121 WEBB ST - BUILDING INSPECTION I I The Commonwealth of Massachusetts
Board ol'Building Regulations and Standards CITY
Massachusetts State Building Code, 730 CMR, 7ih edition OF SALEM
111 Revised Janitor
Building Permit Application'ro Construct,Repair, Renovate Or Demolish a 1, =008
One-or Two-Family Dwelling
This Sec on or Official Use Only
Building Permit No er: 4 PptAAppJdd:
Signature: ✓° // //�
Building Commissioner/Inspector of Buil i' Date
SECTION 1/SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
/c�1 tt�C�1 E - / r
I.la Is this an accepted street?Yes-X— no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) 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) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public Private❑ — Municipal❑ Onsite disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners Record: � `� n 5 �j/,� ^n
ia)I4yN� 2055 (� 5 l- 11
Name(Print) Address for Service:
9.2 Q -�y y -,S&Bo
S gnature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S I. Building Permit Fee:$ Indicate how fee is determined:
?. Electrical S 13 Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
[6.
. Mechanical (Fire S
u ression Total All Fees:S
Check No._Check Amount: Cash Amount:_
Total Project Cost; S
QQ�
0Paid in Full ❑Outstanding Balance Due:
A
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor((CSL)
I.iccnsc Number lispiratiun Date
Name of CSI;I rider }
a0 �l!QaoG�7 /'✓)J�'%L �� List CSL lype(see below)
Address Lip rJ B�y f�� f 1 Description
Il l!nrcslricteJ(tip to 35,000 Cu.Ft.
It Restricted 1&2 Family Dwelling
Signmure 8�/ of Masonry Only
RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SFResidential Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 �isy HoCNmS'fCtGt t rntitraJctor(HIC)
OmO
/NG
I IIC CCmp� , Registration Number
Sy�
Address
`j '�� Gxpimtion 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 ..........13 No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AG NT OR CONTRACTOR
"APPLIES
SFFOR BUILDING PERMIT
1, A / �/�y'r�� 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, as Owner or Authorized Agent hereby declare
that tatements and i brmation on the foregoing application are true and accurate,to the best of my knowledge and
byh If.
Pnnt�' e
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to Jo hislher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IIIc)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 790 CMR Regulations 110.116 and 110.115,respectively.
2. When Substantial work is planned,provide the information below:
Total tloors 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"
N
' CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.Mirog:ry:lxM OI 1.
\I�\l to 12^�WASH.\a11 US 578 ELT s JAI l`il,Ivf.WSACI II iF I,I S)197.^
I'H 978.745-9595 of P.\x.978.74C:1846
Workers' Compensation insurance :Vftdavit: Builders/Contracturs/Electricians/Plumber9
%onlicant Infurmution C Please Print Leeibly
Name lDudnessi(Jrganintia(Vlndmdual): ]/l9i/�77/Ue C�U�'l/
:Address: `S T 6-z-0,0 m00%
City,Starc,/sip: 5,4z_61K tl914 019)0 Phone,!: . '929-2`1Y—
Are
29JNYAre you an employer'!Check the appropriate box: 'T'y'po of project(required):
4. ❑ 1 am a general contractor and I
i.El 1 am a employer with G. E] New construction
employees(full indfur part-tine).• have hired the sub-contractors
_.❑ 1 :un a sole proprietor or partner-
listed on rhe attached sheet. �• E] Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working Ibr me in any capacity. %vorkers'comp. insurance. 9. ❑ Building addition
Na workers'sump. insurance 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions
required.] )tyiccrs have exercised their
3.❑ 1 ant a homeowner doing all work right of exemption per NIGL I Ig Plumbing repairs or additions
myself. (Ko workers'cunlp. C. 152,j 1(3),and we have no 12. Roof repairs
insurance required.)t employees. (Ko workers' 13.❑Other
comp. insurance required.]
'Any:Gtphcaul that chucks box dl must alba lilt uu1 the union Lv luw slwwing their x'urkui cumpunsmiwt policy inliurtwtitm.
'I lumcuwrcrs who submil(his atndavit in aliening Ihcy are cluing all wurk al j then him outside ewurnc(orx mull aubmir anew airdavil indicating shah.
fommcurn arra check this box mutat mlaehud.m addiliunal shur:l showing Ihu nano of tho sub.omracton and(heir wurkuri comis puliuy informidun.
l tun un eaq)loyer drat it prol•iditkg rvorkers'cmnpeasation insuraaee for ray employees. Beloly is the polity mrd job.rife
irtfortautioa.
Insurance Company Name: —.. .: .... _.._.__.....-._._----
Policy if or Sclf-ins. Lic.5-3: __.. .... .__ Expirauon Date:
lob Site Address: _ City,Slatc/Zip:
Attach it copy of lite workers'compensation policy declaration page(showing the policy number and expiration date).
failure to secure coverage as required under Scction 25A uf.%lGL c. 152 call lead to the imposition of criminal penalties of a
tine up to 51.5110.00 and/or one-year imprisonment,as wLll as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5230.00 it day against dee violator. lie advised that a copy of this slutement may be forwarded to the Office of
IIt%' sngallolti ul IIIc DIA Ibr witlrance coverage \i r111Gl1r1111.
I do hereby certify under the pairs and penalties of perjury that the in/urination provided above
/is true and correct.
tii •aautro: --- ! Date' IT/— 0
I'Iun'L:i i
Of
lit•ial use unly. Donal noire is this area, to be cumpleted by city or torva aj)iciul.
City or'fown; Permit/License.-_._.
Issuing Aulhorily (circle one):
1. hoard of Health 2. Building Department 3.Cili,1'onn Clerk a. L••lectricai Inspector 5. Plumbing luspeetor
6. 011ier . .__.
CmILal'I Tenon: .. Phone y:
Information and Instructions
.V assachuscts General Laws chapter 152 requires all employers to provide workers' compensation fix 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 tither legal entity,or any two or more
,,f the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
feceaver 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.,rounds 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. NIGL chapter 152, a25C(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-contractors) namc(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 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 date the affidavit. The aditlavit 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'rown Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided u space tit 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 pennitllicense 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he a)I lice of Investigations would like to drank you in advance fur your cooperation and shutild you have any questions,
please du nut hesitate to give us a call.
The Dcpartinent's 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
Fax N 617-727-7749
Rt,:Iscd i-26-05
www.mass.gov/dia
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b CITY OF S.U.E.NI, .LisSACHUSETTS
• BUIMIING DEPARTMENT
120 WASHLNGTON STREET, Y°FLOOR
TEL (978)74S-9595
FAX(978) 740-9846
gI-%ffiFRr t:Y DRISCOLL
MAYOR THo us ST.PiEm
DIRECTOR OF PUBLIC PROPERTY/BVILDLNG 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 It 1.5
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
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)
( CA-&k
signature ifpermitapplicant
15-1�
datC
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