19 BROAD ST - BUILDING INSPECTION The Commonwealth of Massachusetts
r� A Board of Building Regulations and Standards Town of
V k' Massachusetts State Building Code, 780 CMR, 7"edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tiro-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
�4( \ Signature: �h-�
Cmmt
Building ssioner/Inspector of Buildings Dale �
'�---
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.l a Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R) �,
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;q Private❑ Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record:
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building( Owner-Occupied Ot Repairs(s) 9Alteration(s) Addition ❑
Demolition 9 Accessory Bldg. ❑ Number ofUnits / Other ❑ Specify:
Brief Description of Proposed Work':�jr-yt��i/ (r— .CF.✓'J,(,�. /rl 2/{,CtJ //,p-s3i h;r.
/�rs�Ji�/lv�lr l��r�sfi�? fig iwir�/ c JPlJv�7e u( �i f1� iw
cH w.0 — ./
�/T�tO LU
SECTION 4:iSTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OlTicial Use Only
Labor and Materials y
1. Building $ D �� 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
��O ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ vp 6) 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $ 0+
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S oo O ❑ Paid in Full ❑ Outstanding Balance Due:
7
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) e I/ 7 / �D a 5 a0/0
License<Number Expiration ate
N.4me of CSL-Hglder t List CSL Type(see below) �✓
'y �� _ Type
Description
Addres's U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signatur po / �7 M Mason Only
Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) /f32�JCY
HIC Company Name or HIC Registrant Name
Registration Number
/DA 5- 2 0l O
Address Expiration 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 to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........16, No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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. `
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
assQtistctrr-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.
o f 1 ,— C--kj z-
Print Name - /A? Z6
Signature of Owner u on d Agent Date z
Signed under the pans and penalties of er 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 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 I O.R6 and I I O.R5, 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
PUBLIC PROPRERTY
DEPARTMENT
Mf1\' 1MHl 141
tit w,w Mt II: W,+,tu Mi laN S I:ILL r e SAt l X4.MANS".III it I I\01`/7�
I'r.t. 978-713-93'15 a hsx 978-74"'t846
Workers' Compensation insurance :%flidasit: Builders/Contractors/Electricians/Plumbers
gi t rliaant Information / Please Print Legihly
NamcUiu.uw stir amratinNlndtsufual): i�/3r21 �(/` 3tscJS"
Addross: /4/4/city,Stage,Zip- �n/��� �� I'hunrN: 27d — Y&C —a9f1L—
.tire you an employer? Check the appropriate box: "Type of project (required):
1.❑ 1 all,a employer with 4. ❑ 1 ang a guncral contractor and 1 6. ❑ new construction
tan iloyces lull antL'ur art-tittle).• have hired the tuh-contracture
I (" p 7. Z Remodeling
2.XI ;un a tole proprietor or partner- listed on the:inachcd sheet. '-
ship and have no employees These tub-contractors have B. ❑ Dernolition
working for me in any capacity. workers' comp. Insurance. q, ❑ Building addition
No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
I required.] officers have exercised their
right of excnt tion per htGL 1 I.❑ Plumbing repairs or additions
3.❑ I ant i hnmuowrke doing all work c 5152, s 1(4),and sP have no myself. IKo workers' comp. b12.❑ Ruuf rcpain
insurance required.j r unployecs. IKo workers' 13.0 Uglier
comp. insurance required.)
-4�p yplteant thus checks box flI MosY:deu I11Pum the`el""lwtuw shuwina their wurkcui cumpcn i iuo Iwlicy iuriirmation-
' I lam.uwrwn whu uabnlit this affidavit indicu ana Ihcy am duina wor
k rk acid then hire uutside curur:telom must submit a new All vil indicauna sash.
4'ontra.wr,that t.hcclr that box m,wi atiwhcxl an aediti„nal Meet.huwina the name of this sub-conu actors and their wurken'comp.pnhcy mrurmation,
lain an employer that is pro vidirir workers'cumpensntion insurance fur troy etopluyecg. Be/ary is the pulicy and job sari
iufvrnwtion. I r
Ir.,urancc Company Vame: /+�f _._ C
• ��2t7� —-- --'—
1'olicv 4 or Sclf-ins. Lic. it: h z7 U R 75_56/7 I96.. Expirauun Date:
Job Site Address: �� �/fi� s�--- C1ty;StataZlp: .5,7, /ftl. 011;�O
.tillach it copy of the workers' compensation policy declaration page (showing the policy mmnbcr and expiration date).
Failure to sccun:coverage as required under SCL(iun 25A ul'.%IGL c. 152 can lead to the imposition of criminal penalties of a
tint up to 51.500.00 and/ur une-year imprisonincnt, us %cell as civil penolucs in the furm of a STOP WORK ORDER and a fine
orup to S250.00 it day againsl dle violator. lie advised that a copy of this slateincnl may be !'urwarded to the 011ice of
Ian.>ti;amrm uY the DLti :or msuracwx coscragu seriticauon.
/Ju hrn•hy c.rtifr roofer der Brains r _')Iettu/tia•s of perjury that the infurinurion provided above is true and correct.
ntd
U/jiriul ase oily. Do not write in this area, to be tuuipleted by city or tolvn ojJitial.
('iiv or fovvn: __ Pcrmit/I.iccnxc _
Issuing;.tiulhurily (circle one):
I. Hoard of Ile:dih 2. molding i)epartancnl ). I INA'o+sn Clerk 4. L•'Iectricld Inspector 5. Plunibingl Inspector
6. 01 her - -.
ContactPcrson: .. _- Ilhone4:
Information and Instructions
1.1:usadm>cus General Laws chapter I i2 requires all employers to provide workers' compensation for their employces. _
Purmiant to this .statute, an empooree is defined as "._every person in the service of another under.my contract of hire,
c apress or iinplied, oral or written."
An employer n defined as "an individual, partnership, associatiou, corporation or tither legal entity,or any two or more _
art the t;regoing engaged Lit a)onnt enterprise. and including the legal representatives of a deceased emplu)er, or the
recetver Or truotee ut .m individual, pwiricrship, association or other legal cnnty,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, cunstruction 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 152, $25C(6) also states that "every state or locai 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 "Ito has not produced acceptable evidence of compliance with the insurance coverage required."
Additiunally, v1GL 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 fill 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 Depurtment of Industrial
Accidents for confimnalion 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
I ndustrial Accidents. Should you have any questions regarding the law or if you arcrequired 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
orthe 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 pennil/license number which will be used as a reference number. In addition,an applicant
than must submit multiple pennitilicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and tinder"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 as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must he 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lic i)[lice of hlvesligationS wUuld line io thank )'ou in advance fur your cooperation and should you have:my 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 lovestigsdans
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPAIZT'vtENT
I'; A XY 11%, IN S 19I:1 T 0 SA l I V, \L\ i\i
Construction Debris Disposal Affidavit
(reiluired for all demolition and renovation work)
In accordance %�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 # is issued with the condition that the debris resulting from
this work shall be disposed of in it properly licensed waste disposal lacility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(name of hauler)
'I he debris will bedisposed of in
(name ut lacility)
Inddress of facililvl
igua /pcnnit/:ppligcant
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