98-100 BRIDGE ST - BP 11-406 Ik The Commonwealth of Massachusetts►. .� Board of Building Regulations and Standards CITY
'Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
!r u0 Nrvirw/lannwr
u Iuilding Permit Application To Cunst 1, Repair, Renovate Or Demolish a
One-or Trvu nrily Dwelling
This Spfion For Official Use Only
Building Perrni N ber Date Applied: /1/O/l .3. delC.)
Signature: tl 1, p
B miuilding Cu si 1160mor of Buildings Date t
SECTION 1:SITE INFORMATION
1.1 Property Address: V 1.2 Assessors Map a Pared Numbers
1.1 a Is this an accepted street? es no Map Number Parcel Number
IJ Zoning Informalloo: 1.4 Property Dimensions:
Zoning District Proposed Uu Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(it)
From Yard Side Yards Raw Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zoo@ Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: — Outside Flood Zone?
Check if es❑ Munlei On site dlaposal system ❑
ZI-OwnerloflitecVr SECTION2: PROPERTY OWNERSHIP'
o ^7
Nome Pri 1) 9 Addross for Service:
'pwwv Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(cbeck oil that apply)
New Construction Existing Building Owner-Occupied O 1 Repairs(s) ❑ I Alleration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Unib_� Other ❑ Speeily:
Brief Description of Proposed Work': r_r , y, // n✓_Ca_ Gr' i,��r iN �r Fi=
�•�, Jar/.A.., / y�Jp/1�J V�iT��O� n� /A//�. /X/rt/rsl. f'hF -!
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Ua@ Only
labor and Materials 7
I. Building S 1. Building Permit Fee:S Indicate how fee is deJlermned:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S 2. Ocher Fen: S
4. Mechanical (ifVAC) S List: '� r�s�
c 3. Mechanical (fire
Suppression) S Total A Fen:S
Check No. _Check Amount: Cash Amount:
6. Total Protect Cost: S ❑Paid in Full O Outstanding Balance Due:
4? % y
SECTION !: CONSTRUCTION SERVICES
5.1 Licensed Constru lion Supervisor(CSI.) �S'_ �SG7 cr (
/, I.icense Numiser Hspintiun Imic
Name of M.• I lot f List l'SL type(u'e below)
7 Fes, z / s f / (,le,, � f Ikscri ion
Address/../�� �� ` U unrestricted 1035,000CU-I'l.
R Restricted 132 Fsmil D%ellin
Sigrwiwre M M Onl
RC Residential Roulin Covering
WS Residential Window and Sidi"
I'eleplwais SF Residemial Staid Fuel 11—in A liance Insallatiun
D Residential Demolition
5.2 Registered Hann Improvement contractor(HIC)
Registrsiion Number
I IIC Company Name or IIIC Registrant Name
Address Expiration Dace
Signalura "fclephurrs
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.is ISL 12S OD
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...........O
SECTION 72:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I as Owner of the subject property hereby
to act on my behalf,in all matters
authorize
relative to work authorized by this building permit application.
Si ore of(Tuner Date
SECTION 7111: OWNERr OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application we true and accurate,to the best of my knowledge and
behalf.
Print Narp�� l 520
y��c`l it.� -
Signature of Owner or Authorized Agent Date
Si umkr the sins and nalties of u
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 Contfaclor(HIC)Program), will ag have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and 1 IO.R1,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.) flabiusble room count
Number of fireplxes Number of bedrooms
Number of bathrooms Number of halt'/balhs
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3
. "Total Project Square Footage"may he substituted for'Tolal Project Cost"
CITY OF SiULEM, U)SSACHUSETTS
• BUII.DLNG DEP*.R'I*%MNT
120 WASPINGTON STREET, P FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
IcStBERLEY DRISCOLL
MAYOR T1iONAs ST.PIERRti
DIRECTOR OF PUBLIC PROPERTY/BUILDIDIG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
II, Building Permit# is issued with the condition that the debris resulting from -
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
-eC A
(name of fa(ility)_
(address of facility)
sign re of permit applica
( I ( 3I d7Jto
date
!a CITY OF SM—EENI, ANSSACHLSETTS
i BL'ILDL\G DEPART1tENT
• i�a'TR']' - 120 WASHINGTON STREET, 3w FLOOR
\ ka,eaa Tm (978) 745-9595
F.mr(978) 740-9846
KI\[BERLSY DRISCOLL THONLkSST.PtFAen
,V1AYOR. DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pfumbero
4 Iicant information Please Print Legibly.
Name(Busiikss,Organizatiomindiivvidual):�('! in rha r/ e -
Address: 0 F�AaM S 4
City/State/Zip: CCA � Yt%6-, 69 1�7: Phone #: :50J--
Are you an employer?Cheek the appropriate boa: Type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
cos to eea full and/or part-time).* have hired the sub-contractors
p y ( P
2I am a sok 7. ❑5z Remodeling
proprietor or partner- listed on the attached sheet. I
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
right of exemption r MGL I If] Plumbing repairs or additions
3.❑ I ys a.(N homeowner doing all work c 6152, '1(4), nd we have no '
myself.(No workers'comp. 412.❑ Roof repairs
insurance required.)t employees. [No workers' 13.❑ Other h.&,t -T),zt Nc
comp. insurance required.]
-Any upplicar 11101 dusky box al main also fill out the section below showing their waken'compensation Pansy information.
'11,"cownus who wltmit this affidavit indicating they me doing all work and then hire outride canimu'tara mtnl suhmit a new airdavit indicating such
:Comroctors that ch vk this box must anached an adtktiomul sheer showing the name of the rub.contractor and their worker'comp.policy information.
fain an employer that is provfding worker'compensadon insurance for my employees. Below is ate policy and job vile
information.
Insurance Company Nome:-_
Policy Jf or Self-ifs. Lic. N: Expiration Date:
Job Site Address: City/State/Zip:
,%usch a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of VIOL c. 152 can lead to the imposition of criminal penalties of a
tine up to SI,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be-furwarded to the Office of
Investigutiuns of the DIA for insurance coverage verification.
[do hereby c erlfy to er the pains mf d naldes of perjury tlrat the information provided above is true and correct
Sion pure ���'��/�/u � ilnr Data: f d 3/ -.I
Phone A Sr`) P- / / - gL- Z
Official use only. Do not write in this area,to be completed by city or town affkiaL
l
City or Town• ___ . . Pcrmidl3ccme# _..__.
Issuing Authority(circle one):
1. Bourd of Ilcalth 2.Building Department 3.Cilyirown Clerk 4. Electrical Inspector 5. Plumbing luspector
6.Other _._ __...___-- _
Contact Person: - ---- - . Phone#:
1
Information and Instructions
Massachusetts GCOeral Laws chapter I j2 requires all employers to provide workers' compensation f6r their employees.
Pkirsuaatt to this simute, an emplererr is defined as "...every pcaxon in the service of another under:airy contract of hire,
capress or Implied,oral or written."
.\n employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more
,)I the torCwmg engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee uI .ar individual,patmership,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 in 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. N,IGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
' onher into any contract for the performance of public work until acceptable evidence of compliurice with the insurance
requirements of this chapter have been piesented to the contracting authority."
Applicants
Plcase fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors) namc(s), address(es)and phone nwmber(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 dale the allidavil. 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 of you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Sclf-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Official
Please be suns that the affidavit is complete and printed legibly. The Department has provided u 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.
Pl;ase be sure to fill in the permitflicense number which will be used as a reference number. In addition,an applicant
that owl submit multiple pernitllicense 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 die 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 atfdavit 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 dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
t he Of-lice of Investigations would like to thank you in advance far your cooperation and Should you have any questions,
please do nut hesitate to give us it call. -
fhe lJcparnncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston. MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-NIASSAFE
Fax N 617-727-7749
www.mas3.gov/dia