21 FLINT ST - BUILDING INSPECTION (3) t /
vA
a The Commonwealth of Massachusetts
/J I } Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised Jurwury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 200.1
' One-or Two-Family Dwelling
This Section For icial Use Only
Building Permit Number: e A plied:
Signature:
Building Commis toner/Inspectub6f Buildings Date
SECTION 1:S E INFORMATION
1.1 Property�ddr ss: ,,A 1.2 Assessors Map& Parcel Numbers
chi l /y/;n Ss . '4
L l a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use i Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
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 es❑ Municipal❑ On site disposal system ❑
_ SECTION 2: PROPERTY OWNERSHIP'
2.1 O n'r'of(Recrd:
ato t(, ant) Address for Service:
Sign lure 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 ❑ Specify:
Brief Descr' lion of Proposed Work':
Owe ee
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(It 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S Oi/4. D 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) i^ g i S -3 l/�Q j
A4�«// 5.,A d er S License Number Espirutiun Note
Name of CSL- I��lul��l1e�r List CSL'I'ype(see below)
fy Pe
Descri twn
01 Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature �/S �� 4—S M Mason Only
RC Residential Roaring Covrrin
Telephone WS Residential Window and Sidinit
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered !Ionic Improvem t Cy+Nracpr`IC) �3 /
HIC umpan IN ranee or IC Re ar;tnt Name �—� Registration Number
o i
Ad. 's —� _ . -. Expiration Date
S uture " elephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 9 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 BUILDING PERMIT
1 J O er 9f One subject property hereby
authorize G m behalf, in all matters
relative work authorize*by this building pe tt application.
%D /2 O
Si,
i a ore of own Date
SECTION 7b: O pWNERt OR AUTHORIZED AGENT DECLARATION
I, I:: 4 r'rl/// Scc n-d +C/"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.
Print Nam / y^ /
Signature of Owner or Authorized Agent Date ,`,S,J�{
(Si mired under the pains and penalties ofperjury)
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&ol 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 110.116 and I IO.RS, 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.) jCg�� 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 One
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
0110,11 • MLitt - I:C\YA4au.. LV 51'Ntri •).\II N,\L\..\I �ItJ I,.:I'l•:
-N 1•rl•'I)t•.•�t%W� 1 t°\:t:y»•NS'/111A
construction11 Debris un�13 renovation 111d,v"
(requi• 'ult edition of the State Building Code, 730 CMR section 111.3
In accun!uxt with the st c 40 S 54: from
MGL resulting na ul debris ff
visions the
Debra, and the pro is issued with the condition that c
16 _ fined b MGL
Building Permit M 1 Gernsod waste disposal facility as defined y
phis work shall he disposed of in a proper y
I 11. S I50A.
The debris will be transported by: f
putne of hauler)
The debris will be disposed of in
Ina"of Willy
(mkims of fxdity)
sanaturs'If Wlmit applicant
f� 1119 Ja a 10
.late
i
Massachusetts- Department of Public Safet%
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 68153
1
DARRELLJ SANDERS
25 DOTYAVE
DANVERS, MA 01923
v�L if-fsy� Expiration: iogr2012
('onunicvionrr Tr#: 4486
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.i uLl of FY:)KNCr n.I.
\1\Yoa I!�^WMHINci IUN ST$ELT • SALEM,Msss.xca II SI.'I l s OI97^�
Tkl,978-745-9595 • 1'.sx:978.740•9s46
Yorkers' Compensation insurance :Vffidavit: Builders/Contractors/Electricians/Plumbers
t rlicant Information Please Print Le ihly
Name IBucincsyOrganvatioNlndw utuu4: .�
:Address: ���✓�
City iSt:ac;%ip /TS�"�/o•(�7 Phonei::
Are you an employer:' Check the appropriate box: "Type of project(required):
4. ❑ 1 general contractor and 1 Few construction
1.❑ 1 an,a employer with am a 6. ❑
el rlo ecs full and/or urt-tinte).r have hired the sub-contractors
y ( p 7. ❑ Remodeling
un a sole pmpricto pa listed on the attached sheet.
tl and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers' comp. 5, El We are a corporation and its
� insurance officers have exercised their 10.❑ Electrical repairs or additions
acquired.] a
3.❑ i ,tm a homeowner doing all work right of exemption per MG 1 1.L ❑ Plumbing b repairs or additions
P'
Myself. (No workers' cop. c. 152, j 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. iNo workers' i�
IUther
comp. insurance required] O
-Any:yiplicaut,lul checks box BI must also fill our the se-chen Lclow showing iheir workers'cumpenvnion pulicy udionulium
r i fomeuwners who suumit this nflldavir indiuung lhc-y are duing all work ana then hire oulside cumm- lam mull autmtil a new al'r:davit indicting such.
4'orlrtcu,n Ihar check this box mull ailwhcd:m additional Wheel.hawing the nmne of the subcontractors and licit workers'comp.pulicy information.
/our all employer that is providing workers'roo pensnlion iosurnrree for my employees. Below is the policy and lob site
ioforrrratiun.
Insurance Company Name:—.. - ...—..----....---------
Irolicv a or Scif-ins. Lie. n: .. .. ._-__ Expiration Date: _
Job site Address: city/Slate/zip;
Attach it copy of Ilse workers' wtnpen.sation policy declaration pale(showing; the policy number and expiration date)..
Failure to secure coverage as required under Section 25A of.'vIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to s1.51to.00 and/or one-year imprisoluncnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up its S250.00 it Jay against [Ile violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invcsngauoos of the DIA for insurance coverage verification.
ilia hereby certify under the pains and penalties u erjury 1h inforination provided above true ind correct.
O[/idol a se only. Do not nvite in this area, to be completed by city or mrvn afficiul.
Cgty or'fown: _ _ Permit/l.icvnse X.___
Issuing,tuihurily(circle one):
I. Iluard of llcaith 2. Duildinq Department ]. Cityi I'o,s it Clerk 4. Electrical Inspector 5, Plumbing Inspector
6. Other .--- - .
Contact Verson:---._. Phone#:
r
Information and Instructions
.,tassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eniplo'ycts. '
Pursuant to liiis,tatwe, an empli myee 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 ail individual, patmership,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 in employer."
.%iGL 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 ol'cunipliance 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 rcnimed io 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(lie 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 permitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple perink/lieetse 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 muit be filled out each
year. where a hone 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.
I he 01 'icc Ot Investigations would like to thank you in advance fur 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
Department of Industrial Accidents
OPHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. tl 617-727-4900 ext 406 or 1-877-MASSAFE
K,viscd 5-26-05 Fax #617-727-7749
www.mass.gov/dia