34 BELLEVIEW AVE - BUILDING INSPECTION (2) The Comnionvrealth of Ma55aCIAISetts
Hoard of Building Regulations and Standards
Massachusetts State Building Code, 780 C'MR, 7 edition
Building Permit Application To Construct. Repair. Reno\ate Or Demolish a R, iwd hrnmu,
One- or Tit n-Funrih' Dtrrlling
This Section For Official Use Only
Building Permit Number: Date Applied: d` —
Signature: s «` O O -----
Building con u...oned Inspector of Buildings Date
SECTION I: SITE INFORMATION _
1.1 Property :'Lddress: 1.2 Assessors Map & Parcel Numbers
3�I.la Is this an accepted street.1 yes_ no_ blap Number Parcel Numhei
(.3 Zoning Information: 1.4 Property Dimensions:
I zoning Dist,iCt Yropw,ed Usr. Lot Areu(sq fir Frontaee tit)
1.5 Building Setbacks (ft)
j Front Yard Side Yards Rear Yard
! Required Provided Required Provided Required Nnrvided
1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'! Municipal ❑ On tiltl`disposal s stem ❑
Public❑ Private❑ Check if yes❑ p I y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerin
of Record:
'tT l ie= _ 311 13Cr/v.H.i AaG�
Name(Print) Address for Service: 1
617—f/7— 7 7,YJ
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition 9?11 Acce�:sory Bldg. ❑ Number of Unirs-1 1, Other '0 Specify:��_
Brief Description of Proposed Work': f, M0&-A- 6. ^tt_- 11
e�siy o� L T t 5 Fr.It I.' ri yer -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building $ IOUD VO I. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
i
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ Lise
5. Mechanical (Fire $ Total All Fees: $
Suppression)
") Check No./32n Check Amount: Cash :\nu unit:__ �
e. Total Project Cost: $ W6FJI.,✓!� aid in Fuli 0 Outstanding Balance Due:_____
SECTION 5: CONSTRUCTION SERVICES
5A Licensed Construction Supervisor(CSL)
VA It rr— 'J Gh„` License Number lizp latton Date
_-
Name of CSL- I folder
3 y t.t a.fl ✓1�"� (}K�' List Csl_'rype (sce below) Desch
\ddrcss .I. c riiun
Unresrtcted nil to 15.000 Cu. F(.)
R Resinocd lye'_ Family Dwelling
Signature r� �1 %Iasonri, Onlv
174-� g�7� 17y3 RC Residential RootingCo,enne
Telephone WS Residential \\ ndmk ,md Siding
SF Rcsideuti:d Solid FOCI 13urnine :\„h:ui.e Instil Lan-n
D Ras iden(ial Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address —
Expiration Date
Signature .. Telephone
SECTIO '6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 157. S 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pitmde
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
1 wlGt.rF 6 Girt Gi , as Owner of the subject property hereby
authorize Mk T `4rl` to act on my behalf, in all matters
relative to work authorized by this building permit application.
Si nature o(Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, W'1!1 'f'T O'til.✓L L , as Owner or Authorized Agent hereby declare
that the siatemc..t.. and !re true an; tzi the best of my
behalf. RR
1'1'I,ct,� lJGh�fi —
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the 2ains and penalties of per u )
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(nut 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 1 10 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/bmhs
Type of heating system Number of decks/ porches
'Type of cooling system Enclosed Upon-
3. "Total Project Square Footage" may be substituted fir "To(:d Project Cost'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1 1 :�M:., 'I
. ... \Ls., n I:_ \\ l.l�:�., :,,� i::.'� II • il;: ll. \I 1�.1, �. . .� � . :II '
Nnrkrrs' Compensation Insurance At'lldaNit: Builders/ContractorsiElectricians/Plumbers
\ 1 lluant Information
Please Print Leeibly
\.Inlc tlryanv,t❑,tn InJtsi.lualC
jM k
City stale.Zip: stli�"t Phone #: 07 ?_ 7743
\re vuu an employer:' Chock the appropriate box:
'type of project(required);-
I.❑ I :un a employer ss ith 4. ❑ 1 :un a general contractor and 1 6 ❑ New construction-�N
zolployees (full and'or part-time) hake hired the sub-contractors-_:_ -) Remodeling
]. listed on the attached sheet. '
Epol and a sole proprietor or partner-
I hese sub-contractors have 8. ❑ Demolition
ship and have no employees r
workers' comp. insurance. y. ❑ 13uilding addition .n
working for me it any urance 5. ❑ We are a corporation and its
[Nu workers' sump. insurance 1o.Q Electrical repairs or additions ,
required.[ officers have exercised their
ng ht of exemption per MGL 11.0 Plumbing repairs or additions
3.❑ I am a homeowner doing all work C. 152 $1(4)and we have no 12.0 Roof repairs
myself. [No workers'comp. employees. [No workers'
insurance required.] 13.❑ Other
comp. insurance required.[ V Y
\oy"PlaI itant that checks box n 1 mint also lilt out the section below.how mg their workers'compensation policy information.
' Homeowners who suhmit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new iftidavil indicating such.
t'n'nr'it lots that check this hox moat attached an additional sheet showing the name of the sub-contractors and(heir workers'comp.policy inf nnation.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site '
infortnarion. r�
Insurance Company Name:--
Expiration Date: _
Policy q or Self-ins. Lic. q:
City,State/Zip:
lob tine Address:
.\ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure cucerage as required under Section 25A of hIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S I.Soo.00 and'or one-year imprisonment. Is hell as civil penalties in the form of a STOP WORK ORDER and a tine
of till to )'_50.(11).1 I,iv aL!alll.st the l lolator. He ad%ised That a cUpy Jf Illis statelllent may be torw'arded to the Office of
Irs c.n cations tit the 1)I:\ for inwrance coscrage lerlficanun.
l flu hereby rcrtiji under the pains and penalriec of perjury that the Inlortnati nr pros ided irh a e n free and orrer l.
Dille s
I'll.wc =
--oJ/i,hd use tmlr. Do not it rite in this area, to he,moopleted by riry or utnvr uf/ic iuL
_—
( in or fuss it:
Issuing \ulhority (circle one): -
I. Board ut Ilealth 2. Building; Dcparhlient 3. (it)ifuwn (lerk 4. Electrical Inspector 5. Plumbing Inspector
b. Other .--' --- -----_._
('untact Person: ..----' ---_--- -------------
----
Information and Instructions
\LI,.a:Lusetts (Fenced l avvs :haptcr I rrquoc, .111 cnytlovcr, n,pro%ide workers' conq,cn,awm for their cntplovice1.
I'ut.u.uu oI tins .inure, .tit emplen ee I,defined .0 ' cv cry person it, dtc scn Ice of .mother under .Inv :ontract of lure.
or implied. aril or vvriucn."
\r. emplu ter is dctined .Is ".ui mdn:dual. p.lru:cr.hip. ,I„ocl.uton. :olporation or other legal coats. or .tin tvvo or more
,,I the fol:_outg cn_aged In a.loutt cnicrprue. and In:lu.hng the Ic_al reprc•scnlatI%e, of a do:eased cntpL!yera or the
earn cr or tiu,tce of Ili uldry idudl. partncr.hip. ,I„ocimtun or other Icgal cnnty, :ntplovmg emplo�"s. Ilovvcver the
,•,�tier of:I dwelling house having not more th.ut three .Ipartntcnts and w Ito resides therein. or the occupant of the
dw:i!ulg house of.utother who cinploys person, to do mauucnan:e. construction or rcpa r work on such dwelling house
c ,n the _rolulds or building AlIpurtcn.ull thereto shall not bcr.Iu.>,r oj,,uch emplot nlcnt be dcctucd it, be an employer."
\I(d- :haptcr I i?, s_'i(lot also .rates than 'evcrystare,ur local licensing pgcnci Is.huII withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the'commonwealtli for any
applicant who has nioi',p�uduig�d-a eep'table ev idence of cuntpliance with the insur;)nS(r coverage required."
.\.Ivh tionally, .WiL chapter 152, j 2i('I'I ,rates "Neither the conunor»vcalth nor any or its plilitiial subdiv irons shall
enter into any contract for the perlo ntance of public work until acceptable cv idence of cumpliance 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-cuntractor(s) name(s), addresses) 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 dues have
employees, a policy is required. Be advised that this at idavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The atfidavit 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
,elf-insurance license number on the appropriate line.
City or Town Ofrtcials
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.
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 permivlicense applications in any given year, need only submit one affidavit indicating current
policy information I if'necessary) and under"Job Site Address" the applicant should write "all locations in (city or
iow n)." A copy of the affidavit that has been officially ,tamped or marked by the city or town may be provided to the
:Ipplicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
I,car. Where a home owner ur citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn lea%cs etc.) said person Is NOT required to complete this of fidavlt.
I he (/Rice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
plal,e do not he,u.ue to Vice its a call
t he Dvratnncnt': address. telephone and tax number:
'The Commonwealth of Massachusetts,,
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
^ PUBLIC PROPRERTY
DEPARTMENT
tli'.: i'I P1 !9tly i !I
'd 12, %\.d11l.\I,.0N11 RIJ'T * S.\I I'.M. \I.\ii%l !II it I "_I')
978..74 `1S46
Construction Debris Disposal Affidavit
(required li)r all denwlition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 C141R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N _. 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
111• S 150A.
The debris will be transported by:
- - Inamc of hauler)
I he debris will be disposed of in
/VGyfy ,s;uc, G
(name of facility)
(address of facility)
sienature of permit applicant
date
,�, .
1 .. . . . " .
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