29 BARNES RD - BUILDING INSPECTION • ,may- U�
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
wIVY'atLtl
LLswen 12C V40*0 aMS tUff a UUK 1Las wn siis01t00
MLL•9 ?45."% a F%x:gW00.9"
wwkws' Coopousittlw Insnrson AiNavir BtdldwzfCQa&Woers/Elaetriditlaw in ttrs
a
Name�M..ipeslors.poi:sriorlm4vrh.er�-e .
Add 61
CityistuciziV:
An yet w eat yser?Chselt tM approprlata hone
1.❑ 1 arse a empbyar,with 4. [31 on a Seawal comtaetat and l ryM alpA�sat(►M�adk
employs s(fun anwor p;tratime).• have hired the wb.commatatn
d 0 N'ew constrstetios
1 am a sole propriemr or partner• listed as the attached sheet t 7. ❑ Remodeling
and Ism ee ianployum These ksw k ❑Demolition
working for ma is any capacity. workers'eoep.imumflos
(Ne workots'Comp.inauanoe S. 0 we am a corporation teed Its 9. 0�ddiv addition
required] osfleae have exercised their 10.0 Electrical repairs or additions
7.❑ I am a homeowner Doing aU work right of exaenption per MGL 11.0 Plumbing repro or additions
myself.INS workers'comp. c. 152,i 1(4).and we have no I2.f$Rseof repairs
insurance eequitrd) r 9MPIGYW&We VV42119 ors.�P •nsu um required J 12A
t
A,n Vp►aa wa eheeiw has at ter the as eat eat an,"huhew Awing Uir wotas'arapw he pwtyy afrerrisa
'ewerube=who uordl deb dUdwk idbathy*Ay am defy an.weed an hen eww.so•rrsetste nwt whrwie a+..amd♦etr indldiiy ce.;
c• Mrs Zen rho alma ere ewer we aft al as addMlaY.hWLADW"r nnte of err as►weeaewn sd rhee wuAew'rwrap.Pdky iethrrseuea
/aw an rtapforer that b prevldfng work"'roer/raraden 10saranC8Jor roar rnrpforra% Bifow b rAr puj%7 sad Jo LX*
In urarm Company*is mt / �- wW
Policy S or Self-ins. Lit.0., Espirauon Date S
Job Sire Addrem: C�Ij City,StaLVZtp: '
Attach wcupy*(the warkers eompensatlus pulley declaration paps(showing th t polity au
mber and esplrsrlw date)
I;ai Iura to%;cwa coverage as required unrkr Section 25A of.%IGL c. 152 can lead to the imposition of criminal penalties oft
tin4 up ere SI.500.00 and/or one-year imprisonment,as wall as civil penallita is des form of a STOP WORK ORDER and a flan
Af up to S250.00 a Jay ap(rinat the,violator. Ile advised that a copy urthis seatemum may be Jurvsarded to the Office of
Ln:aiaauutts uf:hc DIA for in.urarce coscrao v%wifrrattun.
I Jr hereby rem ndei tlyr pains rrt r11 v1Rer/aq that die Injeranttfon pror8frd thew ' and omet
U/Jlriaf art uw/)t b rq/wdii!a ebb one.re tfr rewpJetaellr t/yp or roww oQ4•/a[
cry or Tows: Pcrmibl.Iccase
Issuing Autburity (circle one): _ —
1. IJuard of llealrb t. Uui ding Department ]. City/fond Clerk J.Electrical Inspector S. Plumbing laspeeror
G. Other
GnUacl Person: - _ Phone q•
Information and Instructions
152 nrquints all empbyers to provide wocken• compensation for trait�1�
ptawant to thi Gomral Laws chapter is the service of another under any toeteie Of ba �
tLsnaxarm w this ataucst.m seed°/�s 1s daRrtsd� ...stay Penoa
express or UROi,sd•oral a wrisas
as ara�/Mpm!is deiffead s-M oustrwMaL pasaswaklg m ooeiso&a0'o°raOOa or other deal entity,er day two or mow
sn is a joist eaerp um and iseMdil{dq le11i reprOusadves of a deceased employer the
of the foregaine Ptpd employees.other �.�p�'1Oe
tocsivor or uwme off vmemo �'der an atus ar �why reside thewio6 t:1he aatupw of 1Y
owner eta dw011tag wen llts�tos°°lama oo OO.c.rssaxsc�tt or repair work as such dwsUime hauq
dwelu t�Oohs of sresheir who deploys PyraOms be detastd to be OR Ompioyor.
or on On IQosnda or bWldig spptmemsat �their set bsaarea of sack Oeplsytmamr
htGt ehaaer 132,i2X%(`)also seta due"evsq statei tfr Meal Mssaslsg sllsmq rka/wMkkel/MG la recent or
pOrslt a Operate a limb e r a tuateratt bm11dbW Is IM eOss•OswOOMk far MW
eptble faswal Of
ei seew orevidesm Of esrlp6se with tb'Osamu"esvereiie rNidec&
appYeaat wM W sleit pradnsad ae A7)som
.Addidiniatly.MOIL chapter 152.;=sein scare work ucal• aeeW is evidson doff eosplbwwo w num"m s
enter into MW comma for the perfc mamcst �cotmeieaag atabority'
requir""M of this abspter have best°presented
Appesamn
. affidavit completely.by cbecking de boxes their apply m your aifuatiw dada if
please
ry.out apply ulocen compensation s al wick their cmriffcau(s)of
necessery. auY'aom°metomp n ies CL a)or Lied and ahoy number(s) aai odw their shy
insursmoa Limited Liability Companies(LLCM arm Liability `insumom if an LLC LLP dam haw
caw not required to carry werkaa•eamtpsmedom
members sus policy
tttgtrind as advised that dais affidavit may be submitted to the Department of induairw
.tacidyars far cmff is requdeas oe inrmraocy Coverage, Abe be sun tst s1p maid date Ike a111davIL The affidavit should
be resumed to de city a town that ebs application fbr the permit a Besets is being requested. sot drO OepOesaeat of
Id you have any questions ratsrding shy law or if you am required to obtain a workers'
In.lurtrirl AcciJeata Shou
corpenaariom policy.pbas call tbo Dapeirtmyat�cumber Hand below. Self-insured companies ahou yc their
self-irinran"license number oa the
city or za.a OfffeMas
to n The Department he provided a speed at this balo4 .
Plcase be sure that the affidavit is complete and printed g'b11• the lieana.
of the affidavit for you to fill out in the event de Office of fatvystiAtations has 10 contact you regarding spa
e purmiulieense number which will be used as a reference number. In addition,an applicant
1't,•asa be sure to till in It only
that must submit multiple per=)ant! a applications S e in day given year.need should write"all locations _�cigy Of
policy information(if necessary)and under lab She Address"tht car
town).-A copy of he affidavit that has been officially stamped or marked by the city a town may be provided to isle
applicant as prof that a valid affidavit is on file for fliture permits or
licensee. A or partialt not enlaced to sow affidavit
business be filled l t monist
year. What ehams Permit 0ci m leaves js person 1 is OT required to complete this affidavit
a Jag keener er permit
Vhu t)tii.c Jf Investigatiuns v ouW lard to thank you:n AJvAncc for your cooperation and should you have Any questranf,
lcme Ju rwt hesitate to Alive us a uU.
The Dcpaamenes address. telephone and fax number:
The Commonwealth of MassachuseM
Deparoment of Industrial Accidents
own of In odpded
600 Washio0we Street
Badoda MA 02111
TeL 0 617-7274900 en 406 or 1-MMASSAFE
Fax 0 617-727-7749
Z.v iacJ i-?G-US www.a'na.gov/dill
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
]L�+•• l'1•.�N::.1Ns 7aiT•i�t:fr,ftavur:w .r�1s:.�
Co4structios Debris Dispowt A ltdsvit
(reyuimd FW an danouaon a"twobad"wart)
is maniame with dw dstb adhim olthe Sam Building Codsti 730 CWt saatios 111.11
Dcbr*vA dw provisions of MCL a 34 S 54
9uildtn4 rwndt p is(said with the conditias that the darts resulting foal
ghis wort shall be disposed of in a proprrtr licensed wsm disposal &dlity as defined by%taL a
l 11. S 15OA.
The debris will be I by:
tam�r t,art.r)
rho debris will be disposedd of in :
to ur'fx�t,ty)✓
— ,.J.ata. of fra.ty►
,w
The Commonwealth of Massachusetts
;t Board of Building Regulations and Standards FOR
�j Massachusetts State Building Code. 780 CMR, 7"'edition N1tiNICIP:U.I'I'1'
USI
Building Permit Application To Construct, Repair. Renovate Or Demolish a Rerfrrd Junuut.r
One- or Tate_ unrrly Dwelling 1. �003
This,Section FcJ Official Use Only
Building Permit Number: Date Applied: Z /- do,
Signature:
B d 411fz��
n oussioner/ Ins ltor f Bu' rags Date
SECTION l: SITE INFORMATION
1.1 Proper.1dWddress: 1.2 Assessors Nlap & Parcel Numbers
L`7 r A C O 00 /0
I.la Is this an accepted street? yes-(yes—LX no Map Number Parcel Number
1.3 Zooming Information: 40utsideFloo��e
Property Dimensions:
Zoning District Proposed Userea(sq ti) Frontage Ui)
1.5 Building Setbacks(ft)
Front Yard Rear Yard
Required Provided RProvided Required Provided
1.6 Water Supply: (M.G.L c. 40. 554) 1.7 Flation: 1.8 Sewage Disposal System:
Public Zone: ood Z .1Private ❑ yes19" Municipal f��Ori site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
C4, f
Naine TV)) Address for Service:
J!79-
SignaAre Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Altera[ion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ,N Specify: 1
Brief escription of Proposed Work': T
c,
t5T
SECTION 4: ESTIMATED CONSTRUCTION COS
Item Estimated Costs: Official Use Ol
(Labor and Materials) ny
I. Building $ 1. Building Per Permit Fee: $ Indicate ow fze is dztennined:
2 tandard City/Town Application Fee �% �,eoo
. Electrical $ i,
❑Total Project Cost(Item 6) x multiplier x
3. Plumbing $ I. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees:
Check No. Check Amount- Gash Amount:
6. Total Project Cost: $ (Jzj„Cj� ❑ Paid in Full ❑ Outstanding Balance Due:
P
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) r
License Number Expiration Date
Nano of CSL- Holder List CSL Type(see below) --- - -- -- - -
T c Description
Address U Unrestricted I LLD to 35.000 Cu. Pt.t
R Restricted I&"_' Family Dwellin,
Signature
Yt blasonry Onl
RC Residential Root"me Cos•enn,
ephone \VS Rcsidential \Vinduw :mJ SiJina
SF Residential Suhd Fucl I3urmne A >dential Demolition
Registered Home Improvemgn[zContracior (HIC)
Regatrauun Nr Whet
HIC Company Name Of 1-11C R5 istrnnt N' ne� rJ �
r �
Addrs _ Expiry ion Dare -"
/Sign, ore 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 j n v/-i, , as Owner of the subject property hereby
�fFh ' to act on my behalf, in all matters
uuthun7�
relatives to work authori ed by this building permit application.
r_
d
natur of Owner Dat
N
SECTION 7b: OWNERt OR AUTHORIZED A ENT ECLARATIO
I ,as Owner or Authorized Agent hereby declare
that the sta ements and information on the fo going application are true and accurate, to the best of my knowledge and
beha
not Nam (f
Signa re of w er or tit orize Agent Date
(Si ed tin er the ai %and enalties of eriu ) 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 trot 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 110.R6 and I I0.R5, respectively.
2. When substantial work is planned, provide the information below:
Total Flours 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 OPC°
3. "Total Project Square Footage" maybe substituted for "Total Project Cost'