B-19-1283 - 0002 BOTTS COURT - Building Permit 0 --� -
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This sec ton"For Official Use Only
Building Permit Number: Date Applied20
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: - 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
ti
1.3 Zoning Information: 1.4 Property Dimensions:
J
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) --.
Front Yard Side Yards Rear Yard 00
Required Provided Required Provided Required Provi ed ;�
1.6 Water Supply:(M.G.L c.40,§54) Zo Flood Zone?Flood ZoneOutside Fl 1.8 Sewage Disposal System:
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ .p
SECTION 2: PROPERTY:OWNERSHIP'
2.1 Owner'of ecord:
Name(Pri ) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ld Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed World: / S e s13
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ j S, c, c C L Building Permit.Fee:$ Indicate how feeds determined:
2.Electrical $ S �,G ❑Standard,City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 6, s 66 2. Other Fees: $
4.Mechanical (HVAC) $ J List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
G
Check No, Check Amount: Cash Amount:
6.Total Project Cost: $
S r ❑Paid in Full D Outstanding Balance Due:
l EA 6.c
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) lG I
C U License Number Expiration D to
Name of CSL Mlder
I� List CSL Type(see below)
No.and eet Type Description
G Q` U Unrestricted(Buildings up to 35,000 cu.ft.
b �t R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
//
SF Solid Fuel Burning Appliances
A �cs�c53�,✓ie. I Insulation
Telephone Email address D I Demolition
5.2 Regisltered Home
//!I/mpro(/vemen Contractor(HIC) Ia q a �0 >d
HIC Registration Number Expiration Date
HIC lowany N e or HIC Regis t Name 1
No. d Street s Dl /G Email address
City/Town,St6te,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.I52.§ 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 Issuapce of the building permit.
Signed Affidavit Attached? Yes .......... No-.........❑
SECTION jai OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR(APPLIES FOR BUILDING PERMIT A I,as Owner of the subject property,hereby authorize +/+ i G45 LJ
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner' ame(Electronic Signature) Date
SECTION 71b:OWNERS 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.
I/ � V
/� �C S
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
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.goy/dps
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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
"
The Commonwealth of Massachusetts
Department of Industrial Accidents
' Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual);
Address:. 4�/`r L>I .4)7 S .
City/State/Zip: ,. i S�r 'Phone#.>
Are you an employer?Check the appropriate boat Type of&oject(required):
I.❑.Iam a employer with 4. I.am a general contractor an d I -
6 ❑:New construction
employees'(full and/or part-time),* have hired the sub-contractors.
2. I am a sole proprietor or partner- listed on the attached sheet.t ❑Remodeling
ship and have no employees These sub-contractors have 8: []:Demolition
working for me in any capacity. workers'comp.insurance. 9 El Building addition
[No workers'comp.insurance 5. ❑,We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions•
3.❑1;am a homeowner doing all work right of exemption per,MOL I LD Plumbing repairs or additions
myself[No workers'comp. c. 152,>§l(4),and we have no- 12.❑Roof repairs
insurance required. employees_[No workers'. 13.❑Other
comp.insurance required.]
"Any applicant that checks box:il1 must also till out the smtion:bdow showing thcir workers'compcttsation policy'information.
t Homeowners who submit this:affidavit indicating they are doing all work and then hire outside cotriractors must submit anew affidavit indicating suchi
'Contractors that check this box must attached an additional sheet showing the name of the sub contracty and their workers'comp policy.information.
I am an employer that is providing workers'compensation insurance for my employees. Below u'the policy and job site
aforteratton. ,
Insurance Company Name:
Policy#or Self-ins.Lic:#: Expiration Date:'
Job'Site Address: City/State/Zip:
Attach it copy of the workers'compensation policy'declaration page(showing the poWy:number and expiration date):
Failure to secure coverage as required under Section 25A of MGL e;152 can ead to the imposition of crinunal penalties of a,
fine up to$1,500:00 and/or one-year imprisontnent;as well.as,civil,penalties mi the form of.a STOP WORK ORDER and.a fine
- - - of ii 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.,
I do hereby ce*t V Fr,the pains acid penalties of perjury that the infor adore provided above is true,'and correct,
Sign lure:. _ i Date d / f
` Phone
7*7 312--0f9j
QjJ`ieial use only: Do:not,write in this area,to be completed by city or town.offieiaL
., City:or Town: Perinit/License#
Issuing Authority(circle one):
L Board of Health 2.Building Department 1 eity/Town Clerk A.Electrical Inspector S.;Plumbing Inspector
' 6.Other <
Contact Person: Phone M
Information and Instructions
Massachusetts General Laws;chapter;152,requires all employers to provide workers'compensation for their employees:.
Pursuant.tathis statute,an erisployee'is.d"etined as"...every person in the service of another under<any contract of hire,
express or implied,oralor written:"
An`employ ne is defined as-"an individuals parthership,association,corporation or other legal ent#y,_6r 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 individ.ual,.partnership,association or other legal entity,employing employees. However the
owner.of a dw(Iling house having not more Khan Ihrt:r,aparlmanls and wliis re'sifts N roin,"or the r;cnpant of thP'
dwelling:house ofanother who:employs persons to do maintenance,c6nstruction`or repair:Work on'+such"dwelling house
oron 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 everv-state:or Iocal licensing agency shall withhold:the issuance or
renewal of.a license or permit to operate a:business;or to construct;buildngs in the:commonwealth for any
applicant who has:notprodiiced acceptable evidence ofvompliance with'the insurance coverage required."
Additionally MGL chapter 152 §Z5C(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 sub-contractor(§)name(s),address(es)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 carry:workers'compensation insurance. If an LLC or,LLP does have
employees a policy is,requiced. Be advised that this.affidavit,may belsubmitted:to the Department of Industrial
Accidents for confnmation-:of:insurance coverage. Also be sure to:sign andAate the affidavit. The affidavit should
be;returned;to the city or town that the appl cation.for the pern it,or license is being requested,not the Department of
Industrial Accidents: Should You have'aby questions regarding the law.or if you are required to obtain a workefs'
compensation policy;;pleas6:c li the Departriient at the number listed below. Self:insured companies should enter their
self insurance license-number:on the.,appropriate Tine.
Qity or Town Officials ; rs
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 Itrvestigations 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"n.any grvenyear,need pplysubmit,orte affidavitindicating current
policy information•(if necessary)and`under :Job Site Address"tfie applicant should write"all locations`in (city or
- ----- --
town)."A copy of the affidavit that has been•officialiy stamped of marked bythe,city or town maybe provided fa.the.
applicant as proof tltat a vand;affidayat?is on;fil.e:for fiiture'peirrtits ordicenses.:A new affidavit must be filled.out each
year.Where a hdme;'Own&-,br crtizell`is.obtain nga license or permitnofrelatedt0 any business or commercial venture
(}e.;a dog license:or;pemut to burn leaves ete.)said person is NOT required to complete this affidavit.
The;Oflice of Iitvestigations'would like to thank you inadvance for youreooperation and should;you have any questions,
please do not,hesitate to give us"a call;
The,Depaitment's address.;telephone'and;fax numbers `
The Commonwealth of Massachusetts
Department of IndustrialA.ecidents
Office of investigations
600:Washington Street,
Boston,MA 02111
Tel #"617 727-4900 ext 406 or 1-.877 M-A., .
#6I7-727-774.9
Revised 5 26-Q5. Fax
wwwmass.gov/dia
Y MUNICIPAL INSPECTIONS
CONSTRUCTION DEBRIS DISPOSAL FOISM[
780 CMR 111.5 &5111.5 Debris.As a condition of issuing a permit for the demolition,
' renovation,rehabilitation or other alteration of a building or structure,M.G.L. c. 40, § 54
requires that the debris resulting there from shall be disposed of in a properly licensed °7
solid waste disposal facility as defined by M.G.L. c. 111, § 150A. Signature of the permit
applicant, date and number of the building permit to be issued shall be indicated on a
form provided by the building department, and attached to the office copy of the building
permit retained by the building department.If the debris will not be disposed of as
indicated,the holder of the permit shall notify the building official, in writing, as to the
location where the debris will be disposed; also refer to DEP Regulations 310 CMR
7.09(2) and 310 CMR 7.15,when applicable.
In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit
Number- is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111,
S 1.50A.The debris will be disposed of in:e
LOCATION OF FACILITY I U!
CONSTRUCTION SITE ADDRESS {dk G 3
Signature of Applicant $�"" . � Date j� lE ✓y
� PP
AFFIDAVIT .
As a result of the provisions of MGL c 40, S 54,I acknowledge that as a condition of s
Building Permit Number . all debris resulting from the
construction activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
I certify that I will notify the Building Official by (two months
maximum)Iof the location of the solid waste disposal facility where the debris resulting
from the said construction activity shall be disposed of, and I shall submit the appropriate
form for attachment to the Building.Permit.
\�'
Signature of Applicant / Date
(PRINT OR TYPE THE FOLLOWING INFORMATION)
Name of Permit Applicant 4
Firm.Name, if any
Commonwealth of Massachusetts
®) Division of Professional Licensure
✓ Board of Building Regulations and Standards
Constructio $Y e i ,1 &2 Family
CSFA-106204 I, alp ires: 04/201,2021
1 r
PHILIP MICHA�t1D
2"LYNN STFt5E
PEABODY MA
- Commissioner coz
�«� `' VfLG (PG�77�m,0i�?.L/1$ "O�VI�CCLQ�tIi6P,�b '
Office of Consumer Affairs&Buslness Regulation
ti FIOME IMPROVEMENT CONTRACTOR'
TYPES Inds ldual
Registrro €jcuratlon
1 1.2/08/201'9�
,PLiILIPLEONARQ�CIiAD� y
#� " PHILIP L".#'NIICHAU
+tr 944 LYNN.ST
REABO`DY;:MA`61960
Undersecretary'
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