1 VALLEY ST WAY - BPA 11-571 FIREPLACEM
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a The Commonwealth of Massachusetts
Board of Building Regulations and Standards
blassachusetts State Building � Code, 730 CNIR, 7'h edition
't
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or TwO Ft roily Dwelling
CITY
OF SALEM
Revised Junuary
l • 1008
This Section For Oflicial U e Only
Building Permit Num r:
Ap tela
e�
Signature: I&I
Building Commissioner/ re for of Buila(iin� Dale
SECTIOV: SITE INFORMATION
1.1 P operty Address:
\I athc-vc _V Uj �y Sc.l.es�'w
1.2 Assessors Map & Parcel Numbers
IH 00-79
Map Number Parcel Number
1. [a Is this an accepted street? yes_ no
1.3 Zoning Information:
K.1 - "101"
Zoning District Proposed Use
1.4 Property Dimensions:
-11aa kD q 5
Lot Area (sq 11) 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)
❑ Private ❑
1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Check
Check ifyes❑ Municipal ❑ Onsite disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
ri P tsort 1 �' \I� SL e
Nam (P int Address 1'or Service: '
cot -1. B' 3t-1. act-75-
°t-7SSignature 'relephone
Signature
SECTION 3: DESCRIPTION OF PROPOSED WORK= (check all that apply)
New Construction ❑
Existing Buildin
Owner -Occupied ❑
Repairs(s) ❑
1 Alteration(s)
Addition ❑
Demolition ❑
Accessory Bldg. ❑
Number of Units
I Other ❑ Specify:
Brief Description of Proposed Work': t ; lu ;
lue, 0.ri r1'✓� rl rl +i Oy1aQ. 11yG 'mei
i
yaw4teePropl0.(imeN4,L,
-
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
1 Labor and Materials)
Official Use Only
I. Building
S IOi D00
I. Building Permit Fee: S Indicate how fie is determined:
❑ Standard City/Town Application Fee
❑ Total Project Cost (Item 6) x multiplier x
2. Other Fees: S
List:
2. Electrical
S
3. Plumbing
S
4. Mechanical (IIVAC)
S
5. Mechanical (Fire
Suppression)
S
Total All Fees: S
Check No. _Check Amount: Cash Amount:_
❑ Paid in Full ❑ Outstanding Balance Due:
6. Total Project Cost:
S I l7 p 0�
TWA (1�4T)pz
x
X
X
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor (CSL)C5-
51$00 (0 PR $0+a
JeJRre..��ooW.+'
License Number Expiration Date
List CSL I') pe (see below)
Nano of CSI.- I folder
B5 Cnran'te 5t 1 or boyo M
Tv Description
dr ss
ll l!nrestricteJ a to 35,000 Cu. Ft.)
R Restricted 1&2 FamilyDwellin
Sigt tur
8� 1-7- 1 IZ
M Mason Only
RC Residential Rooting Covering
WS Residential Window and Sidin
I clephone
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor (HIC)
ttic- lage
013
le�J2?.y anr)krr
Number
Registration Numr
I IIC' Company Name or IIIC Registrant Name
8s Grm;tc S-6 For6 r_) MA 02035
s� 4 a6 11
Address
51-1 $I Z
Expiration Date
Signature relephone7
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 .......... Q4 No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Chrisk,. har P O1solo as Own er of the subject property hereby
authorize to act on my behalf, in all matters
relat' a to workaut to d y this building permit application.
i 3-aou
Si at re of owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, , 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.
CJt1ris4c,,gkV14(31s6n
Prin Na
�-3-aou
Sigriq!yriiof Owner or Authorized Agent Date
(Signed under the pains and penalties orperjury)
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 110.116 and I I O.R5, respectively.
2. When substantial work is planned, provide the information below:
Total fours 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 he substituted for "Total Project Cost"
ri
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12C. WMkII.\G 1U\ S-1'9EL•T 1 5,\t li N, MASSM.I n ill ISO 197.^
l'iA.:979.74i9595 • P.,x. 979.74^--7.446
Workers' Compensation Insurance atridavit: Builders/Contractors/Electricians/Plumbers
%policant Information Please Print Leeihly
Name lnuuucvs/Or�sni7:ItinNlndlvtduull: Jt �re�,B mka.f
Address: 95 StYtt-t
City,Stmei%ip! Foscboro, MA ozoO 5 Phoneik
Are vola an employer'! Check the appropriate box:
❑ 1 :un a employer with 4. ❑ I am a general contractor and t
employees (full ind/ur part -tints).'
2. ® I ant a sale proprietor or partner-
ship and have no canpluyces
working for me in any capacity.
I No workers' culnp. insurance
required.]
3. ❑ I ant a homeowner doing all work
lny'self. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
workers' comp. insurance.
5. [1 We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
cmployces. LNo workers'
comp. insurance required.]
sots. 5(1• lc6la
Type of project (required):
6. ❑ New construction
7. ® Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
-Any appheant That chocks box al must alias IIII wt the Sidion wow'how'.10 IIICIr works compen Wion policy m6airlatiun
' I Iummlwlwn who udsmil this affidavit indicating Ihcy am doing all work and Ihen him oulsido cu inion must auhmil a new al'rdavil indicating .arch.
d'amrxwty that check this box must aowNd an additional .,heel showing the name of the subtarkuacto s and their wurken• camp. policy infurminon.
/ger rot crupfoy¢r U7ur Lr pro•fding workers' I•ompcnsnt/on insurnurn fur ury eurpluyeer. Below is the polity and job .tile
imforeration.
Insurance Company Name:__..
Policy filar Sclr-ins. Lic. n: _ __ ..-_ Expiration
Job Site Address: _ CitylState/Zip:
Attach a copy of the workers' compensation policy declaration pulse (showing; the policy number and expiration date).
Failure to secure coverage as required under Section 25A ul'.NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/or one-year imprisunincnt, is well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Ile advised that a copy of this statement may be 1•urwarded to the Office of
Invasugauons ut'thu DIA for insurance coverage sciitication.
/ du hereby crrtijyJw.lfr the pains and pemrhiev yLperjury that the infortnuNon provided above is trite and carred.
tii�!:r,wlre.
-----------------
Official use only. Do not write in this arca, to be completed by city or fillers ofjiviaL
i
City or Torn: Pcnnit/License 4_
Issuing Authority (circle one): i
1. Iluard of Ilvalth 2. Building Department 3. City/ Town Clerk 4. Electrical Inspector i. Plumbing; Inspector
6. Other
Couluct 1'crsum: Thune 4:
Information and Instructions
Massachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this snatute, an empforee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer a defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
,,i the Ibreguing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of :ua individual, paimership, 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."
MGL 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 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 far 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 -contractors) name(s), address(es) and phone nuimber(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 rcmrned 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 line.
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 till in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pennitilicense 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 the city or town may be provided to the
applicant as proof that 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. it dug license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
I'hc 01,11ce of Invevig'atnon5 would like to diank you In advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Dcparnnnds address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Off ce of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
Rcvi,cd i-26-05
www.mass.gov/iiia
CITY OF S.U.&M, NLksSACHUSETTS
BIYI.DLNG DEPARTM&NT
' 130 WASHNGTON STREET, 3iD FLOOR,
TEL(978)745-9595
FAX (978) 740-9846
Ki.NtgERLfiY DRISCOL L
1NMAYOR THomu ST.PmRm
DIRECTOR OF PUBLIC PROPERTY/Bl.'tIDLNG CONWISSIONER
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 defined by MGL c
I 11, S 150A.
The debris will be transported by:
*/mfr ccty\ W aSIQ Mq,Mt 1�i sPese Sero e e
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
d, b,wrr d,.
LA
signature of permit applicant
I>'3�t1
date