35C FIRST STREET - BUILDING INSPECTION The Commonwealth of Massachusetts FOR
t r ��` �— li„ard tit Building ReMIlatiuns and Standards \11 Vi1'li'.V I I 1
t �.! Massachusetts State Building Code. 7SU('MR. 7"' edition 1.SL
Building Permit Application To('onsu•uct. Repair. Renoaate Or Den,ulisl, a Wrrw,l Lumau,
One- or- Tit o I'URrih' Du elling
This Section For Official Use Only
BuildingPrnnit Number Date Applied: -
/�,
5tgnature: __--
Budding Cuninnssun,ed hsprrm,r of Buildings Date
1 SECTION 1: SITE INFORMATION
1.1 Pro rrt \ rr: 1.2 Assessors Slap '& Parcel Numbers
*,la Number
I.la Is thin an accepted street? yes,_ no_ p Number Panel
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq h) Frontage i I'l, —�
1- Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Require) Provided Required Pmcided RequnrJ Pnr.,dcd
1.6 Water Supply: (M.G.L c. 40.§5J) 1.7 Hand Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'.' M1lunicipal IKOn site disposal system, ❑
Public).'1 Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. /Owner' f Re f Uf
Na tit Address for Service: /L1//)d4--
St at Tclephune !�f
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) rkiteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_. Other ❑ Specify: —.
Brief D/C> t�l�Proposed ks
// SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item I labor and Materials) —
1. Building $ V 1. Building Permit Fee: $ Indicate how fee is deternuncd:
O Standard City/Town Application Fee
2. Electrical S - ❑'rutal Project Cush (Item 6) x multiplier )G�x�
3. Plumbing $ 2. Other Fees: $ -c7E�--
4. Mechanical IH\'AC) $ List:
5. Mechanical (Fire $ � Total All Fees:
Suppression)
Check No. ._l'heck Amount: ('ash .\nuamt:
b rutuf Project Cost $ (N _
J U. ❑ Paid m Full ❑ Outstanding Balance Uur:— - r
/� #19 ��� Ae 0//e//
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed C•onstructiunStpervisor III CSLI
� o License Number E%puanon Dale
Kane I SL I 'uJ•r /l ,`
C'SI-'fylxls hciut.l
� WJrcss / /7
��`� � 'fv Descri rood
l v5 �/ 1. Unrcstnvtcd lop pt iS.tNN)l'u 1=t.1 t
1. Resotcted 1&2 Fanuk Duelling
A Signature _ )t \I:nonn IAuv
RC' RestJenual Routine Co\erut•
Telephone \1'S Ire VdC❑(JAI and S1d11le 1
SF R.•vJentlal.Suhd Fuel Iitunule \ t�I1.mn• h1 d.d L1u1 n>�
' D Readellllal Dennlhuun
5.2 Registered Home Improvement Contractor(IIIC)
IIIC Company Name or NIC Registrant Name Registration Number.-_—
1 Address
Expiration Date
Signature Telephone
g SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure b1 pros ide
this affidavit will result in the denial of the Issuance of the building permit.
} Signed Affidavit Attached? Yes .......... ❑ No.......... ❑ I
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
{ I, as Owner of the subject property hereby
e
9 authorize to act on my beh:df, in all minters
g relative to work authorized by this building permit application.
i EEp
Signature of Owner Date 7
Y/n //9 SECTION 7b: OWJINEW OR AUTHORIZED AGENT DECLARATION f
I, " /f/AN I/" , 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.
t
7�fgnm
-�
fowner or Authorized Agent Date
er the ains and nalties of •r u )
NOTES:
ner who obtains a building permit to du his/her own work,or an owner who hires an unregistered Contractor
gistered in the Home Improvement Contractor (HIC) program). will rent have access to the m'bitrionm orguaranty fund under M.G.L.c. 142A. Other important infinmation tin the HIC Program and
uction Supervisor Licensing (CSL)can be found in 780 C'MR Regulations 110.146 and 110.115. respectively.
-' When substantial work is planned.provide the information below:
Total flours area(Sq. Ft.l (including garage, finished hasement/atttcs,decks or purchl
Gross living area(Sq. Ft) Habitahle room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of had l/baths
Type of heating system. Number of decks/porches
Type of curling system Enclosed open
1 "Total Project Square rootage•' maybe substituted fore "Potal Project Cost•'
. CITY OF SALEM
3
it PUBLIC PROPRERTY
DEPARTMENT
�ryrN P
�IVitP KI P1' ItRlia �tl I
V1.A!i. It [IN;;1,�N 11RI 1-.1 • S.tl
Workers' Compensation Insurance Aftidasit: Builders/Contractors/Electricians/Plumbers
ilicant Information Please Print Le ibl
N;ltllC t liu;ins>s t Irtdnvuuun I dt%uluall'.
UST
City,St:ttciZip: Phoned: 9/� ✓Tr���
Are you an employer'.' Check the appropriate box: "1-ype of project (required):
I.❑ I :un a employer with 4. 1 aut a general contractor and 1 6. ❑ New construction
tmpluvees.(full and/or part-time).' have hired the sub-contractors 7. ❑ Remodeling
❑ 1 ant a sole proprietor or partner- listed o i the attached
have 8. ❑ Demolition
sheet.
;hip and have uo employees fhese su
i workers' ewnp.-Insurance. 9, ❑ Building addition
working for me in any capacity.
[No workers' cum insurance 5. ❑ We are a corporation and its
p. 10.❑ Electrical repairs or additions
required.] otticers have exercised their
i ght of exemption per NIGL 1 L❑ Plumbing repairs or additions
3.❑ m r
I ❑ a homeowner cluing all work S P P
myself. [No workers' comp. C. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers 13.y Other`?2? &Ale
comp. insurance required.]
•:\ny,grplicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t I lomeownere who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
-t'ontr.¢nvs that cheek this hox nmst attached an addo Tonal sheet showing the name of the sub-contractors and their workers'comp. lim Policy inform .
l ant an employer that is providing workers'compensation insurance far my employees. Below is the policy and jab site
inl'orntation.
Insurance Company Nano:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address:$����
���! (/II�P�� City/State/Zip: u[L /�i"
Attach a copy of the workers' compensation policy declaration page (showing the policy number and e. piration 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 1.500.00 and/or one-year imprisonment, as well as civil penalties in the torm of a STOP WORK ORDER and a fine
,tt up to S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Ince>ti�ations of the DI:\ for insurance ruvcrage vcrificanon.
l do hereby aerril.l.under the pains and penalties al perjury that the injirrmation provided above is true and correct.
Date:
I'httne
011icial ase only. Do not write in this area, to he completed by city or town ofjiciaL
('itv or Town: _-- _--- PennitiLicense #----__---—----
Issuing .%whority (circle one):
I. Board of Health 2. Building Department 3. Cihil'orrn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone #:--
Information and Instructions
NI:uS:nrlu tsc Is (ie Ile I al Laws chapter I Is 2 requveS .111 ei np loser to prim%[de workers' compensation Ior their employees.
I'unu.tnt to this statute, an esmplut'ee is &Ilned as ". cm cn person in the sea ice of another under any contract of hire.
c\prrss or implied. oral or written...
ALL emplurer is Joined as "an imli%idual, p.tntcrship. association. corporation or other legal cntin. or any mo Sr store
of the tiuegoing engaged in ,join cntcrprise. and including the legal represcnt-.tises ota deceased employer. or the
reccim cr or trustee of an individual, part tiers],ip. association or other lc,-,al entity, cnmploy ing enmplovices. l lowever the
,,•a tier Ora dwelling house haying not :pore than three apartments and who resides therein. or [lie occupant of the
dw el ling house of aIIOTIICr who employs persons to do maintenance. construction Or repair work on such dwelling house
Or on the grounds or building appurtenant thereto Shall not bCeanie Of Such eumpluyinent be deemed to be an cmplo}'er. •
NI(if_ chapter I i2, j25C(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, NIOL chapter 152, s25C(7) states "Neither the coimnonwcalth nor any of ifs political -subdivisions Shall
enter into any contract for tine performance of public .voik until acceptable ct idence 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) mmne(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 he 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 (lie event die Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permiulicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permiulicense 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 atfidavit is on file for future permits or licenses. A new atfidavit 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
t i.e. ;t dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Orrice of Investigations would like to thank you in advance for your cooper non and should you have any questions,
Please do nut hesitate m give us a call
File I)cpartnmcnt's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. tf 617-727-4900 ext 406 or 1-877-MASSAFE
Kc%i;cd �-'0-05 Fax k 617-727-7749
www.mass.gov/dia