0004 CHEVAL AVENUE - BPA-08-2051 The Commonwealth of Massachusetts
► Board of Building Regulations and Standards FOR
III
t. Massachusetts State Building Code. 780 CMR. 7'"edition MU.VI4.US[-:`III 1
W� Building Permit Application To Construct. Repair. Renovate Or Demolish a Ret io-d Amum i
One- or Tit v-Furnil Duelling
This Section For Official Use Only
Building Permit Num c Date Applied: // 0 _
Signature: �/1 W /
Buddi itCommissioner/ Inspector of Buildings Date
SECTION I: SITE INFORMATION
t.l Pr pe e y %fdre 1.2 Assessors Nlup & Parcel Numbers
I.la Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: (A Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage tit)
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:
Zone: _ Outside Flood Zone?
Public ❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Rec rd:
s Cln eV G ( 5
Name(Pri Address for Service:
1-1s 8s5 zSd?
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Speedy:
Brie Description ofiProposed Work':
Avon r �1. t,tC SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building 1 $ 5660 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
?jElectrical $ ?.U06 ❑Total Project Cost (Item 6) x multiplier x _
3mbing $ 8oco 2. Other Fees: $
4chanical (HVAC) $ Lisr.5hanical (Fire $Session) Total All Fees: S
(�
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ � ' 00 ❑ Paid in Full O Outstanding Balance Due:
f
SECTION 5: CONSTRUCTION SERVICES
5.1nLicensed Construction Supervisor(CSL) Qq 1 3 Q ( (2 G
1`LI(A� /' ,, l`t� Licenlse Nunher Enpoaauui Date
Nan%JJ1 SL- H,tlJer .Z _ VIN ,n List CSL Type tsee heluw) GV
1L) `�Y. ` P"' T Description
Aid ssss p 1n Unrestricted to to i51"Cu. Ft i
1 7 AAA R Restricted Idt2 Fanul l D,scllin
Signal a �3! c SG .M Mason Onl
u1. V 1,j
L RC Residential Ruutin Cosrnn
Telephone W'S Residential Wi...h— and Sid"'Ll
SF Residemtal Solid Fuel 1lunune :1 s,h:mr; Iu,t.J lauou
D Residential Demolition
5.2 Re ' erect 1lom1e Improv( t C�uactor(HIC) 14 Co If
HIC Co wYuIm �uCorK''d 1 egntae EVQp, ey Registration Numher
hU , l
LtI _! 5 {f II I 0—�
so E.apirau' uh Dale
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. S 2506))
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 .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I J V$a" �-Q�W i S as Owner of the Imy
roperty hereby
authorize Mt•, RK to act onhalf. in all matters
relative to work authorized by this building permit application.
Signature o Owner Date
SECTION II 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1. Si g �s.�.tcJ
C" l S , 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.
:5.,
Print ;Name
Signature of Owne or Authorized Agent Date
(Si tied under the sins and penalties of ru )
NOTES:
1. An Owner who obtains a building permit to do his/her own work.or an owner who hires an unregistered contractor
(nut 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 110.R6 and 110.115. 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 j
Number of bathrooms Number of halt/baths
Type of heating system Number of decks/ porches
Type of cowling system Enclosed Olen j
3. 'Total Project Square Footage" may be substituted for"Total Project Cost"
CITY OF SALEM
7, PUBLIC PROPRERTY
DEPARTMENT
M.NW! KI i I
M I,'K 120W.VJ HNG ONSLBLET + SAI lASiM-!I I S1 I iSO 19/-
11:j.:978-7439;95 * J:AX:978 740-9846
Construction Debris Disposal Affidavit
(required lor all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft_. -- is issued with the condition that the debris resultingfront
this work shall he disposed of in a properly licensed waste disposal racility as defined by MGL c
111, S I 50A.
The dZebris will be transported by:
,
(0
(name of hauler)
The debris will be disposed of in
of ra-,Illty)
(address of facility)
V
sigitatuic of permit applicant
(late
` .� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1' 9-8-.'4 -'t846
Workers' Compensation insurance :kffdavit: Builders/ContractorsiElectricians/Plumbers
knIflicant Information Please Print Le ibl
Name I lfu;mcs, I hgunizaoon Indic ideal): ( t
Address: I �\1 C�G✓ R� ZZ//
City,stateZip: Phoned: `17� SJIP I��d
Are you an employer'!Check the appropriate box: "Cope of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6 ❑ New construction
employees(full and/or art-time).` have hired the sub-contractors
P' 7. ❑ Remodeling
sole proprietor or partner- listed on the attached sheet.
ship and have no employees 'I here sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. 0 We are a corporation and its 10 ❑ Electrical repairs or additions
officers have exercised their
required.] l I. Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL ❑ g P
myself. [No workers' comp. C. 152, $1(4), and we have no 12.❑ Roof repairs
insurance required.] f employees. [No workers' 13.0 Other
comp. insurance required.]
, \uy;applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
r I fomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
K:ontractors that check this box must attached an additional sheet showing the name of the sub-cuntractors and their workers'comp.policy information.
l one on employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
infornhation.
Insurance Company Name:
Policy #or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S I,Soo.00 and/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a tine
of(I p m S1_50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI:\ for insurance coverge verification.
l do herehy certifi'under the pains and penalrie.s of perjury that the information provide)above is true and correct
ii n;uure: Date:
Phone s
fl(ficial rise only. Do not write in this area, to he completed by city or town official
City or Town: _—__— --_-- Permit/License #-- _--
Issuing Authority (circle one):
I. Board of Bealth 2. Building Department 3.Cityi town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: __ — _ Phone
F i
Information and Instructions ✓
%I:ts:aatu>etts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
I'ur.u.tnt to this statute, an emplglee is defined :u "._every person in the sett ice of:mother under any contract of hire,
cypress or iny?lied, oral or wri ttcn."
.\Ti employer is .10ined as "an indivi.lual, parmcrship, a socianon, 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
o%.Tier of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of:mother 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 employ meat be deemed to be an employer"
%RiL chapter 152, §_'SC(tt) 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, j2507) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perforniance of public �kork 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 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 the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pernmulicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license 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. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Ott ice of 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.
fhe Department's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-2ci-u5 Fax # 617-727-7749
www.mass.gov/dia