23 CLIFTON AVE - BUILDING INSPECTION (5) 591 c # 55 � 3
The Commonwealth of Massachusetts RECENED V lY OF
Board of Building Regulations and Standards CTIDNA� $ SALEM
Massachusetts State Building Code, 780 CAPE Reevisgt.Mar 2011
Building Permit Application To Construct,Repair,Renovate Or D�eclist a SS jS
One-or Two-Family Dwelling 1��5 Dec
T his Section For Official Use Only
Building Permit Number: - Date App'e
11
C'Q Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1 t� 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
J 3 fi F�,� '4Vt
I 1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yazd Side Yards Rear Yazd
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 S-" Private❑ Zone: _ Outside Flood Zone? Municipal M4 site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwnert of RecoTrd.: 0J '3 /e-m M4/ O /97 0
1/ Name(Print)
City,State,ZIP `
a3 Cl/7Ckt �t✓C '73/3/6-2-3/7 Qfu✓G Ao, rc. m4 r-C
No.and Street - Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : f<elh ` oor
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1900. 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
( o O a ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 10 0 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Cheek Amount: Cash Amount:
6.Total Project Cost: $ 3 0 ❑Paid in Pill O Outstanding Balance Due:
eYl A t L 1-t� •('rl q�-�-. i�(i�ETZ,c� r f'n p-t t.-� $-�13
Y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Oro 124 tt l,J�
-M o_r t- Em e -p License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
-C C'or8is 8 f
No.and Street Type Description.
'AA �,�O U Unrestricted Buildin u to 35,000 cu.ft.)
City/I'own,Slate,ZIP t '- A R Restricted 1&2 FamilyDwelling
M I Masonry
RC I Roofing Covering
WS I Window and Siding
7;( 2q ��'�'A SF Solid Fuel Bunting Appliances
-i�^i ,� I I Insulation
Telephone Email address D Demolition
5.2 yRegistered Home Improvement Contractor(HIC) I Zz/Z y
/In,r L T I rn ro HIC Registration Number Expiration Date
HIC Comp Name or HIC Registrant Name
IF rJ1,T S 4
No.and Street (1 ` �r,� q CC !/ Email address
Ctate ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AMDAVIT(M G:L c.152.¢25C(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 .......... No...........❑
SECTION 7a:gWNER AUTHORIZ,41ION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT "
I,as Owner of the subject property,hereby authorize a-A -r Chi e-.,-v
to act on my behalf,in all matters relative authorized by this building permit application.
X S-/Z -/S
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
n2ny,n ass.gov.%oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachuseas
t Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,AM 02I14-2017
www.massgov/dia
Firorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERN97TING AUTHORITY. _
Applicant Information - Please Print Leltibly
Name(Business/Organization/Individual): ]Ap-r- —r Eh'lern
Address: rS�d �rbl-tS Sf
City/State/Zip: f��
EJm .L_ Raj j[Y/� Phone#!: 771 - '2.2`f- ZY(4J—
Are you an employer?Check the appropriate box: Type of project(required):
1.❑fan,a employer with employees(Tull and/orpart-time).* 7. ❑New construction
2.Eqfm a sole proprietor or partnership and have no employees working for are in 8. �ealpdeliug
any capacity.[No workeis'comp.iuusmanoe requmed.]
3.❑lam a homeowner doing all work myself.(No workers'comp.insurance required.)t 9: El Demoltion
10 E)Building addition.
4.n I am a homeowner and will be hiving contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compcnsation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees' 12.❑Plumbing repairs or additions
5.Q I am a general coimumor and I have hired the sub-c"muctors listed on the attached sheet. 13.E Roof repairs
These sub-contractors have employees and have workers'comp,imsommM t - -
6.�We are a corporation and its officers right of exemption per have exercised their ri on MOL c. 14.Q Other
152,§1(4),and we have no employees.(No workers'comp.insurance regrmed.) -
•Any applicant that checks box#1 must also fill out the section below showing their workers'compensation pokryinformation. -
t Homeowners who subunit this affidavit indicating they are doing all work and then hire outside contractors must submit a new-affidavit indicating such.
lConnctors that check this box must attached an additional sheet showing the name of the subcomrectors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'.comp.policy number... ..
I am an employer that is providing workers'compensation insurance for my employees. Below is the poticy andjob 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 M&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 certify under the pains a'nd pena�ltiessoofperjury that the information provided above is true and correct
Si®ature•' ��� � Date: 5'`! /� l�
Phone
O
fficialse only. Do not write in this area,to be completed by city or town ofpcial
own: Permit/idcense#
uthority(circle one):
of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
erson: 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 writtep."
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 arid,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 fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pernut/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 dqg 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
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALE14 MASSACHUSETIS
BuErDiNGDEPARTA ENT
120 WAStm4GTON SUEET,31D F"R
7tL(978)745-9395
KIMERLEYDRiSCOLL FAX(978)740-9846
MAYOR 7110MAS STMEM
DIRECTOROFPIIDLTCPROPERTY/Bu[DDmODIv ussiONER
Construction Debris Disposal Affidavit
(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#1 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 150A.
The debris will be transported by:
h LrL E-mem
(name of hauler)
The debris will be disposed of in:
PL46. 4 -rfi4-Aj yc�r
(name of facility)
44 1 T _
(address of facility)
Signature of applicant
Date
. 1.--^pe`-...~ ~ ft2 U�dYW/IItIYH.GIClII.I�O�C-//�(,2d�[ltfl.LldP,Clb,
f
Office of Consumer Affairs&Business-Regulafion
QME IMPROVFAENT COjUndeneereUrY
_ e9istretion ,4122114 -
Expvahon 701�8
MARK EMERO
MARK EMERO
5§CORDIS STREETWAKEFIELD,MA 01880
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-00334
MARK T EMERO POO
56 CORDIS ST
WAJKEFIElDb i 01
J � .,rrn`' Expiration
Commissioner
1110812015