150R BRIDGE ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
Board of Building Regulations and Standards - Town of
Massachusetts State Building Code, 780 CMR, 71b edition Building Dept
C�\ Building Permit Application To Construct, Repair, Renovate Or Demolish a *k*dmb*Ma
One- or Two-Fmnilp Dwelling
Building Permit Numbe/ This Section For Official Use Only
Date Applied:
�/
Signature: 'Gr0 �ala9io�
Building Commissioner I spector of Buildings Date
>? SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
].Is Is this an accepted street?yes-sl/--- no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(tt)
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?
Check ifyes❑ Municipal❑ On site disposal system ❑
ION 2: PROPERTY OWNERSHIP'
2.1 O•�wn�er'of Record:
76 C- ZAi nl-,�.rNS-OJ
Name(Print) Address for Service:
�Q e,xx/ � 7YS - 573 5'
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSES WORK'(check all that apply)
New Constmetion❑ Existing Building❑ Owner-Occupied Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
escnPtion of Propo ed Work':
��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
_ ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: �/)
5. Mechanical (Fire $
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
. Total Project Cost: $'?� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) _ O
License Number E.pirau n Dale
Npme of C SL- 1?l r
List CSL Type(see below) >J
Description
A ess T U Unrestricted u to 35,000 Co. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
ekazK=fib'— '��S \ RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
Registe ome Improvement Contractor(HIC)
M `n
HIC Co y N me or HIC R istrant Name Registration Number
ress Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 AGE/N�Ty OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/
I. r cat `-_ t.�/ , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this buil ing permit application.
Si nature of - Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 �j�.%y� L° f-�,�, —/fpv ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Nat
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
NOTES:
I. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and 110.115, 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/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"
CITY OF SALEM
KV
l PUBLIC PROPRERTY
- 0 DEPARTMENT
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'..1�I I::RI I:Y Dot ISCI-IA
M A t'l IR 120 W nsru.NG I0.N S I RELT •SA LEM,MASSA011-s1:'I I S 01970
Ti,i.:978-745-9595 • Fax:978-740-9.446
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers
-% 3 ylicant Information Please Print Le ibly
Blaine o3usincssior-anirttion/indly idua0:
Address:-l-I QCoC\ ,C-
City'Starei%i)r�`a�r��
Are you an employer!Check the appropriate box: 'Type of project(required):
4. ❑ I ain a general contractor and[
1.❑ I am a employer with G. ❑ New construction
mtlo -ces full undlur art-note).` have hired the sub-contractors
�/� l ) ( p" 7. ❑ Retnodeling
2.UV 1 ant a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
Ike workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.[] Plumbing repairs or additions
myself. [No workers' comp. C. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] r employees. [No workers' 13.0 Other
comp. insurance required.]
-!1ny:applicant ibut decks box it I must also till out the wction Ir:low showing their workus'cumpensation policy inl orm,aivic
'I lomcuwners who xdmtin this affidavit indicating they am doing all work and then hire W11W<comrK(ors Must suhmit a new al'ridavit indiutins oeh. -
�C'ontndur.that chuck this box motor auachcol an additional shut showing the name of the sub.ontractors and(heir workers'conhp.policy information.
I ant ua employer that ie providing workers'compensation irssurrutce jot•my einplo),eec. Below is the pulicy and job.cite
irrfurmution.
Insurance Company Name: --."_.._
Pulicv Sur Self-ins. Lie. #: ___.... ..-.. .._.__.._..- Expiration Date:
Job Site Address: City/State/Zip:
Attach it 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`IGL c. 152 can lead to the imposition of criminal penalties of a
tine up trt S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. 13c advised that a copy of this statement may be forwarded so the Office of
In%csti.gations ul'Lhc MA for insurance covcragc ccrification.
I du hereby certify and�`-7hhe emirs and penalties ofperjury that the infunnation provided above is true and correct.
SiL, t nor- ( `� — , D J
ate• NCO\\ I o-S
r� �
Official ruse unly. Do not sprite in this area,to be completed by city or town official
Cilv or Town: .- Pcrmit/l.icense X—--_._ _
Issuing Aul horily (circle one):
1. Board of Health 2. Building Department 3.Cit%7town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Persou:. _...._ -- _.--. Phone tit:
Information and Instructions
:v4assadnsetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this Statute, in errtplut•ee 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 ;n a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of:m 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."
.%IGL chapter M, §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, IviGL 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
he retunled 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 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 till out in the event the Office of Investigations has to contact you regarding the applicant. -
I'lease be Sure to till ;n the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennio9icense 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 ;n (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 tilled 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 bun leaves etc.)said person is NOT required to complete this affidavit.
I he c)ilice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised >-26-05
Fax #617-727-7749
www.mass.gov/tiia