0002 CEDARVIEW ST - BPA-09-158 Y
OI The Conunonwealth of Massachusetts
e)
Hoard of Building Regulations and Standards FIZ NII'NICIP.\I.fll
Massachusetts State Building Code. 730 CMR. 7"e edition I,til, I
Building Permit Application To CotlslrLICL Repair. Reno\ate Or Demolish a Rrrisr,/lmm,ur
One- or Tov-Fr u crlling 'M)5
This Sec in For Of -vial Use Only
Building Permit N tuber: ate Ap lied: _
Signature: 0 ----
Building Cununissioi d hupector ut t,Idi.. Date
—_�
SECTION IF SITE INFORMATION
l,l roperty :�ddress: 1.2 Assessors Nlap & Parcel Numbers
ap --
M Nuhet Parcel N•amhcr
l.I.r is this un accepted streeR yes___.. no m ..--
1.3 Zun;.,g Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy ft) Frontage I it)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yurd
Rcyuired Provided Required Provided ReyuireJ PnrviJrJ
l
iI
r 1.6 Water Supply: (M.G.L c. 40. §_54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? /
LPublic ®� Private❑ Check if yes❑ Municipal® On site disposal sysicin ❑
SECTION 2: PROPERTY OW NERSNIPt2. _
cn� /I c-z � s
]
���r ter of ecor r?
Name (Prior ddress for Service: z
Signature -- lephune
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) 7I
---
New Construction Existing Building ❑ I Owner-Occupied ❑ Repaus(s) ❑ Alteralinr.(s) ❑ :Wdition ❑
Demolition ❑ Access.rry Bldg. ❑ Number of Units-__._ Other peciiy:,�6C
_ — T
17,ief Description of Proposed \York': �Q��-r/.�L�ll!y���C�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs: Official Use Only
(Labor and Materials) _
I. Building S �'p06. I. Building Permit Fee: $__ Indicate how fee is determined
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item G) x multiplier x
I
1. Plumbing S ?. Other Fees: $
4. Mechanical (HVAC) .$ List:
i
5. Mechanical (Fire
Suppression) Total All Fees: $
Check No. Check Amount: Cush :\mount:__
0. Total Project Cost: $ /(JD U 11 ❑ Paid in Full ❑ Outstanding Balance
q7 . Ot) Hot. 2 19w,) 2,Y
r.
SECTION 5: CONSTRUCTION SERVICES
5.11 )Lice/nsed_Construction Supervisor(CSL)
I C�/A License Numher I:vpiratiom Dale
Name o CSL- ItulJcr
yD ��2 List CSI_ Type Isee hclom)
Desc
1JJressl � T e , y D%N riiun
F��// C Unresincled ui l to 35.(p)0('u. 11 1
R Restricted 18c_ Family De rllinc
Signa urc / .\1 SLasonry Only
?� -76a , Dy—�—s. RC Residential Roofing C'osering
Telephone \\'S ResiJrnlial w,ndow :utd S`112 _-
SF Residential SoIId Fuel liu,n,ng :\ t)l.urce In.f,J
D Residential Winolmon
5.2 RegisterYd Ilome Improvement contractor (HIC) .,
6
2T"�5 A.� cA•�•,D,trUt34 a�wa6.r L —_
HIC Company Name or HIC Registry Name/ Reeistrati�n Numher
�/�.2'^�". '73�V AID `
Audis.,
"J Expiration Date
-Sig acute 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 prucide
this affidavit will result in the denial of the Issuance f the building permit. - I
Si'lled Affidavit Attached? Yes .......... No ........... r-I --- .----- _—
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN l
` ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i 0�1'NER'S AG - --- -- .---. _
� s
LG/I Z. ( mil as Owner of the subject property hereby
authurize.
Co act on my behalf, in all matters �
relative to ,Hork auth' i7 d by the tilding pc� .it application.
n
Signature of Owner
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
__, as Owner Authorized Age reby declare
that the statements and information on the foregoing application are true and accurate, to t to my knowledge and I
behalf.,
s � a
Print Name .i ---- f
/J D
i
Signature of Owner Authonze Date
(Signed under the pains anu penalties of perjury,
NOTES:
L An Owner who obtains a building permit to do his/her own work,or owner who hires ❑n unregistered contractor
(nut registered in the Home Improvement Contractor (HIC) Program), will not have access to the albitr:uiun
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 730 C'MR Regulations I IO.R6 and 110.R5, respectively,
_' When substantial work is planned, provide the information below:
Total flours area lSq. FLI �f�-� (including garage, finished basement/attics, erks o porch)
Gross living area (Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of hathrooms Number of halt/bafhs
'fvpe of heating system Number of Jerks/ porches
Type ut cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
. - r •
DEPARTMENT
Construction Debris Disposal .affidavit
(rcrluired lirr all demolition and renovation work)
In accordance ith the sixth edition otthe State Building Code, 780 CMR section 111.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit rf is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c
l 11, S 154A.
The debris will be transported by:
A21c41-or(/
(namc of hauler)
I lie debris will be disposed of*in
(name ut laolity)/ '
IadJrew u(I�nlirv)
l
ag1tatulc of pirmn .11,pl1cartt
late
CITY OF SALEM
- PUBLIC PROPRERTY
?' -= DEPARTMENT
-n PIL;'Nf kk n.l.
\i�iOa l 12^W.vsrltNi:fo.N S7aflt>T * SAt.t:a3,M.,StiACI a-sr:I I ti 01970
71a.:978-745-9595 • p:,x:978-740-M46
Workers' Compensation Insurance Affidavit: Builders/Contractors/El Pease Print Lee Builders/contractors/Electricians/Plumbers
3 311t.ant Information /
iblv
a/ !t rh /0�'+�e/c o ✓ ,DSy cLin/l� T'So 2tt
�lafT3e t13u((in��css/Or�a�nira�tionNindlvlduap;/1�.,
Akldress- �
Cilyistateizip:� 'r Ja
/ a/F03 Phone ; :�' F/ ' 76 o O�..•5--.�
:\re youan employer! Check the appropriate box: 'Type of project(required):
i 4.;-r+m it general contractor and I ft w construction
El 1. I a employer with
on llo -cez full anuL'or art-tinie).• have hired the sub-contractors eRemodeling
I y ( P listed on the attached sheet. ❑
2.❑ and a state proprietor or partner-
t3
ship and have no employees These sub-contractors have . ❑ Demolition
working for me in any capacity.
workers' comp. Insurance. 9. ❑ Building addition
Igo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
1 required.) officers have exercised their
right of exemption per MGL
myself. [No workers' comp. c. 152, b 1 I.[] Plumbing repairs or additions
3.❑ f ant a hnmcowk doing all work g 12.❑ Roof repairs
e �l 4 O,and we have no
insurance required.) .anployccs. LNo workers' l3 tber
comp. insurance required.)
-.non applicant Ihu[el•.ccks bo%dl must also rill out the,,,runt blow showing their w'orlwts'cumpensalion puli y infurnutiun.
' I lomeuwnum who submit this affidavit indicating Ihcy are doing all work and then him outside cuntmeton must suhmll a new affidavit indicating,mh.
=C,mtrackors dult chvck this box must auachcd al additional,heel ht wing the name of the subcontractors and their workers'comp.policy information.
/mrr can employer that is providing workers'c•oatperrsntion insurance fa•my employees. Below is the policy and fob site
inforinurium
I nsurancc Qinipany Name: Ati
I'olicv h or Self-ins. Lie. r'�BD O ,1�J—cDc7.-X ----.----- Expiration Date:
Job Site :\ddross:
�/iD.o-fUITA- � _ .. . CayiState/Zip��r�' ^x,
--- -
Attach it copy of the workers' cotnpensation policy declaration page(showing; the policy number and expiration date).
hailure to secure coverage as required under Section 25A of`IGL c. 152 can lead to the imposition of criminal penalties of a
tint up (o S1.500.00 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 smternent may be tilmarded to the Office of
Iucts[igalions of the MA for insuralxe covcrago %esiticatiun.
/du hery y certi +er th'p tit. can t �fpjury that th�infv
nution provided d ��is�1)e d correct.
Dan
I'll 7 F—/
Official rise only. Do not write in this area, to be completed by city or town official.
City or town:
Issuing Authority (circle one):
I. IStiard of health 2. Building Department J.Cilyi Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
h.Other ----
Contact 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 empluree 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 toreeoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an 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, b1GL 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) nsme(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 confinnation 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 time event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permiVlicense number which will be used as it 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 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 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 ben leaves etc.)said person is NOT required to complete this affidavit.
l he OI)icc of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Deparunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Omee of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
rzcvised i-1_6-05 -
www.mass.gov/dia
, Jul 01 00 02: 51p p. 2
JUN-30-2006 14:14 FROM:EA5rERN L" 9-M&Y
c7la�Qo bard �flpoo� � aoQoae IIoa0
prafessinnet tend Sm Vom a CNII Ervlii em
ORTESSM(SURVEY SERVICE 1958• 1998
MP]AT DB I14of IANPCTIDN 09a0RN PALMER .1911 •1970
PLOT PLAN OF LAND
i°OCAT® IN BRADFORD a WEED 1SS6 . 1972
54LEk1 MASS.
1
3%
CL
T•'
[u71 qu r
�0 2
lu'
I, Christopher Be McUO, A BBgifiteted I SLalreyoFY DO`I�ebY'�'�Y That T+e Above M=tgagr-
Ixlspeation Plot Plan Was Rrepared --�1 In Cozmection Wttd A New
Mortgage And Is Not Intended Or Rapreeen - Line Survey. No Cornera
Were get. It Cmmot Be Used For Setahliehing Fence, Hedge Or Iwilding I,izlea. No Responsibility
Is Extender] HereU % The Land Owner Or Occupant. 1fiia an aording.
Plan Sbll Not Be Accepted For Recording
The Location.of The Structures AS ShO9n HOr'e0II This plan Has Been Prepared For
Is In Campliaoce With The Loral Applicable OoarveyatlCisig Putposee Only For The
Zoning By-Lon In Effect $hen Conattvcted, Bbove Perty ADd IIe Not To Be Used
With Respect To Horizontal Dimensional Q; , For Boundary Hes ts.
Requirements or Chapter 48l Of 1987. Subject Property I9 Located In
Zone On A Federal Insurance
1u= 14 G 4�tratlon Designated Flood
..--- .. Hazard At 69 Per Map
Dated Y��S
HATE: 'Jcf`rx,��4Tr<t
REFERENCE', B& 1510 PG 2Z3.
• 194 LCWELI STREET
PEABODY,MASS.01"0