149 WHALERS LN - BUILDING INSPECTION $2.31
The Commonwealth of Massachusetts CITY OF
3 Board of Building Regulations and Standards SALEM
{ � Massachusetts State Building Code, 780 CMR RECEI t?eYired�Llar 11
Building Permit Application To Construct, Repair, Renovate O*Tfctite{i�hid °: L ��'
Ocie-or TWo-Family Dwelling
1 ^ This Section For.Offfcial Use On
Building Permit Number. Date Applied
IZ 14 'i
1 Building OB)cial(Print Name) ;,Stgnaturo, .. Date
sEcrroNltsiTE"mFOR<r1ATloa�r
I.1 Propjr}y,.yW(es� 11 Assessors 61ap.4 Pnrcel Numbersn I.la Is this an acne ted street9 es no klop Number Parcel Number
1.3 Zoning Informations 1.4 Property Dimensions:
Zoning Distrito Proposed Use Lot Area(sq 8) Frontage(R)
1.5 Building Setbacks(R)
Front Yard - Side Vals. Rear Yard '
Ile red Provided Required Provided It4opedProvided
1.6 Water Supply:(M.G.6 c:40,§54) 1.7 7lood Zone Informatlon: 1.8 Sewage DisposalSystem:
Public O PrivatZane: — Outside Flood clout O On site d'9posYsten`CMuni
Cbedrlf'; C,
SECTIOiYi: JPROPEItTYOWNERSIIN' , .
2.1 w ert of
�(1��(✓ Idel-ley
t7)me(Print) l�Y6 'ZIF
3�' S� 41 *yL(10dM# 4h _IAly SIV
No.and Street Telephone
Email Address r>,
SECTION 3:DESCRIPTION OF PROPOSED WORKS(cheek all tint apply),
New Constmction O 9. sting Building C Owner-Occupied C Repairs(s) O Altemtion(s) Addition O
Demolition O Accessory Bldg.O Number of Units Other D Speeity:
Brief Descf*ption of Proposed Work1:
Vctry.ulr lN1S (- Tl uC
Ale i— 7soij
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itcin Estimated Costs: Official Use Only
Labor and Materials
I. Building 1. Building Permit Fee:$ Indicate how fee is determined:
12. Electrical S �jucJ C Standard Cilylrawn Applicadon Fee
❑Totol Project.Cost'(Item 6)x multiplier x
1.Plumbing S 4Po0 2?Qther Fees: $
a.Mechanical (FIVAC) $ List: (�
5.Mechanical (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash rbnounC
6.Total Project Cust S 2 ) UuCJ ❑Paid in Full 13Outstanding Balance Due:
J-b 00t4/ae461,' Mr&L'010 o cepa
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction SupervisorL/icense(CS/L_) / I' )�LC��I Ii�zl-Zoi�,
✓b i &/h bH '^ -Licenso Number Expiration Date
Name of CSL Holder List CSL Typc(see below)
SL P✓, i(, Sf
T '. ': : . Description .
No.and Street - -
UUnrestricted Bu OUO cu R.
S,tah LyRestricted 1&2 Family Dwelling
Cityaown,state,ZIP M M
RC RooM Coverin
WS window and Siding
SF Solid Fuel Burning Appliances
61 1511 chos
1 Insulation
Tele hone Email address D Demolition
5.2 Registered Horne Improvement`Contraf tar(H IQ I '7 9 ( Yo
12-Z Yi '2 �
C kOe b) (74(y ytItCIA
�
{ C ,�( `�' &k&4- HIC Registration Number Expiration Date
I AIC Cppamtpany jJa y Qr FIIC Registrant Name /
)L I�✓U I[.,..} Jfi" CRGaSSf/`h Sv"' at 1. lJY�
No.and Street Email address
�..ro.ye(oFtmg61diul bt7-�S�-7S�t
Ci /town State ZIP Telephone
SECTION&WORKERS'.COMPENSATION INSURAPICE AFFIDAVPF(M:G.I::.a 14 4 21IC(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 Isluance of the building permiL
Signed Affidavit Attached? Yes..........O No...........O
SECTION 7n-OWNER AUTHORIZATION,TO BE-COMPLETED.W HEN' r,' '.
OWNER'S AGENT Olt
CONTRACTOIt4P ESFO BUILDING.PERMIT
1,as Owner of the subject properly,hereby authorize
t9 act o my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNIZ OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agcnt's Namc(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
_knot registered in the Home Improvement Contractor(NIC)Program),will Br(have access to the arbitration
program or guaranty fund under M.G.L.c. 14M-.Otherimport nl-infomwfion on Ota HIC-Program can be foundT
www.mnss eoe'oca Information on the Construction Supervisor License can be found at www•.nmss.novAlps
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) N .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halObaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
j. "Total Project Square Footage"may be substituted for"'futal Project Cost"
�\ Office of CoY�usumerAQg Bayieess✓ Regulation
_ROME IMPROVEMENTCONTRACTOR_
VGABALE
n¢`�74140. - T Ype:
lranon: A2016 DBA
CON�T�
CHARFfES GAM6� : .=i
.Z?PROSPECT ST;�' ?�
f S�UVAMP,SCOT:TrMA1 .;
ry
Massachusetts-Department of Public Safety
P �oar8 ofBmldiag Regulafions and Standafr�r s
.,
Construction Supervisor '
License: CS-102961
p ria
CHART ES GAME
52 PROSPECT S. '
-----MAMP_SCOTT UT
� �.yr A'-� UPiteion
Commissioner 1'112112016
The COmmonweaJt/t ofMassachuseds
' Depa�linent 0fltidust MW,4 cidents
I Congress SftW4 Suite Joe
1000014 M.4 02114-2017
www.masssgov/dia
Wwarkers,Compensation Insurance Affidavit:Builders/Comradors/Elecbicians/Plumbers.
TO BE FH.ED WITH THE PERWITBHG AUMORITY.
Apnllcant Information f /` ,. Pkase Plat lerlbly
Nam(Business/Orgamzetion%In(d�ividusl)n, �n?,Mn,Ltail (UA'S�. .
Address:
City/Stste/Zip:S4.M ajj 61r14)-1 Phone#:_ (7 �V—.71
Are yon voempkyef!(had:tae s"Mpatate hor: - Type Of To deI .
p ) (reyaired):
1.01®a employee with aivio s(full-dtW P-t•t-)•' 7. 0 NCR'Cg11¢WChOn
2.[L]7'ameaokpao rapnnaaa6paoQ)mveao.e�byge9g'°?Ipog tormem B: .QRemodplin8
mYW�ry•(No wakaa'eom9•fobema xquoed) .
3.p! maLome dumgaawolcmYwg..iNowwkae'emp.i aarequimd.)1 9: ODCmoliti ' .
4.�lamahomeowa mdm'nbe LvingcouuactmsmCMdManwmlconmypoperty. Iwo
lOQB1n7d1fig8 d17i .
emmetLecatlan�rmsaeimerluvewmtas'compemavooioananceerareaole 11.0 Electrical tepansoradditions
prepietma with noempiuyeee. i2.�Plumbing'i+epags otedtlidtm"s
s.Olamasennalcoid and lhaw tired am sub4dairsism ffmd od Me afeneW altar 13• :•Roof
7taxe.aubcoaasc hmemplayaa,mdba-wort-ec=p.wmao•: O Tom-
6.0 We are a arpomd®and its offiterslreve eauciaed meatigtt of eaemptionpeYMQ.o.
14.[3C Mar
16$¢114),mdva.hbaoeoumtylmumspicworkm'.eo :mavaoa regaeadj .
_.
*Any witcaotitW cbpeJaekox8l"do SO omPoeaatienitabwaHowing t>w5 wmkeia eompaeatm pohry hdii ,..
t Honaw who SAM*ads affidevitihdir d1Cyaie deka;as work mid thmhw outside amkv ammtsalmis$new af6dHVllmdlmCna nmu:
tConusct M do check tis has mud anaehea m'additional slimtaiiowiog are naofe.oMe"f,"huaetotemd sWt.Wh'fti or ret ffioa eofiao have
amployeea.umesulacoana�ahare.®r!%'mrS tLey.tun tawidemeuwoltins'oomp:po)aymooUv- ',:
Tamanye rLtWisprovldingvtwrAm1;:ompewationWwaiuoeformyearplpreei Belawisthepolicyandjabsife -
infonnadon.
Insurance Company Name:
Policy#or Self-ins.Ihc.#: Expiration Date:
lob Site Address: city/St ix
Attach a copy otthe workers'compensation policy declaration
page(showngthe policy number and expiration date).
Failure to accrue coverage as required under MOI.c: 15Z§25A is a tamrma]vioLition punishable by a fine up to$1,500.00
and/or ane-yearimpcisomnwo as Well W civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the viohrtor.A COPY of this statement may be forwarded to the Office oflmestigations.of the DIA for iusaraoce
coverage va;fication.
I do hereby"7 aaba andpen ofperjnry that the informadon previdepdd above rs owe and eorretL
8;®atvtre• XN Date: Ilii �ti "I - �'
Phone
oJIuw ase only. Do not write hm this area,to be eomplaed by city or town offieW
City orTown: PermlMeense#
Issuing Authority(circle one):
1.Board otHealth t Building Department 3.City/Town Clerk 4.Electrical Inspector 5 Plumbing Inspector
6.Other
Contact Person: Phone#:
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 ofhire,
express or implied,oral or writtep"
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,§25g6)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 pp who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Ncither the commonwealth nor any of its political subdivisions shall
ewer 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)name(s),addresses)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 wry 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-iosmed'companies should ewer 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 permittlicense 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)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 licensee. 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 wminercial venture
(i.e.a dog license or permit to bum 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,Suite 100
Boston,MA 02114-2017.
Tel. #617-727A900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEg AWSACHL SE M
B[.mDmDEPAjmffm
120 WA9MTGMS7WT,rFLOOR
UL(978)7454595.
FAX(978)740-9846
SIIvIBERLEYDRISQ7LL
MAYOR THMAS ST.PMM
DnacrcRoPFuBucrRorExT 1BLuDmcmws►omit
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 00, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit 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:
�.yww
&L�
(name of facility)
1-�r✓� ��
(address of facility)
Signature of applicant
2,U
Date