37 BOARDMAN ST - BPA-16-527 WIRE SMOKE DETECTORS 2S "= c1K (0q5
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The Commonwealth of Massachusetts PE�GZIGNAL SE d 1Y OF
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Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR e i d Mar 2011
Ih �(� a T�� 0 Y 19
BuildingPermit Application To Construct, Repair,Renova�e Or'Demohsh a
PP P
1 One-or Two-Family Dwelling
This Section For Official Use Only
(
Building Permit Number: Date App•
44.tr.
Building Official(Print Name) ..Signature ' Date
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers
"] [1jt�talzf�M AtJ S 1
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY:OWNERSHIP'
2.1 Owner'of Record: M L
5uwle5
Name(Print) City,State ZIP
v &&.stir"an S 1--
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of UnitsI Other ❑ Specify:
Brief Desciptionof Propose dWorl�: Wire. 16rAj2k¢ P ec+ofs -1'hfd eJ� 7 j u✓ ,tV
icsl9 cc
SECTION C ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined;
❑Standard City/Town Application Fee
2.Electrical $ 1 S-00 ClTotal Project Costa([ter 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fine Su ression) $ Total All Fees:$
-
Cheek ND. Check Amount: Cash Amount:
6.Total Project Cost: $ 1 S&) ❑Paid in Full ❑Outstanding Balance Due:
1 `�—i — 1'l l — S Fs 8 y
SECTION 5: CONSTRUCTION SERVICE
5.1 Construction Supervisor License(CSL) 1 T
1 1 1 I ZI789�
2,%�a rd License Number on Date
Name of CSL Holder •- t' i +r. v u,
List CSL Type(see below)
L/,S-Q
�sfOuG'arl/� Type Description ..
No.and Street
�j 2 U Unrestricted(Buildingsam u el in 000 w.ft.
/'F d�g J� R Restricted 1&2 Famil Dwelling
Cityfrow ,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
`I ( 1 SF Solid Fuel Burning Appliances
�i78' �7/G $S/ 7 VJAi r4f�✓21��C� I Insulation
Telephone Email address W wow .Corn D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP Telephone
SECTION 6:WORI{ERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR$UILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the p ' s and ' s of at all of the information
contained in this application is true and accurate to a ow d understandin .
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.a 142A.Other important information on the HIC Program can be found at
mm.masssov'oca Information on the Construction Supervisor License can be found at www ntass.eov/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 CommonweAth ofAfassachuseAts•
Dep ertt of1i&d rid1Aeetidents
I CongressSovetr Suite1O0
Boston, W 492114 2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contradors/EleeMciam/Plumbas.
TO BE FILED WITH THE EPERAI TlING AUTHORITY.
AnoBcant Plea"Fil tt IeaibN
Name(Bosiness/Orgaoizeti vidoal): R �+ 1 J1�� ✓ E r e 4� (-C
Address: yS 6Yoae1ezn e) s1'
City/State/Zip: O lX o Phone#: CYZS� �IZ9 —SSy 7
Are you en emphryef.�(.1'ck the ppyreprlate boz:
T of
Type project
(rafa red):
1.ffiI mo a mrploye wim .eiepbyees(fill md/orpantime).� 7. ❑New .
2.Qlamesok propri arpartpaahpaoQ have no emplores worl{fitg for mom g, -Qla de;Hgg .
myespamty.[No woken'ems.ionvaoee l _
3.❑Ismahomeox doing as wodc myaeif.[No work=*comp.inviaaoccnigoaed.11 9: ❑Demolition-
4.Qlemabomoow mdwi71bebh*conaaamstocondudanwo(kmmypcopeny. Iwo 10 QBWldirig'add 1.
aamagd falleomadoweiidwhavewkm'compmsaeoniosmaoeearammle I1.01lecb'iealrcpaiBoradditions
propaxtmswM r.,o Oyeee. - 12:tj Plumbing repsirs at Additions
5.Qlamasmenl contmaer aid l lume hfied On m64on iamw IWW cA the attached sheet 13.pRoofrepaira .
3hpe.sub-conVadvahave employees and lave wo&m;'coM*nmamce. - .
6.0weme a mryois6®mdi esoin' havimcmimdlhmrigbaofvwmptioopwMG'Lc. 14.QOtlter. .: _
15$i](4)1 and weLaied'o employoM jNo wmkeis'6MMjL4 sivma regaeedl:
•A�appheaol Poet ehavm6ai t'l moat d11 Maat[ha se..,1 hekw dtbwtng lheh waikas eomp.1 a. pokey as .. .
1 Homeowmvs who submit ea"idaritib�eatmg®eyeia doiag.oa`ork and than h6t outside eeadmetms mpat snbIDaaiuwaffidavitbdicatagsucti
rContraeton mal cbeclithis tics must etlee6ed ao'addidonil almet ebtlirmY as a®ieof�e sub-medaspod sense ivliesoim116usebave .
employees.,ff*csab<4aih bayeemployee4 beymustpbvidatbeu-wmbef mo xpobcS:matia
,raw an )w thal ispmv1ding workers'cotnpet+m*x mswu rce for my esipJvyea. BWaw is thepali7 aadJob aka- .
iaformatlou.
Insurance Company Name
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: Cit1' p:
Attack a copy of the workers'compensation policy dedaradon 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
ip and/or one-year mrisonmtat as wep as civil p�alties m the foam of o STOP WORK ORDER end a fine of up to$25.0.00 a
day egeiost the viohm ..A copy of this stateineat may be forwarded to tine Office oflnvestigatipns of the DIA for roeuiaooe
coverage verification.
4:0—
I do hereby der thepains penahies ofperjm7 that the informationprowedmo ...rs true and correeL
Mga Date:
d /
Phone#
r
wW ass only. Do not write in this area,to be eonpieted by calor town o,,(/iciaL
or Town' Peridt/Ltcem#
ng Authority(circle one):
ard of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
her
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their 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 car other legal entity,employing employees. However the
owner of a dwelling house having not more then three apartments and who resides therein,or the occupant of die
dwelling house of another who employs persons to do maintenance,construction or repair work on sucb dwelling house
or on the grounds or building appurtenant thereto abal]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 s 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 convocia weaM 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 checimrg the boxes that apply to your situation and,if
necessary,supply sub-contactors)name(s),address(es)and phone number(s)along with than 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 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-insuredcomrpanies should enter their
self-insurance license number on the appropriate lime.
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 permit/license number which will be used as a reference number. In addition,an applicant
that met submit multiple permWhcense 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 location 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 firture permits or licenses. A new affidavit must be frilled out each
year.Where a home owner or citizen is obtaining a licence 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. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia r
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