17 WILLOW AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
k Massachusetts State Building Code,780 CMR, T°edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Avo-Family,Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: �j,,
Signature: L
Building Co missioner/Inspector of Buildings Date
S CTION 1:SITE INFORMATION
1.1 Property Address: /� / , //� // 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes no— hU Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(B)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ P P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner;ofRecgrQ. p17 / le_
Name(Print) Address for Service! �+
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check a that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other 13Specify:
Bmf D�scn[tion of Pro ed Work: EB J/G /rl a 1 B O d F
cc 6JiYr t U/1'1 A i e v D r a H/'J n ,t�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) $ - List:
5. Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: $ � 0 0 aid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Jjcensed Construction t` Supervi5or(CSL) L �Q 7—�,20
( �R /C�(/ License Number Expiration Date
Name of CSL-HQIJer p 7 List CSL Type(sec below) (/
9y; ,ovZsrax/ J ( Nc��av/y1
Address T Description
U Unrestricted u to 35,000 Cu. Ft.)
Signature R Restricted I&2 Famil Dwellin
M Mason Onl
RC Residential Roofin Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Rggggistered Hofne 1r�proverne �ontractorJHIC) `
(SDrrDFt+ J�Sr �/1//rlNcl
HI Co pang amen^HIC Regystrant Name, rl ry J Registration Number
Address JKJ ^0/0
7 el none Ex t ,tiot ate
Signatur 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 Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 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:OWNER' OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 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 I O.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total 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 I Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
•`' CITY OF SALEM
PUBLIC PROPRERTY
` DEPAR'T'MENT
I'; A 1;311 r • 1.\I I \I, \L\ i\1 r. I _I'I _
I )"4 '4i./;V; • I'\X. ';78.•4_•,;a„
Construction Debris Disposal .affidavit
(required Iilr all demolition and renovation work)
In accordance a ith the sixth edition of the State Building Code, 780 C NIR section I 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit h is issued with the condition that the debris resulting front
this work shall he disposed of in it pruperly licensed waste disposal facility as defined by MGL c
111, 5 150A.
The debris will be transported by:
c
5rok)- �5T t� Irnn/E//
(name of hauler) /
1lie debris will be disposed ot'in : 5O�� l rV p�
(name of I'acili(ty)
/
60pi STC,ct &)A
' - -t:uldres<of lacllily) -
\Ignalwc o 'pcnnrt.y\pllcanl
CITY OF SALEM
7e. r PUBLIC PROPRERTY
DEPARTMENT
N'I1- Intel 1'11
\I I,,nl 11: Wn't 11.\610N 513LhT • 5A tt• MA%!%A1 I u a I IN J197:
l',I. )78.71.j.93115 r 1'lY 97g-74,'0x46
Workers' Compensation Insurance Alftda,,& Builders/ContractorsiElectricians/Plumbers
\ ) )licant luronnalion Plcase Print Le ibly
ValTh:llhnuwsvt7r;;in V.ulrnv Ind,, dua U: e Tr)AIU EST r/H Nb
C ly,state,Zip i� A Ld'" /w Thune
.\re m art cutployer'!Check the appropriate box: Type of project(required):
4 1 mn a general contractor and 1
I. 1 .un a employer with - ❑ G. ❑ New construction
enyiloyeca(full .lndlur pan-ume).a have hired the sub-contracture
2. ❑ 1 .1111 a sole proprietor or partner-
fled on the anachcd shot. ❑ Remodeling
ship and have no cmployecs These sub-contractors have S. ❑ Dentolirion
working tin me in any capacity. workers' cmnp. insurance. q, ❑ Budding addition
1 No workers'comp. insurance 5. ❑ We are a cni porotion and its
I rcquired.) officers have exercised their 10.❑ Electrical repairs or additions
3. ❑ I ant it homeowner doing all work right of exemption per I4011., 1 I.❑ plumbing repairs or additions
'myself.(No workers' contp. c. 152, ¢1(3),and we have no 12.❑ RWI repairs r
insurance required.) r employees. [No workers' 13.❑ Other ,"Mee /PasT t/
camp. in,urance required]
•tm ..,tpllcuul Nut checks box el Mua1:dao fill on Ihc'eclit,In'luw siwwmo;Iheu wurkps'cumpenwtiuu IwlI,y Inliumuliun
' I Wmeawrwn who mdtntil this a1Tl fav it indicuing Ite:y as Juing all work anal Ihcn him uutvlde cauraetun must auhmit a new ulfdavil Indivahng wch.
(-.•nirxwr,Nut(hick this box Mimi aoachod.m addniunal'heel.hawing the man is of Ik sub-cornractars and their wurken'comp,pultcy mfurmation.
l urn an ernp(uyrr Umt i.r pearl 're workers' -utnprnetuiun in.surnnre jar ary employees. Below is der policy and job sire
hi urrouhun. / s.
l �1jdnIAS dl�t�bf r '
Imurancc C'umpmry
I'oli:v Vmne:
a r Sclf-ins. Lic. n: u) � --- ----u.—n—rDa
-t—e:
7
/ te /I�/
11)ob Site Address: City,staleLIp: — / 7BE<yVl'�
.\Stich it copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
I•allurc to secure cuserage as required under Sectiun '_5A ul'\SGL c. 152 cast lead to the imposition oferiminal penalties of
tine up to.i 1.5110101 andlur one-year imprisonment,us trcil as cit d penalties in the furor of a STOP WORK ORDER and a fine Ili
ni till to )250.00 a Jay against file violator He advvicd that a copy of this matearent may be IUrw arded to the Olhce u{
Imul div DIA :or Imul arcc .os eragc wriliuUun.
l du hereby,,rrifyander tho p url sur penalgex rjary that rte in/brinallon provided above is true taid correct.or
Official toe unly. Da not write in this arra, to hr coutplrted by lily ur lown uj/iiia/. I
( itv or Dawn: Pcrmit)lAvrise 0
1,,uing Aufhurily (circle nuc):
I. Ilt,ard of Ilc.tllh 2. Iluddin, Dcparoncot .1. C.iliAtion C'ierk J. Electrical Insp.cror 5. Plumbing Inapcclor
J. Other
('outset 1'cnun: .. ._ Phone h:
Information and Instructions
1.l�s.IJwsetu Gencral Laws chapter I i2 Ivquirrs all eu:plo)ers to provide workers' compensation lar their employees.
I'or+u.mt to this ,tatuie, an empluree is defined as " ccs erg poison in the service )(another un.ler.my Contract of hire,
c%press or nnpIwd, oral of wrnscn."
.\n e,nplaprr Is defined as "an Individual, partnership,association, corporal on or other legal cnliry, or illy two or more
.,I the 1„tceoulg engaged in a pmnt enwrpnsc. and including the Icgal rcpresentali ves of a deceased employer,or the
receiver or trustee of cul Individual, pilinicrship, association or Other legal cnrty,employing employees. Ho%,:%cr the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
awclhng louse of another who employs persons to do maintenance,construction or repair work on such dwelling house
tar ,a: the grounds or hwlJing appurtenant[hereto shall not because of such employment be deemed to be an employer"
NIGL chapter 152, $25C(6)also states that"every stale or local licensing agency shall withhold the issuance or
renewal of u license or permit to operate o business or to construct buildings
in the commonwealth for any
applicant who has not produced acceptable evidence urcumpliance with the insurance coverage required."
Xddiuunally. MGL chapter 152, a. 25C(7)states"Neither the commonwealth not any of its political subdivisions shall
enter into any contract for the perfomlance uf'puhlic work until acceptable evidence of cumpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please GII out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) narttc(s), addresses)and phone number(s) along with their cerlificale(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
ensployees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
\ccidents for confirmation of insurance coverage. Also be sure to sign and dale the•al'f)davit. The affidavit should
be resumed 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pl::sec be sure to fill in the pennittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit:licerse applications in any given year,need only submit one affidavit indicating current
Policy information cif necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)." ,\ copy of she 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
(1,d. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l h; I)Bice ,I lnycsrhatlons would Zine to diank )'Ou ill advance fur your cooperation and siluuld vulr huge .my queJtiolli,
Please du nut hesitate to give us a call.
ncc Dcp.lranctu's address, telephone and fax number'
The Commonwealth of Massachusetts
Department of industrial Accidents
Olflce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax p 617-727-7749
www.mass.gov/dia