22 FOREST AVE - BUILDING INSPECTION u
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
di 7'"0 CMR
Massachusetts State Building Code, 78 , edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 4 '1- --0 1
One-or Two-Fanuly Dwelling
(� This Section For Official Use Only
V^ Building Permit umber Date Applied:
Signature: Bu- 1 ;2/ '
\� J il ing sione Commisr/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Prop ddress: 1.2 Assessors Map& Parcel Numbers
r
I.Ia 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:
PublicpcPrivate❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
l2 wner'of Re d::
a ( int) AcTdress for Service:
� V � >'6
Signature Telephone
SECTION 3: DE'SCRIP'I'ION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s)' Alterations) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brie escription of Pro ed rk2:
K019 A,1
SE ION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost (It e 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ aid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ® / it O
License Number
4'C'. Expiration a
ame o CSL- Qld r List CSL Type(see below)
ddress 1'h.' C, '1/N T Description
U Unrestricted(up to 35,000 Cu. Ft.)
(A IA A t R Restricted 1&2 Family Dwelling
to M Masonry Only
RC Residential Roofing Covering
Tel phone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
egistered omq Improvement Contractor(HIC) T ���. 9 ,
Y
ompan Na eo IIICf Registrant ) Re istrat n Number
ssS `+F'^ a
�W piration Datt
nature elephone
SEC ORKERS' PENSATION 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 BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, . ' h4 f/"�--J ,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
YM e
pame
re er or Author zed Dat under the pains and
6 - t I :::-- NOTES:
I. An Owner who obtains uildin ermit to do his/her rl_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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.115,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.) 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"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.1Vi'.: N I SI1xIR + I1
\1 o'44 11CW,t>tu.\si IoN S lxutr • intr.\l, it II\Jl%7^�
li.l. '778-71595'15 r I:>.x 9711-711'-1s16
Workers' Compensation Insurance :\ffida.ir. Builders/Contractors/Elrctricians/P lumbers
111icant information Please Print Le ihly
\,lillne 16u,,IW%s,Organ.ruina'I ndlvduall:
:dill l-05ti: /�
c ily,Starc'zip: If l one il: OV
Are y%ou an employer? Check the appropriate box: �ri,pe urpruject(required):
1. :fin a employer with m 6, ❑
4. ❑ 1 a a general contractor and 1 new construction
❑ 1
cngtloyccs(full and,ur port-tulle).• have hired the sub-contncwrs 7. ❑ RtmoJeling
t 1 ;fin a sole proprietor or partner- listed on the attached sheet.
,hip and have no employees These sub-contractors have tl. ❑ Demolition
working for me in any capacity. workers comp. Insurance. q. ❑ Building addition
Igo workers' comp. insurance 5. ❑ We are it corporation and its 10.0 Electrical repairs or additions
l required.] officers have exercised their
i ht of exemption per MCI.
I I.[] Plumbing repairs or additions
3.Ela m r
I am hom
eowner doing all work g
Myself. LKo workers' ctanp. c. 152. ¢1(4),and we have no 12.❑ Ruof rcpai
insurance required.] 1 employees. LKo workers' I J. ILer
comp. insurance required.)
-4m .pphum IbW chucks took,01 must:asu Till um the.ccuoo bcluw shuwina,hea workc,i cumpensmiw+lwlicy inliartutiWt.
' I lomm+wrwrs whu>+a+ntil this aflfdavis indiuuns they aIn Jinn,Ill work mul Ihcn hire uutsiae cu+urxwn must submit a new alraavis inainrna.neA.
-fomrxtun Ihut shock thus box must atlaahsd.m aaditiunll slxrl.huwina the u:nne of she suto.mnrwlon and shelf%urkess'comp.policy mformarion.
/,fill fin nnployer that ix providing Ivurkers'c'unipen.vation in.curauc-e jar tisy entpluyee.v. Below is the policy and fob.tile
infunnatian.
In>urance Cunipauy Vmne: ---- -
volicv a or Sclr-ins. Lic. n: . .. ExpirWlon Date:
tub Site Address: ----
City,StataZlp:
Attach a cupy of the workers' compensation policy declaration page(showing the policy nutuber and expiration date).
Failure to>ccure coverage as required under SCd1Un 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/or une-year imprisonment, as well as Coll pcnalltu in the 1'urtn of a STOP WORK ORDER and a fine
.>f till to 5250.00 It day .Igalllst Ilse volaror. lie advls(:d that a Copy of Iht> piste nent inay be forwarded to the 0111ce.of
I nv c.ngauuns uf;hu DIA :or muss: iwc cat crags tClinc.imn.
/ /a herrby i crtifY nod the painv and pasnhiev of pert thul d infurinallon provided above is true aml correct.
Dire
I'Itr. • u
U/Jic'iul use us y Du lot write in this area, to bt c pleted by city up folver 1/)it iaL
( iry or fnw•n: _,._ __ Ycr mitll.icenu 0_
Issuing Authurily (circle one):
I. N„ard of llvalth 2. Building ncparuncul 1. Cily.'fuoo Clerk 4. L•'Icctrical inspector 5. plumbing In>peetor
6. Olhcr _
Coutael l'c r>uu; -. _ Phone tt:
rw
Information and Instructions
\I:usaihu.ietts Gcneral Laws chapter I i2 requires all engllo)ers to provide workers' compensation for their employees.
Pltr]rt:ull to tnis statute, an empkgee is defined irs"...every person in the service of another under any contract of hire,
evpre» or implied. oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity,or any two or more
,a the toregoing engaged in apnnt enterprise, and including the legal representatives of a deceased cmplu)cr, or the
receiver or trustee of aal Individual, pantncrship, association or other legal cnnty, 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 it,. the grounds or building appurtenant thereto shall not because of such employment be deemed to be in employer."
..\1GL 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. bIGL chapter 152, a25C(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-contractors) namc(s), address(es)and phone nuiober(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 dale the affidavit. The affidavit should
be renmmed 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'rown Offlclals
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.
111casc be sure to fill in the pennit/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 shnuld 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. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I h: i)I InCc of lmi'e\tigatlons would line to thank )ou in advance for your cooperatlol and should you haY,:ally questions,
please do not hesitate to give us a call.
The Dcparunent's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PRoPRERTY
DEPARTMENT
construction Debris Disposal .- ffidavit
(retluired lirr all demolition and rcno\atiort \%'ork)
In accordance ill, the sixth edition of the State Building Code, 780 CTIR section 1 1 1 .5
Debris, and the provisions of MGL c 40, S 54:
Building Permit t is issued with the condition that the debris resulting from
this Naork shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
manic of hauler)
The debris will be disposed of in
n CAl \�1^ a)
t namr ul acihty) /
Iaddre;� of I]c�lnvl
i¢n cdp:nnrt .ipt hcaut
ll
.I m