28 CHESTNUT ST - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
I Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
/ Rvvisvr/Jonusvv
Building Permit Application To Construct, Repair, Renovate Or Demolish a
1 One-ai Avo-Fumily Dwelling
Tkis`Tc-c'0qgr1W ORcial Use On
Building Permit Number: ate Appli
Signature: `
Building Conimissioncrl I.spkctwo uil lace
SECTION 4-SITE INFORMATION
1 Prope Address: 1.2 Assessors Map b Parcel Numbers
C < AJj 7 sT
1.1 a Is this an accepted street?yes [/ no Map Number Parcel Number
1J Zoning Information: F[o�I—Amo
erty Dimensions:
Zoning District Proposed Use sq 11) Frontage(0)
1.5 Building Setbacks(11)
From Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.C.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yaD
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: I
4f4h? i ltg/;'/1�s A�✓nIJ Lr�i�nlA�
Name(Print) Address fw Service:
t
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check aB that apply)
New Construction❑ Existing Building O Owner-Occupied O 1 Repairs(s) f( Alteration(s) O Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify.
Brief Description of Proposed Work': tl
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: O(Ilelal Use Onl7Duc:
Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate
2. Electrical S ❑Standard Cityrrown Application Fee
❑Total Project Costa(Item 6)s multiplier1. Plumbing S 1. Other Fea: S
4. Mechanical (HVAC) S List:5. Mechanical (FireSSu ression Total All Fees:S
Check No. Check Amount:6. Total Project Cost: S dDc7 O Paid in Full ❑Outstanding Bala
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction SupervisorlCSL) 3 5
ri T' / /I C.� I."c umber 1: pirtli I}ate
Name of C5�1.-I(older �e I.��t�•x rypr I.ce below)
f Description
dress U tlnmslricteJ u W 73,OOD
R Restricted I6,2 Famil Uwellin
Signature M M On1
7-?72 RC Residential Raulin C'overin
I'elepMute WS Residential Window and Sidin
SF Residential Sulid Fuel Bumin A liane Inswllatiun
D maid itoWm Demolition
[Ad;dm%sZr
ered Home Im rovement Contractor(HIC)
ny Name it Registrant Name Registration Number
Expiration Date
Telephssta
ION 6: WORKERS•COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a ISL f 25C(6))
mpensation Insurance affidavit must be completed and submitted with this application. Failure to provide
it will result in the denial of the Issuance of the building permit.
ned Affidavit Attached? Yes ..........0 No...........O
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 ork authorized by this 'I ing permit application.
Signature of Owner
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I as Owner or Authorized Agent hereby declare
That the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si under the pains and penalties of 'u
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 W have access to the arbitration
program 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 780 CMR Regulations 1 IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total (loon area(Sq. Ft.) (including garage, finished basemenUattics,decks or porch)
Gross living am(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
7. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SALEM
_ , PUBLIC PROPRERTY
14
- DEPARTMENT
JMI::MI 1'Y:1 It M:UI.1.
I.\Yt,s I-C Wnu101610^STMEET * SAL E.M.M.\iiAO II if:ris0197�
11.i.: 978-]-t5-9595 • h.cx: 978-74.^,-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Lepihly
Naint: lllucincvslf)r8anizarinit/In�ivitluull: t/"/�IIf 1 LtOyC R 7�/'7�.5�/" `^«�'�+ ��`'✓
Address: &cwlQL*r 4Ue- t�
CityiStatci/.ip: D4Ajoe-i-$ tnlg- Phone ik? 77�
:\re you an employer?Check t appropriate box: 'Type of project(required):
I.fR 1 am a employer with
4. ❑ am a 6. ❑I general contractor and I New construction
f`
entployces(full and/ pun-unto).' have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
No workers'coo 5. We are a corporation and its
� P- insurance ❑ Or iccrs have exercised their 10.❑ Electrical repairs or additions
required.] 11. Plumbin g re airs or additions
right of exemption per MGL ❑ b P'
3.❑ I am a homeowner doing ant work g P
inysclf. LNo workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs ,, p
insurance required.l t employee.. LNo workers' 131Z Other Cffi�17'l�t-
comp. insurance required.] I -1'
-Any apphcaut dwt checks box dt must also fill our the seaian Wow showing their workui cumpensatiot policy informariun
'I lomniwnen who submit this affidavit indicating they are doing all vark atul then him outside coaracrors must uuhmit anew affidavit indicding.arch.
-('oniracturs than check this box trthit atlachcd an additional sheet showing the natne of the soh<ontrutors and their workers'comp.puhcy information.
f ant an employer that is providing workers'c•ontpensntion liisurance fur aty employee.¢. Belo,is the policy and job site
information.
Insurance Company Name: je�
11olicv 4 or Self-ins. Lie.it: __.__ Expiration Date:
Job Site Address: _ City/slate/Zip:
-Attach it copy of the workers' cumpensatiun policy declaration page (showing; the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up hs S1.500.00 and/or one-year imprisonlncnt, as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to 5250.00 it day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invcangaunv of Lhe DIA for imsurar.ce covcragu veritication.
/da hereby emit i der the pains and p to s of perjory that the inforniallon provided above is true and correct.
bo
tii •mw�rct _. I)at•:
6 ?,c? - GeR so - 3 - .23,;'
f)fjic•iaf use only. Do not write in this area, to be completed by city or town ojjPciu/,
City or Town: _.. ._ Permitil.icense V----.-.- -.
Issuing,\ulhurily (circle one):
1. hoard of llvalth 2. Building; Ilcpartmeol .i.(:ityi fo,w Clerk 4. Electrical lnspector 5, Plumbing Inspector _
6. Other _-. -
CmlLacl l'crsun: _. _ .__. Phone 0:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for 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 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 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'.'rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL chapter 152, p25C(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, w'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 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 confirmation of insurance coverage. Also be sure to sign and dale 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 the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennitilicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennitilicettse 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 tilled 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.
1 1C Office OI Investigations would like to thank you in advance for your cooperation and should you have any 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
Offlce of Invesdgadons
600 Washington Street
Boston, MA 021 t 1
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
t: -i, d ;- r,-us www.mass.gov/dia
,; l 11 Y UV JHLL'.lvt
PUBLIC PRoPRERTY
DEPART' IENT
I
•'. 11111f � 1\II \L \1.\. \I
Construction Debris Disposal .affidavit
(required tier all demulitiun :utd renuviniun work)
In accur(,ance Hill, the sixth edition of the State Building Code, 7S0 CNIR section 11 .1
Debris, and the provisiuns of 1.1GL c 40, S 54;
Building Permit B is issued with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by VIGL c
I l L. S 150A.
The debris will be transported by:
I name fit hauler)
i he debris will be disposed of in
J �Pc t32je1�
(mm�r ut facility)
taJdre�a ut facility)
.1¢uaturc ut permit applicant
dale