23 WALTER ST - BUILDING INSPECTION (3) 1
One or Two-Family Dwelliw
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code 780 CMR, 7th Edition
�y 1
Application to construct,alter,renovate repair or demolish
o Thi ecfion Fond Gcml Usebnl`
Building Permit N /beer: Date of application:
Signature: Z77a 1 �l V11
Building Commissioner/Local Ins ect Date
SE"C1iION i'' 'SITE IN$QRMATI()1V'
1.1 Pro ertyq dd s: � 1.2 Assessors Map&Parcel Numbers
I.1a Is this an accepted street? Yes ❑ No ❑ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use I Lot Area(sq ft) Frontage(ft) -
1.5 Building Setbacks(feet)
Front Yard Side Yard
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:
Public❑ Private❑ Zone: Outside Flood Zone?
Check if yes ❑ Municipal❑ On site disposal system ❑
1.9 ZBA Special Permit 1.10 Old&Historic Commission 1.11 Conservation Commission
Date filed N/A❑ Date filed N/A❑ Number 40- N/A❑
9
TC1lON 2 1?ROPERTI OYyNERSHIP T � <s" � i ? ��� a
' "�-n ✓s, �", tui xx'W_? Sr�_�y.au'a.. �'.afa;^
2.1 Om� er of Record:
N47,> sear I J (� e✓,J
Name(P.iift) o Address for Service
Si ature of Owner Tele hone
SECTION 3 , DESCRIPTION rOF PROPOSED WOf2K{check all that apply) � ' `i (Ff �,�r ,��� � ��-
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Nu er of Units_ Other ❑ Specify:
Description ofProposJjd Work: uH �C�'J :,.i /' rd,i
'1
SECTION 4.. ESTIMATED CONSTRUCTION,COSTS `tBUILpINCrPEIt1VJITtFEE
Item Estimated Costs
(labor and materials) This Section For Official Use Only
1.Building $ 666 0 vo Building: $l0/$1000
2. Electrical $ -7C-O v Building+plumbing:$12/$1000 Building+Electrical: $13/$1000
Building+Electrical+0
3.Plumbing $ aJJ t) Plumbing combined:$15/$1000
. d
4. Mechanical (HVAC) $ Total project cost(labor and materials)$
5. Fire Suppression $ Fee multiplier from above$ /$1000
6. Total Project Cost $ 775 Q C) O Permit Fee 6 w Receipt Number
0- C A �Acv)-eac�lf ,
SECTION 5 CONSTRUCTION SERVICES;
5.1 Cons ction Supervisor�License(CSL) 9L(—(5 7
License-fr�'vo (' Expiration Date `f
Name of CtS�LL c Tye Descri tion
(o l Cr'S > U Unrestricted(up to 35,000 Cu.Ft.
Ad eR Restricted 1&2 Family Dwelling
M Masonry Only
Signature RC Residential Roofing Covering
'Z�(—��� {oto WS Residential Window and Siding
Telephone SF Residential Solid Fuel Burning Appliance
D Residential Demolition
5.2 Home Imp,rMovement Contractor Registration(HIC)
DG ✓ laces-�PtS -ems Registration/t5DO-7 Expiration Date t
HIC Company Name or HIC Registrant Name
Signature
—ino� V
Telephone
SE� I�N b �'OEER'S CO'1VIPF,I�5A'I'IO�T I�SU3tA N�E`A�'FIDA�VI�'(M G L c 1S2 §,�5Gjb))y j f��y��`�i^�:
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affidavit may result in the denial of a building permit.
Signed affidavit attached? Yes ❑ No ❑
\}.yyq ✓rl"4,j '+S3rY § li R �C. f..�-q L .. 3 FL Ji` -y. SP g', S J } 4wf E Y , C �)+�..{t4J 4fi}� �r
S'EC'�ION')/a �WNER�AUq'HORT7�AT70)�'�'OsBECOMPLETbWIIEtN�OWNL+R�)St'AG�NT�03�2 ��t �'�µ
x
.'RACTOR APf%-4ES FOR BUILDING''PERl�3,ITro �"
I, as Owner of the subject property,hereby authorize
to act on my behalf in all matters relevant to work
authooriz'y this builds ermtt apD11cialon. ZZ/ p -n/o
Signature of Owner Date
SECTION 7b `OWNER OR Ai)THORIZED i1(>ENT�DECLARATYON ' �' ` ' �"�
[, ✓" << e as Owner or Authorized Agent, hereby declare that
the st a f5 a d information on the foregoing application are true and accurate,to e best my knowledge and belief.
�. 1 ?- -� C)
Signatu a of Own8vbr Authorized Agent Date
(Signed under the pains and penalties of perjury)
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.R6 and 110.R5.
When substantial work is planned,provide the following information:
Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) Number enclosed of decks/porches
Habitable room count Number open of decks/porches
Number of bedrooms Number of fireplaces
Number of bathrooms Type of heating system
Number of half/baths Type of cooling system
CITY OF SALEM
„ aI', PUBLIC PROPRERTY
DEPARTMENT
♦IUni H:IY:)k isCol1.
%wt,e 1J.�.Wdull\si l US S MT •5Athi N,M.SYSACIn ill 159197.^
778-715-9595 • 1'.1x.979-74-9346
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
%imlicant Information �/G / Please Print Leeihly
V.uTC lOuSnscvsitJr;;mvalinNlndtvuluuD: —� ` G'
Address: �/y� t > C'
City,starei7.ip! v e" tJ�— phone ''!: 7�� �'�S Cri
Are you an employer'.'Check the appropriate box: 'T'y'pe of project(required):
I I :un a employer with 4. 0 1 am a general contractor and 1 6. New construction
employees(full indJur part-tinge).' have hired the sub-contracture
2.0 1 ;un a sole proprietor or
listed on rhe anachcd sheet. 7. Remodeling
partner-
listed
ship and have no employees These sub-contractors have 8. ❑ Demolition
working lbr me in any capacity. workers' camp. insurance. 9. Building addition
IKo workers'comp. insurance 5. 0 Weare a corporation and its
required.] of10.[]Electrical repairs or additions
tieers have exercised their
3.0 1 am a homeowner doing all work right of exemption per h(OL 11.0 Plumbing repairs or additions
myself.[No workers' comp. c. 152,g 1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. IKo workers' 13.0 Other
comp. insurance required.]
'Any xppLcant thin chucks box oh muses also Till out the Section bcluw showing nwir woikus'cumpunwtion policy inlianulion
't lomeuwrcn who submit Ibis affidavit indicting they ase doing all wurk and then hila outside contractor,must suhmit a new affdavil indicting Such.
-romcnwry that check this box mmt anwh xi.m additional bh«I Showing the name of the sub.ontrxton and their wurkon'comp.policy lnformanun.
I ant mi employer thut La providing rvurkers'cuunpensntion incuruuce fur my employees. Below is the policy and job site
injannuriva � �-
Insurance Company Nmne:
Policy A or Self-ins.
77�Lic.5-l: `1 _�_�- Expiration Date: /�
Job Sice Address:o` t�` 'j C'itylStateizip: "� - '
Attach it copy of Ilia workers'cumpensalion policy declaration page(showing;the policy number and expiration date).
Failure to.secure coveragc as required under Section 25A of.%IGL c. 152 can lead to the imposition of criminal penalties of a
line up to 51.5110.00 and/or one-year imp6smuncnt,is well its civil penalties in the form of a STOP WORK ORDER and a fine
of up to i250.00 It day aguinsl lite violator. He advised[hut a copy of this statement may be l'umirded to the OI)ice of
III%'eSitgallmlf ul the DIA hOr witlrancc coverage terilicahiun.
I du hereby Terri "ler the pains,tali penalties of perjnry drat the injurmutlan provided above i5 true end correct.
Danc l� ��//l
¢ y
Si :..urea {{{---
Of iciul use unly. Do not write in lids area, m r
be wupleted by city or town o/jiriul
City or'fown: - Pcnnitil.iccnse d,_
Issuing;Authority(circle ouc):
I. hoard of licalth 2. Building Ilepartiocut .1.Cilli I'onn Clerk 4. Electrical inspector i. Plumbing; Inspector
6.Other
Cuntlael Pcnen: _ .- Phone:7:
Information and Instructions
.%lassachuscus General Laws chapter 152 requires all employers to provide workers' compensation fir their employees.
i'ursuwu to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
evpress or Implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
t the fbroguing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ut In individual,partnership,assocratioa 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
Jwciling 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 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, 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 compliarice with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicant
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 nuniber(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carryworkers' compensation insurance. If an LLC or LLP docs 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 dale the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requester!, not the Department of
Industrial Accident. 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-insured companies should enter their
self-insurance license number on the appropriate line.
City or'rown Officials
Please he 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 penniUlicense number which will be used as a reference number. in addition,an applicant
that muht submit multiple penniUlicense 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 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 commercial venture
(i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he t)t)ice of Investigations would like to thunk you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Deparuncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
www.mas3.gov/(ia
CITY OF S.U.&NI, NLISSACHUSETI'S
&:Lwmr,DEPARTMENT
t 120 WASHLNGTON STREET,31*FLOOR
TEL (978) 74S-9595
FAx(978) 7149846
ICI\(BERLEY DRLSCOLL
MAYOR THows ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG CONMUSSIOrER
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 wilt be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
elate
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