$(oheck all that apply) New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Ali; tion(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bidg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work,. -Aula /goo S4Z Go titg - SECTION 4:ESTIMATED CONSTRUCTION COSTS ' Estimated Costs: OfScial Use Only . Item (Labor and Materials 1.Building $ (tai 0t7t1• 1. 9 Permit Pea:$ Indicate how fee is determined: q Standard GitylTown Application Fee 2.Electrical $ /7 000- ❑Total Project Costs(Item 6)x multiplier x 3.Plumbing $ JZ1 Oto, 2. Other Fees: $ �� 4.Mechanical (HVAC) $ /.r, coo 5.Mechanical (Fire $ ToYal Ail Fees:$ Suppression) eclt No. Cheek Amount: Cash Amount; 6.Total Project Cost: $ / 7jyf 66d, 13 Paid in Poli ❑outstanding Balance Due. SC'r o F rt,-�s- o" f=Lt_C ^ 4YlAtl SECTION 5: CONNST.RUCTION SERVICES 5.1 Construction Supervisor lice /n _se(CSL) � U7 7&Srf TOS �c 5 01kUvS Fl License Number Expiration Date Name of CSL older List CSL Type(see below) No.and Street Type D� ,/_ Q'f� U Unrestricted(Buildings to 35,000 cu.ft. .. ��'✓r R Restricted l&2 Family Dwelling City/Town,State,ZIP M masomy RC Roofing Covedng WS Window and Siding SF Solid Fuel Bunning Appliances I Insulation Tel hone Email address D Demolition 5.2 Registered Home Improvement Contractor(RIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address Ci /Ibwn State ZIP Telephone SECTION 6-WORKERS'"GOMPENSAT 4DN MURANCE AFFIDAVIT(NLG 4 c 152.§ 25CM Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the IssuancepFile building permit Signed Affidavit Attached? Yes .......... No...........❑ SECTION Tai ONMER AUTIF16RIZAtION TO ME COWRLETED WHEN OWNEIt'SAGEN1 Q RCO OR I+O ING» 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. ' Print Owner's Name(Electronic Signature) Date SECTIOf4 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this ap lication is tru and curate to the best of my knowledge and understanding. Print 's Authorized Agent' Name ectronic Signature) Date 1. Ali Owner who obtains a building permit to do his/ber own work,or an owner who hives 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 can be found at wtivw.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 2. When substantial work is planned,provide the information below: Total floor 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 beating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" The Commonwea th ofMassachuseds Depnrlinent ofl"strid[Accidents vi I Congress Street,Suite 100 Boston,MA 02114-1017 www.nu& gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Eledricians/Plomhera. TO BE FILED WITH THE FIRR ITING AUIRORYI Y. Apolicantlnformathn Flom PlIft Ltaibly Name(Basioes�n;Rudivich ao: S rU iK vY Skf: . �ZU-k-�dP/►'C.w'� (�l•.C.., Address: �•d 1$ Zoo City/State/Zip: MA— LS Co S-.jr6Z 3 S( Rhone#•_ Are yea an employer?Oek the awrvplate baa: - Type of Jed(required): 1.01 a employer v+im employes(full F�-�)•' 7. jpf4ew constrluta,n 2. 'am stole pmprieeosaparmerdupaodhaveaocuployplsworo" I--nein 8: :DRemoddmB aW eipachy-lNo vwkma'camp'.faGaaoee requhedJ 3.pfam ahcazcaa erdoiog all work mya Y..(No wmkets•omr0.invmmceaequved.]1 9: ODemnlitlun' . 4.Olamatemeowner®d,'slf be hiring emma aorsmcmm[call vimla on mypropary. IwvL 10 0 But7ding eddifw, . emee that all comrelms either have vatkers'compeataeion ins raax w sole 11.0 Electrical repairs or additions prgextmsw aoaoployees. - 12.0Plumbmgrepairs oradditions s.Olmageaealemtatldaad lhave ti6ed a,etiated on bloc wed chest 13. .. Roof .:: 7Lrda.s*-c?nvaclorshave employees and have wo>3cm'.aomp.azaaaccf EI7CP�: 6.0 We m a corporation and its officers hen exercised thekriot of e[empiionpu MGL c. 14.0(Nher . :.. Is2.¢](4),end�haienu employeea(No worieis'aamyr.iaaaanarerpmed) - . . •Araya That cheeks 6o Yl muat95650 and the section below t6ebivdrlie7e mmpmsodm 040yl t1lonoeowma who suburb rise snm$ltiadieetmg fiwY art dohrgall vroai"dtied hila oobrdea3mmnt satift a my addavb ioirabeg snox tcontuoento check-"hen must attached an°additional theseshmseg the new'oftheand state whelffi m my those eouM love . employees..lith«sub- aLa�?.®P7.%?4Htar.murtsbwor�a`.a�Rpolicyv : . Istar anewployertbatirpmtidingraorkers'CompenBagOnfnrurnnselormyeorplt•yeas. Beloww isthepo&yant iwb sae hajortnoreioa. Insurance Company Name: Policy#or Self-ins.Lic:lt: Expiration bate. Job Site Address: Cily/StatdTp: Attach a copy of the workers'compensation policy declaration page(showingthe policy number and arpirstion date). Fat7ure to secure coverage as required under MGL c.152,125A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year tmpris�mom,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day agamst theviohuor.A Copy of this Statement may be forwarded to the Office oflnvestipt ionti of the DIA for insurance coverage vesification. I do hereby under/�epafas and ' o perjany that the information provided above a one and avrrea 'l ail. 0,,�kW nly. Do nor write In this area,to be eampided by city or town offwfi is City or Town: PermitUcense d Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown 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 another under any contract ofhire, 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 employe,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments end 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." MGL chapter 152 §25C(17 also states that"every state or local licen'siug agency shall withbold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for soy 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 of public 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 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 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-insuredcompanies should enter their self-insurance license number on the atmropriate lime. 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 pemrit/license number which will be used as a reference number. In addition,an applicant that must submit multiple perniMcense 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 ofthe affidavit that bas 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 filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or coannacial venture (i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Shite 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/dia CITY OF SALEK NLSSAQHLEETP. B[II11MDBPAXZWM r 120WA9AN MSVJWr,30 1kL7454M. FAX MIL9M BD�81tlEYD�ISUOLL MAYOR DnWSTJ)M1 to DnEcrcmt crmsxknwP=y/Bum=cccmemxm Construction Debris DisposaiAffrdWit (required forall demolition and,.renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR, Sect 111.5 Debris; and the provisions of MGL coo,S 54; Building Permit#t Is Issued with the condition that the debris resulting from this work shall be disposed of in a property licensed waste deposit facility as defined by MGL c 111,S iwA The debris will be transported by: �� rp lr-4,cr s-aI c( w �� (nami of hauler) The debris will be disposed of in: (name of facility) (address of facility) ' n tune of applicant Date j� '1 CITY OF SALEM ROUTING SLIP New Construction_ La? -� Certificate of Occupancy LOCATION �� �il°fhdi ' „ DATE ASSESSORS DATE 93 Washington t. CITY CLERK ATE 44 93 Washington PUBLIC SERVI SQA DATE 120 Washington St. pp a WATER DATE 120 Washington S . 1 CROSS CONNECTION DATE NIL 5 Jefferson Ave PLANNING DATE �0- 120 Washington St. CONSERVATION TE 5 fo 120 Washington St. ELECTRICAL DATE 48 Lafayette FIRE PRE rNTIONr?(#� DATE 29 Fort Avenue / HEALTH C — DATE 120 Washington . BUILDING INSPECTOR DATE 120 Washington St.