34 BRIGGS ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachuseus State Building Cole, 780 CMR. 7' OF SALEM edition Revised Juomvr
Building Permit Application To Construct, Repair. Re vale Or Demolish a
One-or Tw umily Dwelling
This lion or Official U,4 Only
Building Permit Number: Date Ap ied:
Signature:
Building Commissioner/In lur of Buildi0 Date
SECTION L.WE INFORMATION
lit-/ro R CAI S Address: S% 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning{District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(11)
From 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 O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if es0
SECTION 2: PROPERTY OWNERSHIP'
MSignatum
cord:
Name s dd .�1 pis � sar4 orG 70
Addn:as far Service:SECTION J: DESCRIPTION OF PROPOSED WORK'(check sit that apply)
O Existing Building O Owner-Occupied Repairs(s) ❑ 1 Alteration(s) O 1 Addition O
Demolition ❑ 1 Accessory Bldg. O Number of Unila iL Other ❑ Specily:
Brief escription of Proposed Work-, >/ A c
VaN
W
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omelal Use Only
Labor and Materials
1. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard CirylTown Application Fee
2. Electrical s j OU ❑TotaVroject Cost'I llem 6).x multiplier x
J. Plumbing I S 48SLO 1 2. Other'Fees: S
4. Mechanical (IIVAC) S List: C��2ae,Cb
9. Mechanical (Fire S
So «ssion Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
& r �Fh1�C'Y'f License Number I:spintion Date
Name of CSI.-I lul er List CSL Type Isce below)
�„ S' ( r I Descri ion
t
\ U I Unrestricted to 35,000 Cu.Ft.
` R Restricted Id2 Family Dwellin
S ignumre M Masonry Only
RC Residential Routing Coverin
NlepMme WS Residential Window cowl Sidin
SF I Residential Solid Fuel Burning Appliame Installation
D I Residential Demolition
S.2 Regtsfered Home Improvement Contractor(HIC) / 2
(rE tjL� ?il.iae- 1-1- Number
Number
Nam I IIC Company Na or f IIC Rc istrani Name
-6aMr A-S A 1 IZ
Address ---
_tprntion Date
Signature 'relephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. IS3.f 23C(6))
Workers Compensation Insurance of (davit must be completed and submitted with this application. Failure to provide
this afftdsvit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , 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.
Simmurse of(Tuner Dote
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
�tl�at
-�C W ,as Owner or Authorized Agent hereby declare
the statements and information on the foregoing application are true and accurate,to the bat of my knowledge and
behalf.
(,e �✓�
Print NamU24 'AJ
signstoij orOwner arAulh Agent Date
iSianed under this:pains and penalties of 'u
NOTES:
An Owner who obtains a building permit to do his/her own work, or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will Og have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and
rConstruction
Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and 110.R3,respectively.
2 When substantial work is planned,provide theJ' (formation below:
Tula( floors area ISq. Ft.) / — t L''� (including garage, finished basement/artics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count 3
Number of fireplaces I Number of bedrooms
Number of bathrooms / Number ofhalf/baths
Type of healing system Number of decks/porches
T)peof cooling system. Enclosed Open
). "Total Project Square Footage"maybe substituted for"Tolal Project Cost"
CITY OF SALEM
� , 1r PUBLIC PROPRERTY
DEPARTMENT
,MI K:Py:)KMR-11.
N ksd nt 12C.WA\HIM.tU\S'I'aEL-T * SAL tilt,MASSACI n iL ISO O1')7^.
Ti,i.;978-745-9595 • P.tx: 978.740--9846
Yorkers' Compensation Insurance Affidavit: Builders/ContractorsiEIectricians/Flu mbers
t tiicant Information Please Print Lecibly
r
Nafnt: l0udncsslOr,�,anirarintt/lndly uluab: " �t�" bt / 14'N C H
Addre,ti: (92 (-nw— _ V
CityState;%i(t N� 01�7— Phoneii:
Apra %vuu an canployer' Check the appropriate box: Type orpruject(required):
1.el ant a employer with_�_ 4. ❑ 1 am a ouneral contractor and l 6. ❑ New construction
employees(full and/or part-tine) have hired the sub-contractors 7. 0 Remodeling
?❑ I am a sole proprietor or partner-
listed on the attached sheet. :
ship and have no umpluyces These sub-contractors have 8. ❑ Demolition
working for me in any capacity. worker's' comp. Insurance. 9. ❑ Building addition
I No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I ❑m a homeowner doing all work S exent li P right of per MOL I I.❑ Plumbing repairs or additions
Pon '
myself. LKo workers' comp. c. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.) f employees. LKo workers' 13.0 Other
comp. insurance required.] -
'Ally:yphcant that chucks box el muss also rill om the seniun Iwluw showing Iheir wurkus'cumpen>wion policy inllamalium
' I luma,wners whu submit this affidavit indicating Ihcy are doing all work and Then hire outside cunVaetom must suhmit a new afr:,lil l indi"all;such.
-Cuntrwn,n Ihul check this box must atlachdd:m additional stuxt shuwiny the name of the sub<ontractom and Ihc,r vorken,'comp.policy infutmatiun.
/out un employer that ix providing)vorkers'cwarprn.vatioll insurance jar uty employees. Below is the policy and job site
iojormurion.
Insurance Company N:ine: / —...__ - ..... ..._ -----
Pnlicv a or Self-ins. Lic. 13: (ve�lt�,']Saoaoc�j.. _- ------- Expiration Date, S I I
Job site Address:
3� ��' G-G-s City/slate/"Lip: 5-4 k2I
Attach at 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.`sIGL c. 152 can lead to the imposition of criminal penalties of a
tine up a)SI.500.00 and/or one-year imprisomncnt, as well as civil penalties in the furor of a STOP WORK ORDER and a fine
Of up m S250.00 a day against lilt violator. Ile advised that a copy of this stutcinunt may be Ibrwarded to the Office of
Invcsngations ul dm DIA for insurance coveragu verification.
l du herch V
ify under d ine'and prnoltics•ufperjury that the injurinution provided above r trite and correct.
Sil�nuulr" _ - _ Dat•' ��� � �
D[/ic•iul rise only. Do not write in this area, to be completed by city or tolvn ajjic•iul,
Citv or Town: -
issuing whorily(circle one):
1. Iluard of Health 2. Building Department 3. City fono Clerk 4. Liectrical Inspector 5. Plumbing Inspector
6. 01her —_ -
Contact l'cnun: _ . ._.. Phoned:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fix 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 tither legal entity,or any two or more
f the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual, parmership,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."
N,1GL 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. NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomwnce of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) nama(s), address(es)and phone number(s)along with their certiricate(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 confimtation of insurance coverage. Also be sure to sign and duce the affidavit. The affidavit should
he 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 Offleials
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.cure to fill in the penmitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/ icemw 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 the city or town may be provided to the
applicant;s 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 burn leaves etc.)said person is NOT required to complete this affidavit.
I he Otlice of Investigations would like to thank you in advance fur your cooperation and should you lwve:my questions,
please do not hesitate to give us a call.
The Deparnnenl's address, telephone and fax 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
i2cvised ;__'G-US
Fax #617-727-7749
www.mass.gov/dia
s. CITY OF SALEM
PUBLIC PROPRERTY
DEPAR"CVIENT
•,I ,. : L'CU r . ,.\il ,t. \l.\„\r
Construction Debris Disposal Affidavit
(required lix all demolition :utd renovation work)
In accurdance %%ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H is issued with the condition that the debris resultin.v from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
11 L S 150A.
The debris will be transported by:
(name(it hauler)
A he debris will be disposed ot'in
(nauvr of facility)
laddrcs.ul'lacllity)
,wiatme of p:nn .ytpllcanl -
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