Loading...
22,24,26,28 WHALERS LN - BUILDING INSPECTION 'L� The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, T°edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a � One- or Ttt Fat 41 Dtv This Secti or Offic' Use my Building Permit Numb D e lie o Signature Building Commissioner/Inspector of Buii i Date SECTION 1:SITE INFORMATION I I Property ArJdres ECLot—Area(sq & Parcel Numbers ✓ ((.•�! Parcel Number I.I a Is this an accepted street'?yes_ no 1.3 Zoning Information: nsions: - Zoning District Proposed Use Frontage(R) 1.5 Building Setbacks(ft) ° Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.8 Disposal System: 1.6 Water Supply:(M.G.L C.40,§54) 1.7 Flood Zone Information. Sewage g P osal S Y Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yesO SECTION 2: PROPERTY OWNERSH t r 2�J Owner'of Record: � A4 al k Name(Print) of a.t/ aR,�, 1(/ Ile X-5 W/7 A a for Service: Signature Telephone SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 13Alteration(s) 13Addition 13 Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: f Description of Propos Work2: / d e ` S S SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building 5 1. Building Permit Fee: i i hTdicatc how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x J. Plumbing E 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees: E Suppression) U Check No. _Check Amount: Cash Amount: 6.Total Project Cost: E 8 ��D ❑ Paid in Full ❑Outstanding Balance Due: UJ f r SECTION 5: CONSTRUCTION SERVICES I 5.1 Licensed Construction Supervisor(CSL) /wv/FZS License Number ✓ Expiration Date Nymc of CSL- 1 91de �� ti a J List CSL Type(see below) Ad c 41.9- Type Description U Unrestricted(up to 35,000 Cu. Ft.) R Restricted I&2 Family Dwrllin or M Masonry Only a3- y'i3 RCResidential Roofm Covering clephone WS Residemial Window and Siding SF Residential Solid Fuel Burning Appliance Installation NQS D Residential Demolition 55.2 RegiStered Home s I ,Bry)0 EGgFr~n.,r�on actorA&Xe �1s�i�✓G �l�n �j�` Cyon pa �t Name r H ICC ltcgi//Int lupi?� Regisstt�ation Number Ad &40-811)3—Y �,3 Expiration Date Signature Telephonene SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 .......... No........... [3 ECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 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 c 1, UOAW A"' ,as Owner or Authorized Agent hereby declare that t e statements and information on the foregoing application are t g g e me and accurate to the best of m knowledge and PP Y B behUlAv Print a e L!�' � 6 ' Sign ure of Owner or Aurbotized Agent Date Si d under the pains and penalties of per u NOTES: I.v 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 I I0.R6 and I I0.R5, respectively. 2. When substantial work is planned,provide the information below: TWotal floors 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 ). "Total Project Square Footage"may be substituted for"Total Project Cost" y CITY OF SALEM , I PUBLIC PROPRERTY DEPARTMENT �I r..NI t!� Wn.tunu t,r�5t:uer • Satlst, bf.\».0 nl a I Is JI`17� fi,l. v711-7113-9393 0 f:\s 97N"74C'J:I+6 workers' Compensation lnsurnnce 'i(fida)it: Builders/Contractors/Electricians/Plumbers ill flicant Information /ry�r 'y`y,�✓� Please Print Le fiibly VamctnlnlllcsQl)'rsnl,Jtinlvindl. ,lddrass: / � '/ � '/ Z City,Stare,/if) ✓�7r'17i��4�r OA7eO Thune i!: �oY 7`�./ tire s I u air employer?Check the appropriate box: '1}pe of project(required): , 4 1 :un a general contractor and 1 (i. new construction 1. I ant a employer with - engiloyeea(lull JnLvur part-unto).' haec hired the sub-contractors ,. ❑ 1 ant a sole proprietor or partner- lured art the anachcd sheet. 7. Remodeling .hip and have no employees These subcontractors have S. ❑ Demolition working for Inc in any capacity, workers' comp. Insurance. 9" E] Building addition I No workers'comp. insurance 5. ❑ We are:t corporation and its I required.] officers have c ceicieed their 10.❑ Electrical repairs or additions 3. ❑ 1 ant a homeowner Juing all walk right of exemption per MOL 1 LQ Plumbing repairs or additions workers' cum . c. 152, g 1(3),and we have no 12. Rauf rc airs m self. Po p ❑ P 5 l insurance required.) r employees. Loa workers' I3.❑ Other can . insurance required.] P q ] •\u. .,,ptluut Ihat checks boa OI musta6u till um the section Imluw showing Iheir ssuAcoo cunlpunuaiw,Isultey int:,nrution. ' Ilumanwncn,,,h.,,djuu I this anldaviI indk.ii,ng Ole)ateJuing all ,.,it aul dlcn his uunlde cwurxton musi ouhm it a new Airdav it indi"ing,uc A. d..m rxtun that uhvck this box muss Jaachaxl.in aedaiunal nho:%l,huw:ng rlsu uama of the sub-connxton and their%orkan'comp policy inrurm:mun /unr un employer that i.s pruviding worlkers'eumpanvadon insurance for wry employees. Below is rhe pis/ivy anti job.Ale, 1fornwtiun. Insurance Company -Name: r// /'iQ��/U/✓ l/y`•' i`Q�u"!r1ii W/ "r„” r �^ ! ' 1'olicv sl or Sclf--ins. Lic. f': f/OO �/��1CDD��O✓/`D/DLJ, Ea piratwn Date: 40, p.�7 tub "rte Address: �G✓/�T! G1Y//11_;� City;State Zip: 4l7 Attach it copy of the warders' curripensatlun policy declaration pale (showing the policy number and cspiratiun date). I-allure to secure coseruge as required under Section 25:\ul'>IOL c. 152 can lead to the imposition of criminal penalties of a Fina up to 51.500.00 and.'ur one-year imps isomncnr•as w'cll as cry d penalUcs in the lunn of a STOP WORK ORDER and a fine If up to 1250.00 it Jay Jgairtst the violator. Ile advi.icd that a copy of this statement may be tbrw arded to the Office of I1I\ ul 'dic UL\ cbr wsm oxc eos"a:;u \.ill iwUon. /Ju herrby a:rrifv m ler Jar pat/i�(Jm/ nor// r Iritic'ujyerjary that the infurinrrrlon provided aabovve is tr e l died correel _- DIrq 1A :ae6_3_�V_5 - -7 )/jiriul ave mdy. /)u our write in this urea, to be completed/by rity ur town a//ilio/. ( iry ur fawn: Permit/Liecnce 0 Issuing Aulhuriry (circle noel: i I. li„ard of llc.dth 1. Iludding" Ilcparrtncot .1. (.ih.'I u,\u Clerk J. Electrical Inspccror 5. Plumbing Inspector 6. Oiher _ G,ntact Nritio: ." Phone fl: Information and Instructions �i.usadmsetu (icneraI Laws elaptcr I i2 require,,all elnplo)crs to provide workers' compensation for their employees. Pursuant to rills ,latute, an rmyluree Is dinned as " .emery pc soil in die service of another un.ler any contract of hire, e.pre,s or unt-I oral or wntten." \n employer K defined as "an Individual, partnership, .Issociatiou.corporation or tither legal entity,or any two or more ,r Ow I„rceou;g engaged it a joint cntcrpr,se. and including the :coal represenrativcs of a deceased emploser, or the rel Cl,er or Iru„tee of air "Idlvmdual, pwillehhip,association or other legal cnnty,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwvllulg house of another who employs persons to do maintenance, construction or repair work on such dwelling house or ,n; the grounds or budding appurtenant thereto,hall not because of such employment be deemed to be an emplo)er.” .%,tGL chapter 152, �WC(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 wbo has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, fvIGL chapter 152, a25C(7)crates"Neither the commonwealth nor any of its political subdivisions shall inter 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 Phase 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 nuillber(s)along with their certrfcale(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 lie Ienoled 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 •If-insurance license number on the appropriate line. ('try or Town 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. lll.:ase be sure to fill in the penniulicense number which will be used as a reference number. In addition,an applicant that must wbmit multiple pcnnitllicerlsc applications in any given year,need only submit one affidavit indicating current policy infomation cif necessary) and under"Job Site address" the applicant should conte "all locations in_(city or town)." % 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. lice ,IInve\flgatlUn, would itne to diank You ill ad%ance tur your cooperation and should you brie :my question, please do nut hesitate to give us a call. ncc DJ p.unnent', address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgadons 600 Washington Street Boston, MA 02111 Tel. b 617-727-4900 ext 406 or 1-877-MASSAFE Fax iM 617-727-7749 www.mass.gov/dia CITY OF SALEM j r� PUBLIC PROPRERTY DEPARTMENT I I I 9'N.'4;.'I;4j 0 1 \C 'i_X -4:'•,�4i, Construction Debris Disposal a►1'tidavit (required lirr all demolition and renovation work) In accordance %%itll the sixth edition ol'the State Building Code, 780 CMR section 1 11.5 Debris, and the provisions of MGL c 40, S 54; [3uilding Permit If is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c 11 t. S 150A. The debris will be transported by: 6m) (name(if hauler) I he debris will be disposed of in (namr ul facili y) � ©d-70 Isddres< of Ijc uv) C urc > nnit .Ipphcanl vlllildl�?