20 CALABRESE ST - BUILDING INSPECTION , e
The Commonwealth of Massachusetts
Board of*Building Regulations and Standards CITY
y j Massachusetts State Building Code, 780 CMR, 7In edition tIF SALF.M
ry/ Revised Joinsor•
yl Building Permit Application To Construct, Repair, Renovate Or Demolish a ). 2(xAV
11 One-or Two-Fumily Dwelling
This Sect' n For Official Use Only
Building Permit Number: Date Applied:
Signature:
WIT
Building C mtss N I s uildinlp Date
SECTION 1:SITE INFORMATION
I.I Property Address: 1.2 Assessors Map& Parcel Numbers
i JO �A.I�t.O.E'�.sr-=
I.l a Is this an accepted street?yes ono Map Number Panel Number
IJ Zoning Information: IA Property Dimensions:
Zoning District Proposed Use La Am(sq B) Fromage(11)
1.5 Building Setbacks(R)
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
Cheek if ycsC3
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerr of Record:
/lam//cN�t�L Oct GGE:T� '-2C <7194 B 2 E ST
Nome(Print) Address for Service:
t
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Unis_ Other O Specify,
Brief Description of Proposed Work':
PEFS�Ii�� Tzc.eir SrRi2S .49.rJbi.[7G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCISI Use Only
Labor and Materials
1. Building Is 11. Building Permit Fee:S Indicate how fee is determined:
2. Electrical $ O Standard City/Town Application Fee
O Total Project Cost(Item 6)x multiplier x
J. Plumbing S 2. Other Fen: S
4. Mechanical (i1VAC) S List:
S. Mechanical (Fire S
Suppression) Total All Fees:S
6. Total Protect Cost: S`c—CD r Check No. Check Amount: Cash Amount:
CO 0 Paid in Full 0 Outstanding Balance Due:
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS /P�7oZ //`/p` 20<(
License Number Expiration Date
None of CSI.-l lulder. 5., List C'SL Type(sce below)
LIJ.LG.soAJ r I Description
Addre 175 U Unresricted(up to 35.000 Cu.Ft.
R Restricted 1&2 Family Uweltin
. tgnature M Masonry Only
`�7f3—7f-S —al RC Residential Rooting Covering
NlepMme WS Residential Window and Sidin
SF Residential Solid Fuel Burning A Rance Installation
D Residentid Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Nu :::
mber
Address Expiration Date
Signature 'relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 23C(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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENTO C RACTOg PP ES FOR BUILDING PERMIT
C/ 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.
Simnsturc of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature orOwner or Authorized Agent Date
ri.
jAnOwncr
the ains and penalties or perjury)
NOTES:
who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
stered in the Home Improvement Conractor(HIC)Program). will rip,(have access to the arbitration
or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and 110.115.respectively.
? 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 healing system Number of decks/porches
Typeof cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
„= CITY OF SALEM
*, PUBLIC PROPRERTY
DEPARTMENT
:J]n;:at ISY Uk1iCVLL
%I.%)oa 120 WASHING I ON S'rtcetn' • SALEM.MASS MA a-SE LISO 1970
'fhL:978-745-9595 if P:vx:978.74^•9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A Iplicant information }q `- Please Print Leeiblv
Nam A e tnucincss Or�anintion lndivi iuutl: FC6- DEL 0rB
Address:
cityistate zip: O lQ 7Z) Phone
Are you an employer?Check the:appropriate box: 'Type of project(required):
1 ❑ 1 am a employer with 4. ❑ 1 inn a general contractor and 1 6. ❑ New construction
employees full and/or art-tints).• have hired the sub-contractors
( P 7. ❑ Remodeling
2.❑ 1 ant a sole proprietor or partner- listed on the attached sheet. :
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9• [:] Building addition
N orkers' Comp. insurance S. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
gl11iL'd� Ot�}ICCfS have extt'Clxcd their
3.Vi am a homeowner doing all work right of exemption per MG], I L❑ plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. LNo workers' 13.❑ Other
comp. insurance required.)
'Any;yllitcant dial checks boa BI must alsu lill out the section buluw showing ihcir workers'cumpennaion pulicy infurmation.
r i lomeowners whu submit this affidavit indicating they are doing all work and then him outside contractors m¢tl euhmii a new affidavit indicting such.
�(,rntncnus that check this box must attached on additional shear showing the nan)c of the sub.contractors and their workers'comp.policy information.
I our an employer that is providing workers'compensation insurance jar my ernpinyeLm Below is dre policy and job.site
infurrnatian.
Insurance Company Naihe: ........ .... . ... . .......___..._—..---..-----
Policy is or Self-ins. Lie. >s: -._.-.._.._. Expiration Date:
Job Site Address: City/State/Zip:
Attach it copy of the workers' compensation policy declaration page(showing the policy nutuber and expiration date).
I;ailurc to secure coveruge as required under Secliun 25A of NIGL e. 152 can lead to the imposition of criminal penalties of a
tint up to 51.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to 5250.00 a day against the violator. lie advised that a«)py of this statement may be forwarded to the Office of
Investigations ul'the DIA for insurance coverage atritieation.
I da hereby certify tinder the pains and penid ies of perjury that the information provided above is true and correct.
Sienauhre: -__-.- Date'
Phurc 3:
official use uuly. Do nor write in rhis area, to be cofurpleted by city or town affic•ial.
Cityor'fown: . ._ Permit/I.iccnsex_---_-
Issuing Authority (circle one):
1. Board of health 2. nuiidin:; Department 3. Citv7rowu Clerk 4. Electrical Inspector 5. Plumbing; Inspector
6.Oltier --- _
ConlaCl Person: -__-_ Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplgree 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 in 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."
MGL 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, MGL 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 nunrber(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 OfOcials
Please he 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 nut in the event the Office of Investigations has to contact you regarding the applicant.
Please be Slue to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitflicense 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 its 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l'hc Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do nut hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
01111ce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
� S
r PUBLIC PROPRERTY
` -' DEPARTMENT
oN S I; I:I'T • SA I I M. %I.\tip, !fit ;l I .
978.745.9595 • 1'yx: 978-174---984(i
Construction Debris Disposal Affidavit
(required Ibr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it - _ is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I It. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of per t applicant
date - —