20 CRESCENT DR - BUILDING PERMIT APP (003) y� The Commonwealth of Massachusetts CITY OF
I ®a Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
1 Building Permit Application To Construct,Repair, Renovate Or Demolish a
One or Two Family Dwelling
This Sect or Foi W_icta Useonly 1, "r•''
Date lied ;> "
Budding Permit Number
Buil
ding Official Pun Neme . f p, .�• Signature ,,�t - c ate,'
SECTION 1•: SITE'INFORNIAT;O
1.1 Property Address: 1.2 Assessors Ma areel Numbers
7t2 Ct¢sce .�t
1.1a 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 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipallff On site disposal system ❑
Check if yes❑
SECTION'2;; PROPFPT' OWNERSI3IP `"
2.1 C ,O � I r.}b coil 6
e C C7 �5 0✓. P,G k b (/Ll v {� � U ✓tT--
Name(Print) City,State,ZIP �3
21 �t A _ Pt,. I ��� z334 a57S Cb,d,on al 6.r,s�t��< sovly�c'Cont
No. and Street Telephone Email Address
SECTION 3i DESCRIPTION OF PROPOSED WORT{° (check:all that'apply)'
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': Q , 1 t c L, 2 v w
cK o �c
SECTION 4: ESTIMATED CONSTROCTION COS 1 S
Estimated Costs: Official Use Only
Item Labor and Materials
w,
1. Building $ o o v o I Buildng PermitFee $,-,
Indicate how fee is determined:
❑ Staz dard City(Town Application Fee:
2. Electrical $ ❑Total�pmect Cost' (Item,6)xmultip,l er= x
3. Plumbing $ j p o 2 Othe_r Fees $
4. Mechanical (FIVAC) $ List / � ..
5. Mechanical (Fire . $ Total All Fees.$,
Suppression)
Check.No. Check Amount Gash Amount
6. Total Project Cost: $ 2 a !9 p Paid in Full _ 0 Outstanding J3alance Due
r
SECTIONS: CONSTR_UCTdONSERVICES
5.1 Construction Supervisor Licensee
t (CSL) C S S l a >CD (d — ) R — 1 4
JC? ��u c7r License Number Expiration Date
Name of CSL Holde
List CSL Type(see below) (J
No. and Street :Type �t' , "De`scirpiian __
U Unrestricted Buildm s u. to 35,000 cu.f.)
R Restricted I&2 Family Dwelling
City/Town, State,ZI
M Mason
RC Roofing Covering
\ WS Window and Siding
\ SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) t ��� -7
FIIC Registration Number pi tion Dale
Nit-Com any N�me or HIC Registralnt Name
Cca J'A h t'"E e S
N,,9y�and St(reet — �r Email address `/ t
I—OJC Jorr/ /I/( a dr�-0332�i �
City/Town, State, IP 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 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 BUILDLNG PERMIT;
I, as Owner of the subject property, hereby authorize Jek� r!,f T_ (300Iz�
to
nact on my behalf, in all matters relative to work authorized by this building permit application.
11rts}onhet P-OISot\ 1( Z7 0
Print Owners Name(Electronic Signature) ate
` SECTION 7b: OWNERtOR AUTIiORIZEDAGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in t is application is true and accurate to the best of my knowledge and understanding.
Ae r 3av�e r 7 ba
Print O� e Au rize Agent's Name(Electronic Signature) I I qate
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 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
ivww.rnass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov dos
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.) i t po Habitable room count (e
Number of fireplaces L Number of bedrooms 3
Number of bathrooms ii y2 Number of half/baths I
Type of heating system F.ecc- -°t s Number of decks/porches t
Type of cooling system Nah! Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
U1V www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information r Please Print LeEibly
Name (Business/Organintion/Individual): . 5e 'gyp (� � 1� Iwo tz f
Address: G!
City/State/Zip: —c> o ul-v. 03J Phone.#: S y — S t —7 — t ?R G�,
Are you an employer?Check the appropriate box: -Type of project(required):_
4 general contractor and 1 6. ❑ New construction
i.El I am a employer with ❑. I am a mployees(full and/or part-time).* have hired the sub-contractors ��Denvcilition
2. I anaa sole proprietor or partner- listed on the-attached sheet 7. emodeling
ship and have no employees These sub-contractors have i workingfor me in an capacity. employees and have workers'
Y P ty. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.{
required.] - 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]Any applicant that checks box#I 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 hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subconmetors 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 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 raider Section 25A of MGL c. 152 can lead to the imposition-o€criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u r the pains and penalties o perjury that the information provided above is true and correct.
Signature: L \ Date: _ I
Phone#: � O
Offrcial use only. Do not write in this area, to be completed by city or town official
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-conti'actor(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,r r lease call the Department the number listed below. Self-insured companies should enter their
� r .
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 pernrit/license 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 Office 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.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Dcpartment of Industrial Accidents
Office of Inyestigatioas
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFB
Fax # 617-727-7749
Revised 11-22-06
wwcv.mass.govldia
ti Office of Consumer affairs Si, Business Regina
HOME IMPROVEMEN C0%� TRACTOR Type.,
Registration:
� . 128708
1 rI
Expiration: 51912013 � individuai
-JEFFREY T. BOOKER ,
JEFFREY BOOKER
85 GRANITE ST
FOXBO.RO, MA 020Z5 Underseerctary
License or registration valid for individul use mly
r before tie expiration date. If found return to:
Office a:f Consumer Affairs and Business Regu.:iation
10 Park Plaza - Suite 5170
Poston;:MA 02116
CITY OF S.XL.EINI, -L-kSSACHUSETrS
BUILDING DEPARTMEINT
N • 130%( SNINGTON STREET, 3° FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KI.,tBERLBY DRISCOLL
VLAYOR THo.% SST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/BUIMLNG CONLUISSIONER
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 c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
i 11, S 150A.
The debris will be transported by:
�iWask Mgnanemer�} * Woyurr`
nameofh uler)
The debris will be disposed of in
We es'L "V\e!- rMtv�cl. _
(nam ft-6 Facility)
McNrc'%m0.C. S - ,
(address of Facility)
si iatur of permit applicant
11 . 'A7. la
date
ai>nso:d,w
CITY OF Sm Em) 1NL1S&kCHUSETTS
Buff-oiNG DEPARTM&NT
x / 120 WASHIINGTON STREET, 3se FLOOR
TEL (978) 745-9595
F.ke(978) 740-9844
KIJ(BERLEY DRISCOLL
T
MAYOR t-tOb[AS ST.1?tF3tRB
DIRECTOR OF PUBLIC PROPERTY/BuIIDING CONWISStONER
Workers' Compensation insurance Affidavit- Builders/Contractors/Electricians/Plumbers
Anolicant information Please Print Legibly
Nitire(Bushxs.&Orpnniilzatiorvindividual): J T 'C v OO ks+d'
Address: '35 vlrarsik Sfryxk
City/State/Zip: Foabor,o . AAA GZ0S5T- Phone#: 501 .517. 1,91 ;)
Are you an employer?Check the appropriate box: Type of project(required):
1.0 lama employer with 4. 0 1 am a general contractot and 1
employees(fldl and/or part-time).* have hired the sub-contractor 6. I❑-yNew construction
2 1 am a sole proprietor or partner- listed on the attached sheet.t ?• txt Remadeling
Pwhip and have no employees These sub-contractors have S. emolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.(No workers' cutup. c. 152,§I(4),and we have no I2.[] Roof repairs
insurance required.)1 employe".(No workers'
camp.insurance required.) I3.❑Other
-Any applicum that ducks box rl most also fill uut the section below showing their workers•compensation policy inlurmatiom
11 hvneuwnr who submit this affidavit indleming they an doing all work and that,him outside contractors most submit a new atndavit indicating such.
:Conuactom that ch«k this box meet anachud ate 4"flunul shout showing the name of tho sub e-omractal and their wormss'camp,policy intermation.
I um an employer chat tr provldlnR workers'compensadan lnrurance jar my ampluye¢x Below is the policy and Jab site
injoranallan.
Insurance Company Name:
Policy 4 or Self-ins.Lic. d: Expiration Date-
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Ile advised that a copy of this statcmunt may be forwarded to the Office of
Investigwions of she DIA for insurance coverage verification.
/da hereby y rat r the puln.r and piol"Wer ujperjury that rho tajuranadon provided above is true and correct.
P 0 5/7 I Sla
OJjic iul use only. Da not write in thlr arras to be completed by city ar lawn afjlcial
City err Town: ____ Pcrmlt/i.lccme t1
Issuing Aulhorily(circle one).-
1. Board of health Z. Building;Departnmut i.City(rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Olher
Contact Person: ,.,_ Phone tt•