90 WHARF ST - BUILDING INSPECTION ( 3 c 7-K (5-z
The Commonwealth of Massachusetts
Board of Building Regulations and StandardsL
Massachusetts State Building Code,780 CMR vis8dMar 201!
U816 S P
Building Permit Application To Construct,Repair,Renovate Or Demolish A ID 21
One-or Y'vo-Family Dwelling
t' This S„ee#3an For f}f1Bci tbse Qnl
Building permit Number;; Date 4jAdd:
/. ,4,,,, is y
1uildiug cial(PrintNaiue) Signature nate
SECTION 1:SM INFORMATION!
1.1 Property Address. 1.2 Assessors Map&Parcel Numbers
1.Is Is this an accepted street?y� MVNumber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Disniet Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es[3
SECTION 2 PROPERTY OWNMSIlO'r
2.1 eCor
Ct��S'� j{gNY r��vtdrl �f�
Name(Print) City,State,ZI
az�rrA ill PIV _26r_- zk&
No.and Street Telephoae Email Address
SECTION 3:DESCRIPTION OF PROPOSED W RK'(aback all that aPPIY)
New Construction❑ Existing Building❑ Owner-Occupied Vf Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief ciption of Proposed Work: `� of ✓ r
22
SECTION 4:ESTimATED CONSTRucnOR COSTS
Item
rEstimated Costs: Official Use Only .
(Labor and Materials
1.Building $ 1. Building Parma t Feet$ indicate how fee is determined:
2.Electrical $ �v 0 Standard City/fawn,Application Fee
Total Pngect Cost'(Item 6)x multiplier x
3.Plumbing $ O ,� 2. Other Fees: $ / r�
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total AN Fees:$
Su ression
Check No. Cheek Amount: Cash Amount:
6.Total Project Cost: $ (� Paid in Fall O Outstanding Balance Due: ..
10jq 1tntLDv � G � .
SECTIONS: CONSTRUCTIONSERVIC'ES /
5.1 Construction Supervisor License(CSL) .T
�-
DA, �j@Q-t Irceuse umber Expiration Date d
Name o'TC
me
�.-.w !�✓P List CSL Type(see below)_
No.and Street T. Descriptio
U Unrestricted(Buildings up to 35.000 cu.ft.
Restricted 1&2 Family Dwelling
City/I'o tate,ZIP M Mas
RC Rofn Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improv Ment ntractor
HIRegistration Number Expiration Date
HIC C�e or Re t Nam
No. t Email address
Ci /Town State,ZIP Tel hone
SECTION 6:WORKERS'COMPENSATION RMURANCE AFTMAVIT(ALGJL e.152.§2SC(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 .......... 0 No...........❑
SECTION 7a:OVMkR AUTHORIZAT110N TO BE COP"LETED WHEN
OWNER'S AG&NT OR CONTRACTOR APPLIES FOR RU ING rERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I 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 Agent's Name(Electronic Signature) Date
NOTES:
1. 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 can be found at
xnnymn sssov/oca Information on the Construction Supervisor License can be found at MMi .nrass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor 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 be substituted for"Total Project Cost"
The Commonwealth ofMassaehusetts
Department of IndustrialAccidents
a 1 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 /Nam-e:
Address: qzle_ -
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Business Type(required):
1.[EI am a employer with employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ 1 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] S. ❑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.❑ Manufacturing
no employees. [No workers'comp. insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing 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#I.
/am air employer that is providing workers'compensation insurancefor my employees Below is the policy information.
Insurance Company Name:
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 no 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.
/do hereby certify, under the pains gird pe (ties of perjury that the information provided above is true and correct.
Si nature: Date:
Phone#:
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
Form Revised 02-23-15
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FAXMAYCK 7 sS7.t
Constmc on Debris DisposaiAffidW t
(required forall demolition and,.renovation workj
In accoritience with the shM edhbn of the State MOW Code. 780 CAM, Secdon 113.5 Deter
and the provisions of MGL cW,S 54; Building Permit it is issued with the
condition that the debris resuldne from this worts shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c ill,S 15M
The debris will be transported by.
(nameothauter)
The debris will be disposed of in:
(name of facility)
(address of facility)
6-9i"nature of a icant
Date ;
� V i UL
o CITY OF SALEM, MASSACHUSETTS
BOARD OF APPEAL
e w
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978) 745.9595
B FAX (978) 740-9846
GAS PERMIT FEES
RESIDENTIAL: (One & Two Family Dwelling Only)
New Construction - $50.00 PLUS $5.00 FOR EACH FIXTURE
Remodeling/Repairs $25.00
Ranges $20.00
Dryers $20.00
Gas Log $20.00
Gas Dryer $20.00
Hot Water Tanks $30.00
Boilers $30.00
One 9D: $10.00 with boiler & water connection(Total 40.00)
Piping Only $20.00
Furnace $30.00
Tests $20.00
FINE VIOLATION: $200.00
*COMMERCIAL I INDUSTRIAL I MULTI-FAMILY DWELLINGS*
Initial Permit $60.00 (initial permit) plus $25.00 per each fixture
Piping Only $25.00
Reinspection for unaccepted work $60.00 for each reinspection
Fine violation $200.00
*STRUCTURES CONTAINING THREE OR MORE FAMILY DWELLINGS
INCLUDING RESIDENTIAL HOMES AND CONDOMINIUMS
NOTE: No fee paid in connection with an application for a building,
plumbing or gas permit shall be returned if a permit is granted whether or
not the work is done.
NOTE: Work commenced without obtaining a permit within 48 hours shall
be subject to twice the scheduled fees.