11 CHURCH ST - BUILDING INSPECTION (33) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALENI
O / Massachusetts State Building Code, 780 CMR Revised,L&r 101/
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Onf
Building Permit Number: Date.APp
Building Official(Print Name)- _ Stgnatu!c: Data
SECTION 1:SITE`INFORivIAT10N
I Pro er Addres � �1 1.2 ssessors Map I Parcel Numbers
--1j �e P "1 c,c�ul� s?- rQ0cC 1 E?Qb-�—
Ala Ntunber Parcel Number
I.la Is this an acce ted street?yes no p
1.4 Property D me�s:
LJ ' on)ng Information: nn n p y I
I .
Zoning District Propose)Use-,�' Lot Area(sq R) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Ywds Rear Yard -
Require) Provide) Required Provided. Required _. Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ outside Flood one? Municipal On site disposal system ❑ -
Publie._ Private❑ - Check if
Z•
PROPERTY
WIVERSRIP! ,
SECTION .
Ovnerl. .fR
{1/f tr cc�cb�sitare,pzlOP�l Z �
!� elPrinIt t,IWE)
No.and Street $- Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK;(check a0 that apply)`
R 7ss ❑ Altemtion(s)_bC Addition ❑
� Owner-Occu ied ❑ epm ()
New Construction❑ Existing Building❑ p
Demolition O Accessory Bldg.❑ Number of Units_ Other 17 Specify:
Brief Descriplion of roposed Work':
au r
INP_s_
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllcial Use Only
Item Labor and Materials
I.Building S 0O I. Building Pemtit Fee:S Indicate how fee is determined:
❑Standard City/fown Application Fee
2.Electrical S ❑Total Project Cost?(Item 6)x multiplier x
3.Plumbing S j SO ? Qiher Fees: $
4.Mcchanical (HVAC) S List:
5.Mechanical (Fire S Total All Fees:S
SUPpression)
Check No. Check Amount:-Cash Amount:
6.Total Project Cost: S I Q ❑Paid in Full D Outstanding Balance Due:
o1 C=4
SECTION is CONSTRUCTION SERYtCES
5.1 Construction Supervisor License(CSL) Licensa Number Espuation Uate
lC i, tt1C r S t- �� 1
_ List CSL Type(see below)
Nnmc u(CSL Holder _ ..
I ' S -r £ _7 ( Ty.e .. - - Description
No.:md Street Unnstrieted Buildin it to 35,000 cu.It.
+✓ R Rasuicled I&2 F:unil Dwtllin
City own,State,ZIP Roofin Cavern)RC
NS Window and Siding
Cdi`�=j.tf SF Solid Fuel Burning Appliances
I Insulation
lr - '1 D Demolition
Entail:uldre ,-) �j._r •,�
Talc hone or .S' �3 �(
g,Z,_"istered tfome Improvement Coatract (H!C) FIIC Regis r Espimtion Date
I ill:cutup my Name or kJlC Registrant Name S�I"-� yY1�S�7ciSl' J
- Emud address
No.:uzd SBcett , t � /jl^:" )-Y /VE-.'r'
(1 Tele hone -" -
Cit own,State ZIP _
Oh[PENSATION INSURANCE AFFIDAVIT(M G.L.a Jim 25C(�)
SECTION 6:WORKERS'C -,
Workers Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide
this affidavit will result in the denial of the Isis ante of the building permit
No...........❑
Signed Affidavit Attached? Yea••••••••^G RIZATIONTO BE CONTPLETED WHEM
SECTION 7h:OWNER AUTHO" ZAT1
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDIING.PERNIIT'`
as Owner of the subject property,hereby authorize t'YN
c"-ilt\
i� t act on my behalf,in all ters relative to work authorized by this building permit application.
/ -4- 27- -(
Date
rint Owner's Name(Elecuonie S' more) D/�V I D 51'lr✓`QSD l.)
SECTION 7b:OWNERt ORAUTHORIZED AGENT DECLARATION"
t all of
t;y cntcring my name below,I hereby attest on a to tht,,thee best of my knowains and ledge and understanding.Of pedurY
cord, information/
cord, ed in this application e tin �/
( ' Date
Print Ot 's or, u horized Agrnt's Nwna(Eleevonie Signauve) _ L,
NOTES:
will not have access to the arbitration
1 An Owner who obtains a building permit to do hisAier own work,or an owner who hires an unregistered cu.... of
_ono[regi;tared in the Home Improvement Contractor(HIC)Program):
program oe guaranty fund under NL6.L.C. 1 2A.Other important inPorntbfibn ori-the"HTCProgmm can be to"untT u
-__ tivlooca Information on the Construction Supervisor License can be found at w< • AR,"ov'd rs
�,u_
2. When substantial work is planned,provide the into('n tionclu ug garage,Finished basem m lattics,decks or porch)
'fatal Door area(sq. R.) Habitable room count .---
Gross living area(sq,et-) ,tmnber of bedrooms _ —
Numbcr of fireplaces_ Number of Imtf/balks
Number f bathrooms---- Number of decks/porches-__ -
fype or healing system Enclosed Open
Type or cooling system
), •`Total Project Square Footage"may be substiurtcd 1'or'"total I'roje- Cost-
I
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-091191
Construction Supervisor
JOHN AMBROSE
11 ESTES ST
IPSWICH MA 01938
Expiration:
Commissioner 04127/2018
r
� } A
F � •r
9
This is to certil{, that
John T. Ambrose
11 Estes Street, Ipswitch, MA 01938
CSL# 091191
has successfully completed the 8-how- course
Lead-Safe Renovator - Supervisor Initial
pursuant to 454 CMR 22.00
PB 373 MA Lead-Safe Renovation Sup.Initial course(8.0 DPS CIE HRS.)
Course Approval: CS-2103
Required Topics:Workplace Safety(2Hrs), Business Practices(1 Hr),Lead Safe Practices(2 Hrs),Electives(3 Hrs) '
Course Coordinator:Wendy Johnson,CSL-CD-0021
Course Location
Institute for Environmental Education, Inc.
16 Upton Drive Wilmington, MA 01887
April 6. 2016 *, da16
Course Dates I' ll Examination 1 , . _ y
16-0007-373-265756 "April'Q6 2 1, "�'
Certificate Number Ezpiraiion Date Training Director
a
i
LN
The Commonwealth of Massachusetts
J
Department oflndustrfalAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Fi'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / Please Print Le 'bl
Name (Business/Organization/Individual): pl�r, ��5,e 18A- Si)S+,41Ky+t+-� c-CX'1.1T7L P)
AddressJ(
City/State/Zip: :SW(�/ l�l / Phone#:
Are you an employer?Check the appropriate box: '
Type of project(required):
I.�I am a employer with�emplayees(full and/or part-time).• 7. ❑New construction
2.Q I am a sole proprietor or partnership and have no employees working for me in $. Remodeling
any capacity.[No workers'comp.insurance required.]
3.Q I am a homeowner doing all work myself. 9. ❑Demolition
[No workers'comp.insurance required.]t
4.❑I am a homeowner and will be hiring contractors to conduct all work on m ro 10 Building addition
Y P Pent. I will
ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.= 13.Q Roof repairs
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contactors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub=contractors have employees,they must provide thew workers'comp.polity number.
lam an employer_that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification. ..
I do hereby ce under the pains and ltie ofperiury that the information provided above is true and correct
Signature Date �— 2
Phone#: �� � - z / 7 '6
Official use only. Da not write in this area,to be completed by city or town o;�cial _
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. 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 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 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 number(s)along with their certificate(s)of
Limited Liability Par nerships(LLP).
insurance. Limited Liability Companies(LLC)or ty 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 pemut 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 a ro Ynate 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 permittlicense 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 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 dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-N ASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
07 Y OF SALEA MASSAaIUSE M
BUMDM DEPART1ENr
e 1201WA9mJGwNSTREET,3mRDm
7kL(978)745.9395.
PAX(978)74D-9846
RIMRFiti FYDRISQ7LL
MAYOR MCMU STOEM
DntEcTmcFpuBmcpRcnm/BtmDmccmmomR
Construction Debris Disposa/Afdavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL 00, S 54; Building Permit 4 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 156A.
The debris will be transported by.
�OLL _�)a!4l a AMA( 26 ('Q"�
(name of hauler)
The debris will be disposed of in:
C. (VW(b `
(name of facility)
(address of facility)
Sig ure of applicant
Date