18 FORT AVE - BUILDING INSPECTION f The Commonwealth of Massachusetts
C��U( Board of Building Regulations and Standards CITY OF
Massachusetts State Building Cute, 780 C NIR SALEM
( ) Building Permit Application TO Construct, Repair, Renovate Or Demolish a
\ One-or rnu-Funuh' Dwelling
This Section For Official Use Onl
Building Permit Number: Date Applied:
Building Official( not Name) Sift'aI Dote
SECTION 1:SITE INFORMATION
I.I Propel y Address:: 1.2 Assessors,flap& Parcel Numbers
1.1 a Is this an accepted street?yes na Map Nuniher Purcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zaaing District I'ropuscd Ule 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.1.c.40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ tone: _ Outside Flood Zone?Chock if vsO Municipal❑ On site disposals),tun ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner(of Record:
N/CK/- 4Z-Al'' 00 -7 U
Mane(Print) "�� City,State,LIP
/y' rv2T AFL s,,AAc*P, quo z"� /JONR--�
No.and Street Tcle hone
P Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demulition ❑ 1 Accessory Bldg. ❑ Number of Units_ Cher O Specify:
Brief Description of Proposed work-:
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor;md.\Materials) 01TIcial Use Only
1, Building S 1. Building Permit Fee: f Indicate how fee is determined:
'. lAccirital S ❑Standard City/Tuwn Application Fee
❑Total Project Cost(Item 6)x multiplier
lier
7. I'lumhing S -
_. Other fees: S
1. \kch;mical Ili1'.\<'1 S List:
\lah;mical (fire — '--- -----
su +ressionf S Total .\It Fees: S
h. Total Project Cost: S `y 00d. Check No. _ _('heck Amount: - _ _-- (',iih \mount
❑PaiJ in Full 13 Outstanding Balance Due:
L i
SECTION 5: CONSTRUCTION SERVI('F.S
5.1 Construction Supervisor License(CS1.) /G Z Z 9 J /`rT (Z�
` ---- --- —I y-tc
License Nuohcr I �+ir lie 111:ne
Mune ol'CS`I./I(older
3 C7 C.+Z A1'S� �� I isl CSI. i\ bel Pe(sec ow)
1'%P' K",n
Description
Na. .uld 5trcet q
I Iafluildin-s li Io 15.000 cu. 11
R Re2 Fumil DwdlinC'ilsil'own.State./IP SI MaRC' RorinWiidin
SF SolningAppliances
((('"�411 MAD G1/� �avZ<CU�� �� I Ins
I'cic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) l!/��f:!l
IIIC RegistratioII IIC ny Nw a or I IIC'Rcgistrunt Name
N�md Iq/� -T—(Y-7 ll�7(��/
City/Town,State,ZIP J rel(c hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atIldavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Y .......... ❑ No...........O
SECTION a:OMINEIR AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize /)' �' ' M
to act on my behalf,in all matters relative to work authorized by this building permit application.
/V(CK If,�Gd�✓l� 19P) /` /U
Print Owner's Nano(Electronic Signature) Date
SECTION 7b:OWNERn OR AUTHORIZED AGENT DECLARATION
By entering my name below.I hereby attest under the pains and penalties of perjury that all of the information
connttaained in this application isis true and accNratato the FofliS towledge and understanding.
PrintOwncr'sur:\uthoriieJ \gcnt's ulnaIFlcaronicSign;uurc) etc
NOTES:
7registered
r who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
nottered in the Hume Improvement Contractor(HIC) Program).will no have access to the arbitration
or guaranty Lund under M.G.L.c. I4_2A.Other important information on the HIC Program can be found at
��! of I Information on the Construction Super isor License can be found at ++)+++.tim, �_�� IIll,
bstantial work is planned, provide the information below:
ea(sy. 11.) - 1 including garage, finished basement attics.decks or porch)
Gross living area uy. 11.) _---- -- _-- . -- Habitable room count --- --- _
\unlhenlf tircplaces,..-.. Number of tiedrnums
l Vumherofbathroois — — NumbcroffmIt'h;uhs
I\lie of heating i)stem _ Number of decks, pordles . . .
I'pe of Aoolillg '%stelll Mlle lo>CJ llpen
I
1. "fatal Project Square Footage'may he substituted for"total Project Cost" 6006
CITY OF SiU_EM, ,NL WSACHUS.ETTS
Y BUILDING DEPARTMENT
a9 jl 4- � 130 �'//.\SNCdGTON STREET, 3ra FLOOR
TEL (978) 745-9595
F.11.e(978) 740-9846
KniBERLEY DRISCOLL
AYOR T1-o&w ST.PiERRa
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\L\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Am licant Information Please Print LeAihiy
V;uttc lOatilks.�OrWtniratiorulndividuol): ev'. /G/`/--
Address: 1L9 /Gp-% 4-vP/
City/State/Zip: sue° /t Phone#:
Are "lu an employer9 Check t e appropriate box: type of project(required):
1rIS.J I am a employer with 4. ❑ I am a general contractor and a 6, ❑New construction
employees(full and/or part-time).• have hired the sub•conlractors
2.0 Ian a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These subcontractors have V. ❑ Demolition
working for me in any capacity. workers'comp. insurance.
). ❑ Building addition
[No worker'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3,❑ 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself.(No workers'comp. c. 152, §1(4),and we have no 12,❑ Roof repairs
insurance required.) t employees. [No workers' 13.0Other
comp, insurance required.)
Any upplic:ml Ilus ducks box MI must alw rill uut the section below showing their worker'compensation puliey innntnation,
'I Lvneuwncn whu mbmit this affidavit indicating they am doing all work and i then hire outside conirctan mini submit new omdavit indi,miny ruck rontmewn that check this Dux mull oexhud an addiliuwl+heel showing the owns er the subeontndws and their wohm'wrap.policy infannalion.
l am an employer thatIs providing workers'compensation larurancefor my employees. Lre/ow Lr the policy and job site
inforuration.
Insurance Company Name:
Policy 4 or Sclf-ins. Lie, d: 6 L 9` els,,Z0 7/' Expiration Date:
Job Site Address: / Kh` '��
City/State/Zip:
\each a copy of the workers'compensatloa pulley declaration page(showing the policy number and a spirit tfon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
lino:up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the term of STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. De advised that a copy of this statement may tau turwarded to the Office of
Investigations Oft lie DIA for insurance coverage verification.
I du hereb err ' the pubis and penaities of perjury that the is armatimr provided above iv tru and carnet
�t n uurc x n�y��/
Vhnlc
[6. 0i"t
ial use way. Do not write in arts area,to be completed by city ar town ojjiciaL
i
i
r'1'awm _._ __ Pcrmit/i.lccnsex
g Atithurify (circle one): -
urd of Ilcalth 2. Duildim„ Depurlutenl 3.Citylr"wn Clerk J. Electrical Ltspuctur i. Plumbing Inspector
1cr
ct Peraro: _ _ Phone 1f•. ._ --,--
l
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 Ikensing 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-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
he 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. Sclf-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 permittlicense 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"ail 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 cooperntion 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
OMce of Investigations
600 Washington Street
Boston, MA 02111
Tcl. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5--6-05
www.mass.gov/din