61 BUTLER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
4 Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
O Fanily Dwelling Ext 118
This Sec on For Official Use Only
Building Permit Num Date Applied: 1 %9 -
Signature: 10 , Q ` 0 t7
Building Comm ion r/ s of Buildings Date
SECTION 1: SITE INFORMATION
1.1 7per AddrFs� 1.2 Assessors Map& Parcel Numbers
I.1a Is this an accepted street?yes no Map Number Parcel Number
w
13 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.l jrnert of cord:
),,r, y RLG��S�P
N _ Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': i r - Q-
eX)-3 --
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 5'D r po 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: S
Check No.32S Check Amount: Cash Amount:
6.Total Project Cost: $ �g�,po aid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) &2 2 3
U
6np ca P. �9 n T License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
G Type Description
Ad U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
SK7� e ^_ " Q M Mason Only
i _
� O RC Residential Roofing Covering
Telephone WS Residential Window and Sidine
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
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 .......... G}'- No........... ❑
SECTION 7a: 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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 I IO.R6 and I IO.RS, 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
�.� DEPART"vIENT
,I' I, I I.. �\ \'.II:\I.. ".1:.`IIr � 1\II \I. �1 \. \I •. I . II
'i',Y 'J. '1i J'�
i
Construction Debris Disposal Allidavit
(l L:gttllYd lorall demolition :urd reno%.ution work)
In accordance itll the sixth edition of the State Building Code, 780 CNIR section I 11 .5
Debris, and the provisions of IGL c 40, S 54;
Building Permit ft 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 V UL c
I l l_ S 150A.
f
The debris WiII be transported by: `
01-,)nc
(name of IIJMt 'I -
I he debris will be disposed of in
t uamr ul I'aclhly) -
Iaddre.. i I Inc I I I IVl
.I Ic -If p:lnn[ .Ipp heart
Ia1C
CITY OF SALEM
UZI
�; PUBLIC PROPRERTY
DEPARTMENT
,
.I161 n:I\':)nIA 0nI
\I gn 12L Sc.[t:•I' • SA I F.M.M-WSU.III ill n3197-^
778-7.t5-95'n5 If 1:%X. 978-7+CC91W,
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
tlicant Information Please Printtevibly
Name Inuctnesys�rgsmrxtioNlndty lduall: l Tt�A��nn � v L—y'�`� f
Address:
City,State,Z (2 Phonei': �� d /� yj
r
Are)nu an employer:' Check the appropria(e box: 'f)pt urproject (required):
1.❑ 1 sun a emplo)cr with 4. ❑ 1 :an a general contractor and 1 G. ❑ New construction
employ sb
ees(full in 'or part-time).• have hired the sub-contractors
2.[ I out a sole proprietor partner-
listed on the attached sheet. 7. ❑ Remodeling
ship and haveve noo employees
loo yees These sub-contractors have S. ❑ Demolition _
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
INo workers'comp. insurance 5. ❑ We are it corporation and its
I officers have exercised their 10.❑ Electrical repairs or additions
required.]
right of exemption per MGL I I.❑ Plumbing repairs or additions
3.❑ I ❑tot a homeowner doing all work c sl 52, i 1(4),a nd s e have no
myself. iNo workers' comp. s12.❑ Ruufrcpatrs
Insurance required.) r anployccs. ( '
No workers 13.❑ Other
co np. insurance required.) I I -
-Nat .,,phcsna that checks box of must also fill oils she sentau I.vluw:hewing their wuroxii cumpens:aioo policy in liartutiun.
' I rme,%mrs whu vubmiI this of idaviI indicating they ate doing all work and.then him",side caurxmrs must.uhmit a new afrd.vil mdiulmg.rich.
-C'omrxLLgn that Jwck this box must ariaehed an add,Iiun,I Awvt.hawing sha name of nio sub-contracsors and then workers'rump.policy mfurmanun.
/sun an employer that is providing workers'cutnpeusalion insurance fur sty employees. Below is the policy urns!jab.rite
iufurawtion.
Insurance Company vlame: - ...
Pulicv is or Sclf-ins. Lic. >_: __--_. . __ Expiration Date:
Job Site Address: ___. City:Slatei Zip:
.\ttuch a copy of the workers' cmnpensation policy declaration page (showing; file policy number and expiration date). II
failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51.500.00 and/or one-year imprisamnunt, as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to S250.00 a day ❑gains) tilt violator. lie advised that a copy of this statement may be forwarded to the Office of
Inc.stl,auuns of the DIA for inimarcc coverage tcrificanon.
Ilia hervhy e✓rtifr under the pains uhd penuhicx of perjury that the hifunaation provided above is true and correct.
()flit jai rise anly. Do tool write in this area, to be curuylcred by city or ton in official.
City or Tnw•n: _--_ Permit/License q_
Issuing Authurity (circle onc):
1. Iloard of llvalih 2. Iluilding Department 3. Cit)A"oau Clerk 4. L•'leclrical Inspector i, Plumbing Inrpeewr
b. Other _.
Catalan Pcnontc -- __ Phone M:
Information and Instructions
m n5sachusetts Gcncral Laws chapter 152 requires all engtlo)ers to provide workers' compensation for their enhploytes.
Pursuant to this statute, an emplorre is defined as"...every person in the service of another under any contract of hire,
evpress or implied, oral ar written."
An employer is defined is "an individual, partnership, association,corporation or tither legal entity, or any two or more
,it the t0regoing engaged in a Joint enterprise, and including the legal representatives of a deceased employer,or the
recetv'er or trustee tit an individual, paitnership,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 152, §25C(6) also stares 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, g25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of puhlic work until acceptable evidence otconipliance 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 nuniber(s)along with their certificates)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 confirniatiun 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 are required to obtain a workers'
compensation policy,please call the Department at die number listed below. Sclf-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
of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Phase be Sitrc to till in the pennit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pennit,'liceitse 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 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 dug license Or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he i)(lice of luvcsrigatiuhs would lire to thank you in advance fur your cooperation and should you have .my questions,
please do not hesitate to give us a call.
The Mparnncot's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofte of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
as i.ed 5- U-u5 www.mass.gov/dia