10 BARNES AVE - BUILDING INSPECTION -�.�o� � � 9�a�
� The Commonwealth of Massachusetts
l �° Board of Building Regulations and Standards � `
Massachusetts State Buil ' Code, 780 CMR, 7'"edition a=
�I •�'� Building Permit Application 7' Cons ct, Repair, enovate Or Demolish a Revised
W One��r Two- mily Dwe[ ng A ri!I5, 2009
�� This Secti or Offi al Use Only
Building Pernvt Numbe � D e Applied:
Signature: '�/2'j���
Building Co issioner/Inspector of B Idings Date
SECTION 1: SITE INFORMATION
�t1 Property Address: 1.2 Assessors Map&Parcel Numbers
t �(��rvi�es P,
. 1.1 a Is this an accepted street?yes_�_ no Map Number Parcel Number
t.3 Zoning Information: 1.4 Property Dimensions:
Zoning District 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) 1J Flood Zone Informafion: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes�
SECTION 2: PROPERTY OWNERSHLP'
21 O�w�eraf Record: • • (O �q R(U 2 S J
M i E T'r �G �C�.N R e 5a (e�t /�1
ame(Print) • � Address for Service:
azS �y 5 /i 3f
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construetion❑ Existing Building❑ Owner-0ccupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Worl�:
�2� �7 c�!r'�t�I / OlN .
SECTION 4: ESTIMATED CONSTRUCTION COSTS I
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building_ $ 9g�'� �(�` 1. Building Pemut Fee: $ Indicate how fee is detemuned:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost�(Item�x multiplier x
3. Plumbing $ 2. Othet Fees: $
4. Mechanical (HVAC) $ List: �
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ����, Qv. ❑Paid in Full ❑ Outstanding Balance Due:
�/%'-C � � ��-�-i/,�%�Cyi�•f�y�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor CSL) ��J�/� 8 � �
p�7�.� (' 'M (�L+.��, � License NumberL � Expi ation Date
Name of CS -Holdet q,., List CSL Type(see below) �
Y' i ✓• G2�(
A ess T e Descri tion
- U Unreskicted(u to 35,000 Ca Ft.)
R Restricted l&2 Famil Dwellin
�i ature p M Mason Onl
�� �C�L/�c�30 �� RC Residential Roofin Coverin
Telephone � WS Residential Window and Sidin
SF Residential Solid Fuel B�snin A liance Installation
D Residential Demolition
5. ' ere�}�iome�npro ment ontrac[or(IiIC) /�
�� � ti
C (p n �e qr/HIC�Re�ant�me� � � - ��h'�onON mber
Cl � G2-� . Z (&'� /�oC.
Add s 970 -,�y rX���. �P� • ��'
Ex �ration Date
Si xmre � Teiephone
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 pemut.
Signed Affidavit Attached? Yes ......... No ........... ❑
SECTION 7a: OWNER AUTHORIZATIDN TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I t'he7�rt Q. � ."Tor i 9 i G N , as Owner of the subject property hereby
authorize FrC�f 7M 1 ('�i l-v[ � to act on my behalf, in all matters
relative to work aut orized by this building pernut application.
�c.�.,r� 3-lS -�ol/
Si a[ure of Owner � Date
SECTION 7b: OWNER�OR AUTHORIZED AGENT DECLARATION
I, S�� 1�P(� �� I �� avl, �. ,as-9�or Authorized Agent hereby declare
that the statements and information on the foregoing application are[rue and accurate,to the best of my knowledge and
behalf.
r,,,,t;:�;�
`l�� r V�'1 i ��+-c c .
� /l� , 3Ii �/��
Signature ofi9�or Authorized Agent D��
(Si ed under the ains and enalties of er'u )
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)Progcam),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
Constmction Supervisor Licensing(CSL) can be found in 780 CMR Regulations 110.R6 and I 10.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. FtJ (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 CosY'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
i%lc; N: 1'Y:)NIiU,I I.
\IssAIR l�CWnsru.�s:w�Sialt:7 Smt:u,M.%mm,laiha-Is 0197:
71:1.:978-7t5- 9595 • 1: %x. 979.740•7346
Workers' Compensation insurance Affidavit: Builders/Contractorsi EIectricians/ Plumbers
iCity,slare,Zip:o►i��ti+�/ t / �o� - l'hunc i.: 9 %[Y "�f'1 y—o23�a
:\rc you an employer? Chuck the appropriate box:
I. ❑ 1 :un a employer with 4. ❑ I am a gunural contractor and I
employcus (full and/ur Part-time).•
2.I :un a sole proprietor or partner-
sstip and have no employees
working liar me in any capacity.
No workers' comp. insurance
required.)
3. ❑ I :all a homeowner doing all work
myscif. (No workers* comp.
insurance required.l t
have hired the sub -contractors
listed on the anachcd sheet. :
These sub -contractors have
workers' comp. insurance.
❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
'type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
•Any :appheaunitm chucks box of must also fit our the v.cim, Wow showing lhvir work as cumpvnutiat policy intinntatiun
At temaiwmm who submit this a%Wavit indicating they are doing all work and Ihcn him outside canrwton must submit a new 31'111davit mdiu .nu ,mh.
femcwtun
that chuck this box malt mlsched an additional NKTI .hewing rhe panne of the submontrurors and their wurken' carp_ policy infumatiun.
I run un employer that is proviiii workers' cat» peosation iusaramce for ury emrplayees. Below is the policy and job Nile
iuforalutinm.
Insurance Company Nmne: _...._._...-
Policy is car Sclf-ins. Lic. h:
Job Site
Expiration Date:
C'ity/Steteizip:
Attach it copy of lite workers' compensation policy declaration pale (showing the policy number and expiration date).
failure w secure coverage as required under Section 25A ul'.NIGL e. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/or one-year imprisonment, as well as civil penalties in the I'urrn of a STOP WORK ORDER and a fine
of up to S250.00 it day .against the violator. lie advised that a copy of this .misteirient may be lurwardcd to the Office uI
111% c%l I eaonni at the DIA for insurance coverage Act ilication.
/ ala hereby c tify u(t.(5} the
v Awmms
the information provided above is true and correct.
of/iciai use ouly. no not nvite in this arca, to be cuurpleted by city or tmun affiriaL
City or Town:
Punnit/License
Issuing Authority (circle one):
L Board of llcaldt 2. Building; Deparuneul 3. City/Town Clerk 4. Electrical luspcctor 5. Piu lbing Inspector
6. Other
Cuulact Terson: _ _ Phone
Information and Instructions
.Vassachuscus General Laws chapter 152 requires all employers to provide workers' cumpensation fix their employees.
Pursuant to this statute, an empfuree 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
..f the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee UI art 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 Iwuse of another who employs persons to do maintenance, construction or repair work on such dwelling house
or oat the grounds or building appurtenant thereto shall not because of such employment be deemed to be in 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 comptlance with the Insurance coverage required."
Additionally, NIGL chapter 152, §2512(7) states "Neither the conunonwcalth nor any of its political subdivisions shall
enter into any contract for the performnce of public work until acceptable evidence of cumpliunce 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 ilia boxes that apply to your situation and, if
necessary, supply sub-contractor(s) namc(s), address(es) and phone numbers) along with their certificates) 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
he 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 he 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.
I'lzuse be sure to till in the permit/license number which will be used as a reference number. In addition, an applicant
twat must submit multiple pcnnitilicense 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 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. it dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
f he t)tlice of Investigations R%ould Iike to thank you in advance fur your cooperation and should you hate any questions,
,)[case do not hesitate to give us a call.
The Mparunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
Tel, if 617-7274900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
itcsi>cJ ;-26415
www.mass.govIdle
CITY OF SALEM, A-liSSACHUSETTS
4,D BI;ILOLYG DEPART-M&NT
130 W-UHLNGTON STREET, JiD FLOOR
TEL (978) 745-9595
FAX (978) 740-9846
1CI�BERt.EY DR.LSCOLL
MAYOR THOMAS ST.PtEs sa
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG CO\111ISSIONER
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 I 11.5
Debris, and the -provisions -of MGL -c-40, S-54; — --- —--
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal 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 :
s� t�?
6�a 6,41 ti
(name of facility)
/(address of facility)
signature of permit applicant
flute