25-27 BRIGGS ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts FOR
t Board of Building Regulations and Standards MLINIt'IP:UJIN'
t Massachusetts State Building Code. 780 CMR, 7 edition USF
p, Ro mcd Auunu.c
Building Permit Application To Construct, Repair, Renovate Or Demolish a i iH y
One-or Two-Fanti1v Dwelling
This Section For Official Use Only
\ Building Permit Number: Date Applied:
/per_
Signature:
Building Commissioner/ Inspe rut Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro rt,Y %ddr�yy �/ 1.2 Assessors Map & Parcel Numbers
/ Yn'tG4S 71—/`-c'�"
Ma Number Parcel Number
I.1a Is this an accepted street?yes ( no_ P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq A) Frontage(11)
1.5 Building Setbacks(it)
Front Yard Side Yards - Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40. S. M) -1-.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP' C
2. wne. r of R d•R h ¢t.c-e t
... _ ► �
M
Name r t) , Address for Service: /
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition [I Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work=: P
SECTION 4: ESTIMATED CONSTRUCTION COSTS
ffl$ 0rV_L2
Olflcial Use Only
Item
I. Building Permit Fee: $ Indicate how fee is determined:
1. Building ❑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 $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount.
6. Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance
DDue:
S
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 8/6SI /3 j p
�P ✓fP �///� License Number Enpiratiun air
Narf,epl CSL- Hi er,
LL�� /�M�G4t•,f 5,f> �a�/At —414List CSL Type(see hcluw)
>JJn /Gw Type Description
U I Unrestricted(up to 35.000 Cu. Ft.) �
—" R I Restricted 1&2 Family Dwelling
Signature M I Masonry Only
Y �
RC Rrsidential RootingCovcrin
Telephone - VS Wes
iJrntial Window and Siding
SF Residential Solid Fuel Burnet A pliuncc liwAlauon
D Residential Demolition
5. Reg tered Home Improvement Contractor(HIC)
;�,� rctsh car,iak /36'Sy9
HIC p �`}ame or HIC ate istrant�Vatne Registration Number -
/Y'/ p/ fneeJ $F g �peil
Addre
rGt�Z 7��SYJzr �� xpiration Date
Signature Telephone ^
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 at provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... O
SECTION 7n: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT
�i 1, W ' PL�- v Br�_ — as Owner of the subject property hereby
authorize % l-f to act on my behalf, in all matters
relative to work autho this buildi g permit application.
Z ,O �
SignaturecifOwn0f Y - Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I. 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 Name
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 110.116 and 110.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemendattics, 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 healing system Number of decks/porches
Type of cowling system Enclosed Open
3. 'Total Project Square Footage" may be substituted for"Total Project Cost"
=' CITY OF SALEM
PUBLIC PROPRERTY
3 �r
1 r' DEPARTMENT
:-!V Itf aI P 1' llKlit �`I I
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I'f1: 1)178-'i;-959j ♦ 1�.ts: 9,8-74}7846
Workers' Compensation Insurance :kffida%'it: Builders/Contractors/Electricians/Plumbers
% t nlicant Information Please Print Legibly
Name tlfusuicss dky C04 S�YGcCt�r 'h rile
\sldress:
City:State/Zip: degjj�,?� /yl/e 1i/ a? Phone
Are you an cmployerT Check the appropriate box: Type of project(required):
' I.❑ I am a employer with
4. ❑ I am a general contractor and 1 6. ❑ New construction "
ni lu ees(full and/or art-time).' have hired the sub-contractors
2.gel am a sole proprietor or partner-
P y p listed on the attached sheet. 7. remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. - workers' comp. insurance. y. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption 3.El 1 am a homeowner doing all work per MGL 1 l.❑ Plumbing repairs or additions
g P
myself. (No workers' comp. c. 152, $1(4), and we have no 12.0 Roof repairs
insurance required.) t employees. [No workers' 13.0 Other
comp. insurance required.]
' •.\oy applicant that checks bun pl must also till out the section below showing their workers'compensation policy information.
I llumeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
:Contracaas that check this box must attached an additional sheet showing the name of the sub-cuntractors and their workers'comp.policy information.
l con an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
htsurance Company Name:
Policy k or Self-ins. Lic. 4: Expiration Date:
Job Site Address: City/State/Zip:
:%ttach 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 bIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 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 S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Inecsti�,ations of the DIA for insurance coverage vcrification. -
h do hereby certi�ft under the pains and peena�kiiees of perjury that the infornatiou provided above is/true and rorrerL
li 11 tau /fit � \ 4i / rl^.5fi�,� Date: Jr/w7/QS�
Phone '? /'7y,�—. ;l')
011icial toe Daly. no not write in this area, nt be completed by city or town official
Cily or Town: —_ _--- —— Pennil/License --
Issuing .%uthorily (circle tine):
I. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:___-- Phone q:__
Information and Instructions
S l assaelmsens General Laws Chapter I52 requires all entp Iuy ens to provide workers' compensation for their employees.
I'w:suant to this statute, in emploree is dctined as "...cverv, person in the service of another under any contract of hire,
ryncss or implied, oral or written.-
An engdo.Ver is defined as "an indi% dual. partnership. association, corporation or other legal entity. or any two or more
„t the tiregoing engaged in ajuint enterprise, and including the legal representatic-es of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
net of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of:mother who employs persons to du maintenance, construction or repair work on such dwelling house
M on the grounds or building appurtenant thereto Shall not because of such employ menu be deemed nm be an employer."
\t(iL chapter 152, s2SC(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 conunonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, NIGL chapter 152, 325C(7)star: "No ther the cununomvwlth 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." - V
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) 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 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pennit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permitilicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"lob 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 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 dog license or permit to bur leaves ctc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du nor hesitate to give us a call.
File Department's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia