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19 WINTER ST - BUILDING INSPECTION V AZI The Commonwealth of Massachusetts Board of Building Regulations and Standards TOS Massachusetts State BuildingCode, 780 CMR, T"edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a It-401m --me One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: ' [' Signature: ' • �� Building Commissioner/Inspector of Buildings Date SECTION l:SITE INFORMATION 1.1 Propeft Address• 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(it) 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 yes❑ SECTION 2: PROPERTY OWNERSHIP' Owner of R cord: l,an�rarllP�S /CIhr/sf/'h4 / 9Gf/irJf er �5f . Name(Print) —� ffkq ddress for Service: 75- X 076 Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Workz: H 1'Ck B /h 8 LcJI✓l�vuJS /a.S to V u�u //s /n sulQt _ ,Set Allo l asr-/ 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: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: �� 6.Total Project Cost: $ /� ��� aid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) y© f 3/L-L t 1 'to 4ly.Gl.T-lFtuS p License Number Expiration Date Name of CSL-Holder i List CSL Type(see below) (/ Addr• s d Type Description U Unrestricted(up to 35,000 Cu. Ft.) R Restricted I&2 Family Dwelling Si nature M Masonry Only "— IL. RC Residential Roofing Coverin Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Im rovement Contractor(HIC) l v g -7147�7 __� MbUW �it` R►aS HIC Company Name or HIC Registrant Name Registration Number ( A �u-� ,� 5 dal C IF 7�f�! Address 20 0 n i,oi-- NF"boo t'+ SC" Expiration Date Signature �� -t'�_ 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 ........... " No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Cl4 Rre4 �t , .tSt. i!' t I o...) as Owner of the subject property hereby authorize 7-0I f yJ Cif &W-Uh J r,!L,rl i to act on my behalf,in all matters relative to work authorized by this building permit application. Si nature of Owner Date SECTION,7b:OWNER' OR AUTHORIZED AGENT DECLARATION 1, �O 1-�r-� L7Z "vA- f �qh%r ,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. ac 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 IO.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 Number of decks/porches Type of cooling system Enclosed Open —71 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALEM PUBLIC PROPRERTY a DEPARTMENT IL: W,%1IjjN ;I,^S IALLI s iml it.Id.\\\.N III I I IN5197,C, I1'.1. '179.713.9j95 s 1'ts 9711-74, 1.146 Workers' Compensation Insurance Alfiduvit: Hui lders/Contractors/Electriciuns/Plumbers %moicant Information Please Print LeCihly V.7mC11)u.11wsv l)rsmr.uinNlndn ulual l: �sN.IRfi LiC:,'VZs �SrC..V"`y 1Jdr�sx: �� t"®LCeJict dr �n�tei� Miss � ' Cily'siale.%ip: %A— tit 1Nt*:'% Thune ;! �P, w .%rc)ou an vmployer'! Check the appropriate bus: 7)pe or project(required): un a cm lis cr with 4. ❑ b. ❑ New construction I :un a general contractor and 1 _n I.� P Y ' � n engdoyces(full anLVur part-time).' Irate hired the sub-cunlracturs ❑ 1 ,un a sole proprietor or partner- listed on rhe attachal sheet. 7• CR-oR-etnodeling shipand have no cmpluyccs These tub-contractors have S. ❑ Densolirion working tin Inc in any capacity. workers' comp. Insurance. 0. ❑ Building addition No workers'comp. insurance S. ❑ We area enrporation and its I required.) officers have exercised their 10.[1 Electrical repairs or additions 3.❑ 1 ant m a homeowner oner doing all work right of exemption per NIGL 11.0 Ptumbing repairs or additions myself.(No workers' comp. c. 152, §1(4),and we have no 12.❑ Ruul'repairs nsurance required.) r anployccs. (No worker' 13.0 Other comp. insurance squired.) -s u� .,pphcanl list checks box 01 must:dso fill out rhe wcnnn Was,shuwina rhmr work as'cumpensmial policy ndinmul:un. ' I lomvuw'wn whu suhmil this aIIloilo,it indic.nins Ihcy ars doing all work m,d Ihcn hire uufude raurxton must suhmit a new airdavil indiudmy wwh. -f..nincmry that check this box matt nnohad.,n aadllimul nlw<I shuwina Itw sante of the rub-conlaerors and them wurkun'comppuh'y mformaliun f oar un eorpfoyer that fir providing tveril ers'cumpeisira fon insurance jar ory enyifoyees. Beftnv is rhe pu/it.y um/jub site irrjor„tutioa f y Irnuraocc Company Name: L I ati �_ Y✓ Wit- $ �y t1. '�. - ---------- I'olicv 4 or Scif-ins. Liic.. 0: dWL. 13 )S�J�?�, 60 JQ . _ ._— Expiration Date: l0 I®9 )ob 'Si te Aildress: City;State/zip: ed/? Igo Attach it copy of the workers'compensation policy declaration page(showing the policy uunnber and expiration date). 1•allurc a)secure coxerage as required under Section 25A ul'NIGL c. 152 can lead to the imposition of criminal penalties of a rine tip to 51.5110.9(1 and/or one-year iolprisaamcnt, as well as cis 11 penalties in the form of a STOP WORK ORDER and a fine If op of 5'_50.00 it Jay asaiosr Iha violator. IIe advised that a copy of this smtcmenl may be lures arded to the Oltice ut' :IN ,,a tions at 'tic DIA for Io,un,u:cc a,scra;c tcrilicalmn. [,Its herrby s ertify under thrny,na�e td pray acv of per)ary thin the in/br'nudon provided above is true and correct. !���/1 ey ;1:'1.11 iII� _. !I U"' �' --- 5---- 1 9 P2 �r— � "1 �acs ► -- I)ffi['iaf nue body. Do no/Irrite fa dds arra,tube cumpfc/ed by city ve roown nIjit ia/ I ( Iry or 1'sovn: ... _—. Pcrmiul.iccnse It. Ittuimq Authority (circle site): i I. Ill,ard of IlcAlh E. nuddin:; Mpartiocal 1. L.A.s."fuou Clerk 4. Electrical lu,pector i, Plumbing lutpector G. 011ier _ G,nlact I'cnua: -. .. Phone d: Information and Instructions �t.us.l.hu.:ens General Laws chapter 152 requires all employers to provide workers' compensation for their employees. hUrill.ull to 1:11) Iatutc.all employee Is defined s" .evar) pclson in the service of another Inkier.sly contract of hire, e%press or Iinplled. oral or Written." \n i f"pjOjyr I<derinc as "in Individual, partnership,.iswcullou, corporation or tither legal minty,or ally two or Inure .,t the I,megoa;g engaged in a print enterprise, and including the Icgil representatives of a deceased employer,or the receiver or trustee ul.or utdiv,dual,paivunh,p,association or other legal entity,cmpluymg :niplo)ccs. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the .Iwellrlg huuse of another who employs persons to do maintenance,cunstruction or repair work on such dwelling house or on the eruund5 or budding appurtenant thereto shall nor because of such employment be deemed to be in employer." >IGL chapter 152, �s25C(6)also stares that "every state or local licensing agency shall withhold the issuance or renewal of u license tar 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." AJditlonally. .1616L chapter I52, §2507)sores"Neither the commonwealth nor any of its political subdivisions;hall enter into any contract for the performance of puhiic work until acccplablc evidence of compliance with the insurance requirements of this chapter have been presented lir 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-contractor(s) name(s),address(es)and phone number(s) along with their cerliftcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employLes 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 dale the affidavit. The atlidavit 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 •Ir•insurmlce license number on the appropriate line. City or Town Officials Please he sure that the affidavit is complete and printed legibly. The Department his provided a space ut 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 pennit/license number which will be used as a reference number. In addition,an applicant that must submit multiple peril 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 Icily or town)." A copy of the affidavit(hal 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 liCen Yes. A new of tldavit 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I h.: )I IICC UI Iiive,tlgauons%%uuld live to dlank )ou ill aciv:rlce for your cooperation and slmUuld you have ;rny quebtlollY, ,)[case du nut hesitate to give us a call. fhc Dep.roncnl's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 4 617-1274900 ext 406 or 1-877-MASSAFE Fax 0 617-727-7749 www.mass.gov/dia I I Board of B0011n0 Ri*, #IH iod$and Standards I condtryotibn Sypewisor E.tcsnsk LYoa CS 40336 !2009 7r# 11352 ff� RICHgEtP S 6 ARCHELAUS PL W NEWBURY,AMA 0196'4' i Cominiss�—"" `�,�� o i ���y/i 1at"y6n One Ashburton Place - Room .1301 Boston. Massachusetts 02108 Home Improvemef t,,, ractor Registration Registration: 104747 �, Type: Partnership Ua ;; 3 � sl Expiration: 7/15/`2010 Tru o DEMBOWSKI BROS. CON STRU �O _� ' ;w( Richard Dembowski 6 Archelaus Place W. Newbury, MA 01985 Update Address and return card. Mark reason for change. Address OPS-CAI 0 SOM-01(OI-PCa4ae "----�"` Renewal Employment Lost Card oL c,vc � 3tS 3hgR L �� s CITY OF SALEM l (�y\ PUBLIC PROPRERTY �� DEPARTMENT I ..,C:1;gl I r � 1,\iI V, \L\•i 11 •. I . .I ! _ I I I 'J'S V;.I;vj I \r. 'j-a v; 64,. Construction Debris Disposal .affidavit (required lirr all demolition and renovation \vork) In accordance \kith the sixth edition of the Slate Building Code, 780 CNIR section 1 1 1.5 Debris, and the provisions of MGL e 40, S 54; Building Permit K 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 I 11, S 150A. The debris will be transported by: "tQ A G 4- C..-4-6�A Inane of hauler) I he debris will be disposed of in : (narne of facility) 6+4&A- 40"qac- Of Iacditvl I�natmc of p.nnit .ylphcant date