30 WARD ST - BUILDING INSPECTION The Commonwealth of Massachusetts4? GQs � $N, 4dICIY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CfVl%b OCT —4 A 40.%t/ur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
l� One-or Tivo-Family Dwelling
This Section For Oficial Use Onl
�n Building Permit Number: Date Applied:
to 4 Ice
—• Building Official(print Name). Signature Date
SECTION t:SITE INFORMATION
(( ( 1.1 Property Address 30 , , Jam\ 1.2 Assessors blap&Parcel Numbers
I ti_Ll I.I a Is this an acce ted street? esw no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arca(sq It) Frontage(It)
1.3 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(b1.G.l.c.40,§Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal E3 On site disposal system ❑
Public E3 Private E3 Check if ycsI3
SECTION 2: PROPERTY OWNERSHIP!
2.1 V Ines of Rc• rd:
Sa-'LVtI>�
lme(Print) City,Slate,ZIP
?f) Ca q_ `1V- L"q--056
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied-9 Repairs(s) Alterations) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description fPr os Work':
fkbC
Sw=
da
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) -
1. Building S 30 I. Building Permit Fee:5 Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
•t.Sfech.mical (FIVAC) S List: l�
i. Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:
6.Tu Cd Project Cost: S 3Q�d ❑Paid in Full ❑Outstanding Balance Due:
Gryta,OD lO ( tZ P-U . 1p)rz
- 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) G/ S-U77,S
s
License Number Expiliatiqn Date
Name ofCSL Holder S' List CSL Type(see below)
Type - - Description
No. and Street
//� U- nrcsiricted(Buil in u to 33,000 cu. tt.
OQ AS/%940�>"" �01G Q yJ R Restricted 1&2 R imily Dwelling
'ily/fown,Stale,ZIP M masonry
RC Rooting Covering
WS Window and Siding
�q SF Solid Fuel Burning Appliances
dd` �/ +J 3� - 1 insulation
Telephone Email adds D Demolition
res
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Comp;my Name or HIC Registrant Name
No.mid Street Email address
Ci /Town State ZIP Tele hone
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 Ishuance 9f the building permit.
Signed Affidavit Attached? Yes ..:....... No...........17
SECTION Fell =ERRAUTHORIZATION.TOBE.COMPLETED.WHEN
OWNER'S AGE
G ECONTRACTOR APPLIES FOR BUILDING.PERMIT
I,as Owner of the subject property,hereby authorize �� y L)' 12 Gl�
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
clic
Print Owner's Nae(Elect nic Sign ore) ate
Name
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
B ntering my name below,I hereby attest under the pains and penalties of perjury that all of the information
c nt ine t is, plication is true and accurate to the best of my knowledge and understanding.
Pr' wner's Authorized Agent's Name(Electronic,Signature) Date
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 Lug 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
www mass eov'oca Information on the Construction Supervisor License can be found at www mass.^ov:4lns
2. When substantial work is planned,provide the information below:
'total fluor area(sq. R.) (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/batlis
Type of heating system Number of decks/porches
'type of cooling system Enclosed Open
3. "ffotal project Square Footage"may besubstituted for"'focal Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
a I Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name:�14 ,,./ //E-4-J (� 7 e w
Address: t `/ I u S l-
City/State/Zip: c/ 4L4 0 Phone#: 7r
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
orpart-time).* 6. ❑Restaurant/Bar/EatingEstablishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate, auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]** 11.E] Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp.insurance req.] 12.0 Other
*My applicant that checks box#1 must also fill oul the section belowshowing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy information.
Insurance Company Name: 69�e-
r
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic.# Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cer , u r the pains and penalties ofperjury that the information provided above is Ir and correct.
Si nature: �9 Date: u
Phone#: �^ f r,^G
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 of hire,
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 employer,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 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 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 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 your insurance company's name,address and phone number along with a certificate 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-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 fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). 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 dog license or permit to burn 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
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Fenn Revised 02-23-15
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Construction Deft S.Disposo/Affjdw t
(required forall demolition andrenovatlon work)
In accwdmm**h 1110"editbn of the Stere MOW Code, 780 a^Mcdon 131.5 Debit
and 1110 provisions of MGL o00,s S4; w ftm tS is ftwed with are
ooncM11on Mat the debris resdft from this work do#be dbposed of in a prgx*Ucensed
Waste depot bdfftr as defined by MGL c illy s 156A.
The debris will be transported by:
41
(name ofhauler)
The debris will be disposed of in:
(name offadfity)
u�✓oS �� '
(address of f dl►ty)
gnature of applicant
Date