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46 BARR ST - BPA-09-223 BUILD A DECK The Commonwealth of Nlassaehuseits t Board of Building RCgulations and Standards Lt rlt kffio,"IdinIz IMassachusetts State Building ('uJe. 7S(1('h1R, 7 ' editionBuilding Permit Application To ('onsuuC1. Repair. Reno%ate Or !mdish a Rr 11,.J(hle- or Tour-V,onih Docllin,v 1. _u('a'1-his Section Fur Official Use Only Permit Nurnhrr: Date Ae: Q-v B uddinnu,vuncn In,pruur ai Buildings Uatr SECTION I: SITE INFORMATION Ez — liddress: 1.2 .Assessors Slap &.Parcel Numbers _----- — . . i l accepted +(reet7 yes nu .flap Numhcr Pars! Numhrr information--- ------ LJ Properly Dimensions: Zoningt Proposed Use Lot Area(sq lit Frontage (it) Setbacks (ft) ! Front Yard Side Yards Rem laud Required Provided Required Provided Reyuoed Prodded rl,-6Water. Supply: (M.G.L c 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone''blic ❑ Private❑ Check if yes❑ Municipal ❑ On site disrosal system ❑ SECTION 2: PROPERTY OWNERSHIPt 2.1 Owner'of Record: �(R�,CAC' s77 "`7 ice Na tPnno sA� Address for Service: /L sea 4 , ,?9sr- -8 �/e 9 Signature Telephone SE ION 3: DESCRIPTION OF PROPOSED W RK'(check all that apply) New Construction Existing Building ❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: j Brief Description of Proposed Work': )L l G SECTION J: ESTINIATE CONSTRUCTION COSTS Estimated Costs: Item (Labor:md Materials) Official Use Only I. Bwldine $ I. Building Permit Fee: .$ Indicate haw tee I.L. detcrmmed: ❑ Standard City/Tuwn Application Fee 2. Electrical $ ❑ Total Project Cost (Item 6) x multiplier x 3. Plumbing 5 2. O(her Fees: S {/.J� 1. Mechanical !HV: 0 S List: ' /2 5. Mechanical (Fire _ Total :\II Fees: 5 Sure.siun) Check No. Check Amount: _ ('.oh to nau t i 0 Folal Project Cost: y S�� 0 Paid to Full 0 Outstanding Balance Due:------. SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CS1.) 1_i,en,c Number I-\plea i,�n I).tl: j Name of CSL- Ilolder CSL T,pr I,rr below) l\ e Urxn loon ddrr,* l II11e,l1'ICIed me(,I 1S.0110 it 1'II -_ R Rr,tnaad l_' F amih D%,:lliil_ Si_n:uure ,M Mason Onh RC Rreldrnual R%mwg Co,anml hi 1.phone \1S Rc,id�un,11 \l nlduu .old Siding__ ._.__ SF Rc.Idnilial Sohd I-uel Iiuunne AI,+II i.nlec 111,11"Li; D R, denli.d Demuhtu 5,2 Registered 110 Improrrrnent ContractoIf r 1111C�. -�2SZ y�9!/•� e0 irk 6 SO.Pr IJ1•C Car; Itail', Name or HIC R"istrant Name Reel,lrauuu .\uniha [splrauun Dais —� Signaling Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (N1.G.L. c. 152. § 25061) Workers Compensation Insurance affidavit must be completed and ,uhmitted with this application F:ulure to pnnldc 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• _�/��GL(=' ��'jt/A/(�'_'_$'CQ _ as Owner of th•_ suhlect propel iy hereby authorize --lf�o--to art „n my helt::if. is all ntattcra re!uttve to %vork authorized by :,his building permit application. Si nature ul O,incr - —.— _—.--- —_ Dale SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized .agent herehy declare that the statements :md ntormation on the foregoing application are true and accurate, to the best of my knowledge and i behalf. Si¢nature of Owner or.. orized Agent ` Date !Signed under the pains andlienaltics0l er ur ) NOTES: 1. .An Owner w'ho obtains a building permit In do his/her own work• ur :m o,vner who hires an unregi,leied cunt vacua (nut registered in the Hume Improvement Contractor (HIC) Program), will not have acce,s to the arhitr:ulon program or guaranty fund under M.Q.L. c. 112A. Other important information on the HIC• Program anJ Construction Supervisor Licensing (CSL) can be found In 780 C•MR Regulations I M.R6 and 110R5. rc,pecu%ely. When ,ulimannal work is planned, pnnlde the inlormanon below: Total floors area (Sq. Ft.I (including garage, finished hasemenlJatocs, decks ,,r purrhl ! Gross living area ISy. Ft.) _ Hahitable room count Number of fireplaces Number t,t hedromn, .Number of hall1h.uh, Nlunhcr art h.uhntnms hope of heating ,yNtem - -- --- Number of,Icck,/ hype of cooling system J. 'Total Project Square Rolage•• may be ,ubsututed h,r Total Prolect CII,t ' C � ��%_k CITY OF SALEM PUBLIC PROPRERTY ?` ��r� DEPARTMENT ,I\IIf:N:I'Y:)9IsC,-I I \1\Y,Ice 12^�W rust Nd ION S-1'<U r • SAL 1 M,M.\1\.\Cl ll sr r n 0197^. 1i.1.:978-745-9595 0 17.\x. 978-741--)846 Workers' Compensation Insurance : Millavit: Builders/Contractors/El c eice Print Leb rs -u )licant information ly NaRtd ll)urinusy OrganirstioNlndrviduaU: 0 Gm yui� Sp�S 6;;11 0v i c _ Address: City,State;Zip: Phone :\re an zmploys:r'! Check the appropriate box: 1'ypz of sleet(required): i 2 4. ❑ I Ion a general contractor and I g, new construction I. I sm a employer with have hired the sub-contractors employees(1-ull andifor part-time),' 7. ❑ Remodeling listed on u the attached sheet. 2.❑ I aoa a sole proprietor or partner- These subcontractors have K. ❑ Demolition -«r ship and have no employees 7 ❑ Building addition IKo workers' comp. insurance 5, ❑ a working for me in:my capacity. ,workers' comp. Insunce r, , We are corporation and its Officers have exercised their1 ❑ Plum6 rc 10.❑ Electrical repairs or additions A • I required.) 1. bing airs or additions right of exemption per MGL P 3.❑ I an,a homeowner doing all work c. 152, 51(4),and we have no 12.❑ Roof repairs myself. LKo w,nrlters' comp. employees. (Ko workers' _ insurance required.) 13.❑ Other comp. insurance rcyuircd.J -:1n):�pphcam that checks box AI muss also rill um the s,:aiuu lu:luw showing Ihatr workers cumpensasion pulicy mfurmmiun _ Ill,' who vseckstunio this rsi muvis indicating Ihcy are doing all work and then him outride courxlors must autmsil 4 new al'rdavit indiuling such. (' I s ry thin i •"k this box mswi mbchod an addniunal..,heel showing tile 15Ine of ItW'sub.ontracton and their work en'coup.Policy infomnasiun. Below is the policy and/ab site I it),, au empluy'er that is providing workers'c'onpensntmn utrurance fat my eusplu)re.+. - irljorniatiom Imuratn:c Company Vame:_ ----...- - Expiration Date: z -------- `3— ©G'S ✓?® 09 I'nlicy A or Self-iris. LiC. *: � ------ �" ""--- .� l2 — — City;State/"Lip: �ez0`r Job Site :\ddress:� - .%ttach a copy of lire workers' cumpensatiun policy declaration page (showing; the policy ntunber and expiration date). Failure to secure coverage as required under Section 25A ufNlGL c. 152 can lead to the imposition of criminal penalties of a tine up to SI.500.(N1 and/or one-year imprisonment,a- wvell as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advisedm that a copy of this slatcent m:ry be forwarded to the 0111ce of Inccan,;auons of the Dlr\ for in Kuf:a,U: average strilication. / er the pains and penalties ujpet7ury that the infurtnultatr Provided above and correct do hereby ce Date- O[jiciul else mr/y. Do nor .,•rite in this area, to be cuntp47ed by city or town o/JiciaL City or'torn: —_. Permit/License d._ _ .. . issuing:\ullrurity (circle one): I. Board of Ilealth 2. Building Dvpuruneol .4. Cilyi l'own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other _ --- Contact Pcnon: Phone 0: Information and Instructions ,V ossichu;etts General Laws chapter 152 Requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defiled as"...every person in the service of another under any contract of hire, express or implied, oral or.wi itten." An employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more ,it the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the recei%er or trustee of .ui 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 house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." 'siGL chapter 152. §25C(6) also states that"every state or local licensing agency shall! withhold the issuance or renewal of u license or 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." .additionally, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfornhance 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 file boxes that apply to your situation and,if necessary, supply sub-contractor(s) name(s),address(es)and phone nuniber(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 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 be ronimed 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'Pown 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 till out in the event the Office of Investigations has to contact you regarding the applicant. Please be.cure to till in the pennit/license number which will be used as a reference number. In addition,an applicant that most submit multiple permit/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 (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 peiTnits 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. l he t)IIKe of Investigations wouldlike to thankyou In advance for your cooperation and should VU❑ have any gUCJIWIts, please do not hesitate to give us a call The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston, MA 02111 Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE R,i.i,ed s-26-05 Fax # 617-727-7749 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT rill j - - - '.I .�, ,i' I �� ♦+.., �11'g P.IT # S.V I11. \L Il - ')'8-'4;.);a; ♦ I \S: 'i'8-'4_ 641, Construction Debris Disposal Affidavit (required li)r all demolition and renovation work) In accordance ith the sixth edition of the State Building Code, 780 Cb'1R section 1 1 1.5 Debris, and the provisions of NiGL c 40, S 54; Building Permit it is issued with the condition that the debris resulting front this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c I t 1, S 150A. The debris will be transported by: ) I name of hauler) I he debris will be disposed of in <70 toddress of 1'ac:lilvl w / vgnalulc of p• nit applicant Td, date