40 BELLEVIEW AVE - BUILDING INSPECTION (2) <-�I Sy " -Ak 2-7 s
i 4a The Commonwealth of Massachusetts CITY OF Z
Board of Building Regulations and Standards Sm �p
Massachusetts State Building Code, 780 CMR Revised 4s 20 0
Building Permit Application To Construct,Repair,Renovate Or Demolish a c
One-or Two-Family Dwelling r
This Section For Official Use Only cr
�p Building Permit Number: Dat pplied: ,Co
Building Official(Print Name) Signature D Tt
^ SECTION 1:SITE INFORMATION
1 1.1 Propgyty Address: 1.2 Assessors Map&Parcel Numbers
tl r� l_.l _=n1 y
1
^ l.11a Is this an accepted street7 yes no Map P Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yazd Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2; PROPERTY OWNERSHIP'"
2.1 Owner'of Record:
r
7 Name(Print) City,State,ZIP
gb .� cl7r A-7-may
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)'
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 0 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWorV: Morn, to
V Ovrt c5i 1}7f(
Qwk iR '$,tole GiQ, r'a.y ,tAd n,r..� lever, of-XA no- is iti is
tiu PT &,U4 pyt
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfLeial Use Only
Labor and Materials
1.Building $ '��3ae,) 1. Building Permit Fee;$ Indicate how fee is determined:
2.Electrical $ "❑a.uui azd;Cityr'I'own ApphcatiorriFee -
O Total Project Cosi3.(Item 6)xmultiplier. x
3.Plumbing $ 2. Other Fees: $. -
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression)
Total All Fees:$
Check No. Check Amount: : Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstandnag Balance Due:
I la l L- 1-0 C-OIV Mr-\CT m-
1Yloa
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) GS yvff3 jU 1Ul�$ ( , ,
Nt rt& , be-it W- License Number Expiration Date
Name of CSL Holder t /
List CSL Type(see below) l/
CIS - d$ 9370
No.and Street Type Description
p`l/�triw re Unstricted uildin u to 35,000 cu.ft.
D R Restricted 1&2 Family Dwelling
city/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
617417-71y3 I'Ibc•.n..�VJ*"411 CQb►44 1 Insulation
Telephone Email address'' D Demolition
5.2 Registered Home Improvement Contractor(HIC) 172a 3
Itw 4g L Y 7 Expiration
__�'1.(+_� � HIC Registration Number Expiration Date
HIC Compan Name or HIC Registrant Name
No.and Street C17 14 7,7NM3 Email address
SgWwl 011t7V
City/Town,State,ZIP Tele hone
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
159:—
I,as Owner of the subject property,hereby authorize muv D utne,-
to act on my behalf,in all matters relative to work authorized by this building permit application.
Stets PnIA194 I 71mis
Print Owner's Name(Electronic Signature) Date
SECTION 7bt OWNER' 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.
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
wRvw.mass.eov.'oca Information on the Construction Supervisor License can be found at&LA .nmss.=ovE /dns
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 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 Cost"
The Commonwealth of Massochuseus '
r� Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston,Mi102114-2017
www mass gov/dia
Ukrkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FH.ED WITH THE PERMITTING AUTHORITY.
Applicant Information - - Please Print LeElbly
Name(Business/Organization4ndividual): &Aker GG"L S'irvn+{7'�r]
Address: 3y NagI fyi HLL'
City/State/Zip: p l k7d Phone#: " 6l7-Lr17-77tf3
Are you an employer?Check the appropriate box:. Type of project(required):
l.�I am a employer with employees quit and/or part-time). 7. ❑New construction
2.❑I am a sole proprietor or pomnship and have no employees working forme in g, g3lZemodeling
any capacity.[No workers'comp.insurance required.]
9: ❑Demolition
In Ism a homeowner doing all work myself.(No workers'comp.insurance required,)t
10❑Building addition
4.❑Ism a homeowner and will be hiring contractors to conduct all work m my property. twill
ensure that all contractors either have workers'compensation insurance mare sole 1 LE]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have bind the subcon6actom listed on the attached sheet. 13.❑Roof repairs,
These sub-contractors have employees and have workers'comp.mn+mam - -
6.❑We are a corporatim and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.)
-Any applicant that checks box#]muff also fill out the section below showing then workers'competrsatim policy mtormatim.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside connectors must submit a new-affidavit indicating such.
1Contractors that check this box must attached an additional sheet showing the name of the sub-cohtractors and state whether or not those entities have
employees Ifthe sub<onuactors have employees,they must provide their workers'.gomp.policy number.:.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: lft ><!L e"h y,Y+L✓`
Policy#or Self-firs.Lic.#: Expiration Date: "l'J
l l b to
Job Site Address: KU 3Ll�LI!�vt/ City/State/Zip: d 14 7y
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penaltiees ofperjury that the information provided above is&me and correct
Sianature &,_ Date, 711.-
r lS
Phone#• 617-5l7— 7'71 3
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for then employees.
Pursuant to this statute,an employee 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
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an 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."
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 compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(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(s)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 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 returned to the city or town that the application for the penmt 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 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 Investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that must 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"ail 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.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
00000
75.00'
Assess. Map 10
Lot 202 0
in 7.'500 S.F. E
J
°o 0
w its
52 �.
N UISANG FOUNAMON
l,s w I
I
o a
r r
75.00' ,b or
J.
nN y
BELLE�IEW AVE.
qao super°
ZONING DISRTRICT R-1
SETBACK REQUIREMENTS:
FRONT YARD — 15'
SIDE YARD — 10' PLOT PLAN IN SALEM, MA
REAR YARD — 30'
FOR SEAN T. GALLAGHER
70 HER?AGE QANK.•
/ CERTIFY THAT THE FOUNDA770N SHOWN DATE: 11104199 SCNE.• 1' - 20' 1 JOB. vo. 99173
HEREON /S LOCATED ON THE GROUND AS
SHOWN AND CONFORMS TO THE SMACK LANDMARK
REOUIREA/EM5 FOR THE CITY OF S4LEM. ENGINEERING & SURVEYING, INC.
583 CHESTNUT STREET
LYNN, MA 01904
(781) 592-7015
�4 I
I
I
I
i
i
I
I
't3
t i
i
f
Q-IY OF SALEA MASSAML SEM
a
BLUDMDEPARUENr
120 WASHHgGTONSMtEET,3RDFLooR
TkL(978)745-9595
KDOERLEYDRISQ7LL FAX(978)740.9846
MAYOR THoMM ST.PMM
DiREcroRoppuaucpRopER7y/Bu[LDjNGax&momR
Construction Debris Disposa/Affidavit
(required for all demolition and renovation work]
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 5 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 15oA.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
VwZ— �
Signature of applicant
7/►clts
Date