7 FRONT ST - BUILDING INSPECTION i
File Conunonvi calth of tMassachuseW:
t Board of Building Regulations and St ild u,!s i I'( IIL
i\ielssurhuSCttS StatC Building Code, 7W) CNIR 7"' edition - `II Nil, II 11 I 1
1uildIng PerIIIii Application To Consrluct. Repan. RuuosdIc 0r I)emolI I a
(her- in- Tnv411mily DlrrNin,q
J--- 'this Section For Official Use Only —
Budding Permit N er:
—
ISwI:.mE ,d Buildings Dale
-- --- -- —_-- —SEC"PION I: SITE INFUK:\L\'PION
I - —
1.11 Pr,:grerty .Address: 1.2 .Assessors Map v; Parcel Nun;hcrs
GI :!� •.-'Fled ofRU CY , Nfa�, u:l:hvf
'_..;
Zoning C ;uia _ proposed Use _ Lot NCa l`W Ytl _i,.:ItluEe Iltl —
I��—__
1.5 Building Setbacks (ft)
From Yard Side Yards Rear Yard
! ReyL1110d Provided Reyuued Provided Raywred Pro,IJrJ
F
_J
1.6 Water Supply: (M.G.L c. 40. g 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ Oil .I;e u1tiIN)`;aI :•}"Ic"� O
Puh!ic ❑ Private ❑ Check it yes❑ P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of R d:
Address l'or Service:
Sien:•t,,w Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
Neu C•onstructiun ❑ Emsting Building ❑ Owner-0c•vpied ❑ i Rc0,10 tS) ❑ Alteration(s) ❑ Addition ❑
Damolinon M, Accessory Bldg. ❑ Number of Units r:_)th�er ❑�ecily.
Brio! Uescrip:io!n of P:opused Work''.... .—_ — —.--.--_— —II
SECTION J ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
,or a(Lund Materials) -I
--
I Ruilding 5 1. Building Permit Fee: $ Indicate how i fee is Jcle nuncd:
L— ❑ Standard City/ own Application Fee
'_. Electrical S ,
_ ❑ Total Project Qrsr (Item 6) It multiplier x _
jl-3. Plumbing S 2. Other Fees: S r
a. Me6i:tnical (HVAC) S List: ���✓`� --
i. titechanicdl IF:rt ,s ------
Su rxes,i,n) Total All Fee.: $
Check No. Check :\mount ---('.I,h \nn nuu _- ._
b ruin\ Project Cost: 0 Paid in Full 0 Outsl:mding Balance -_- -
SECTION 5: CONSTRUCTION SERVICES
F5.1 Licensed Cooslructimt Supervisor (CSI.)
Li,time Number I:ynr.uum Dal i
Nal n•oI CSL IIoIJer
LI't CSI_ 'I\pr err hclow I
T
JreeI •
v e Uescn �tion
1. Llllt'1111L1ed ,tl ,(o ;i.IN)u Uo I'fi
— R Resumed I.vr2 Fann IN Dwellure
S i�slcuuro N1 Nla t nn Onls _
RC Rr.idvnual Radinc Cot eini`
heephone \\'S Rc,td ntwl N%wdm, .md Siduic
SF Ri,id.nu.J .Suhd Duel ISu moue \phli.ul.. Imi.JLam�m ,
D ReslJeuual Uruwlutm
5.2 Rexistered Ilome Improvement Con actor IIIICI
� 7��'Z r� ---
il IC Company .Name or IIIC Reentrant . ` ne Regutrauon Number
,d es C't`j� _��5 - F.spuation Dale
Si nature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506)1
Workers Compensation Insurance affidavit must be completed and submitted with this application. F:ulure to proslde
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 un my behalf. in all matters
relative it) wol k authorized by this building permit application. j
i i
I
S ature of Owner Date
SECTION 7A: OWNEW OR AUTHORIZED AGENT DECLARATION
1, , 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 ame
Signjftke of Owner or Authonzed A t Date ( 1
I Si ned under the pains and penalties of neriurvi
NOTES:
I. An Owner who obtains a building permit to do his/her own work. or an owner svho hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under IM.G.L. c. 142A. Other important inhumation on the HIC Progr in and
Construction Supervisor Licensing (CSL)can be fiend in 73O(:,%IR Regulations 1 IO.RO :md 1111.125, re,pecuselc
' When substantial work is planned, pruvlde the information below:
(including garage. finished basernent/atti". decks or to t:hl
(oral flours area 1 Sq. Ft.I g d g I
Gross living area I Sq. Fr) Habitable room count
Number of fireplaces Number of hedrooms _
Number of bathrooms Number of halt/h.ohN --
fspe of heating system __—_ Number of decks/ heN
Type of roolmg system — Lnclused --- --
3. -Total Project Square Footage" may be subsmuted tier food Project Cost- — -�
CITY OF SALEM
'� I PUBLIC PROPRERTY
== J ' DEPARTMENT
Construction Debris Disposal Affidavit
(Ivrluired Ibr all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 C'1`1R section I 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit t is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l t 1. S 150A.
The debris will be transported by:
iname of hauler)
I'he debris will be disposed of in
(name of facility) -
(address of 1461ilv) `
nature of permit applic t
�o
date —
-- CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:J\tl::of I[1"dg11CVl.l.
\1.\)ou 12C WArHINGio.NSrxLp.T • S:LL Ii)1,M.\$.1.\(,IH SE I ISO 1970
11:L:978-.745-9595 • Pax:978-7449840
Workers' Compensation Insurance Affidavit: Builders/Contractors/El Pease Print Leeiblv
Plumbers
n flicant Information
Name ll)u iocxs Or�anizatioNlndlvldual):
City slareizip: e"o' Phone ,'.1:
:-,re you an employer? Check the appropriate box: 'Type of project(required):
4. El am a general contractor and 1 6 New construction
an a employer with ❑
employees(full andror part-time).' have hind the soh-contractors listed on the attached sheet. 7. ❑ Remodeling
2.❑ 1 ;mt a sole proprietor or partner-
ship and have no employees These subcontractors have 8. ❑ Demolition
workers' comp. Insurance. 9. ❑ Building addition
working for me in any capacity. 5. El We are a corporation and its
(Ko workers' comp. insurance officers have exercised their 10.❑ Electrical repairs or additions
required.] 11. Plumbin're, airs or additions
3.❑ I am a homeowner doing all work right of exemption per MIS ❑ b "P'
myself.[No workers' comp. C. 152,g 1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. (1\o workers' 13.❑ Other
comp. insurance required.]
-,4nv u,plicaut that ei,ceks box ill musl albo IIII out the 4:QIon Iw1ow showing their workers'compensation pulley infurnulium
`I Iomauwners whu submit this affidavit indicating Iho)are doing all work and Own him outside contractors must submit a new affidavit indiutmg such.
,C' t t rx that check this box must mtwhed an additional..1h••t showing the name of the subcontractors and their workers'comp.polity information.
l our an employer that is providing workers'compensation insurance for my employees. Below is the policy and job.rite
information.
Insurance Company Name:
--
Expiration Date:
I'olicv:t or Self-ins. Lic. *.'; ___..._..._. ..-----
CitylState/Zip:
Job Site Address:
Attach t copy of the workers' compensation policy declaration page (showing the policy number and expiration 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 S1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of rep to S250.00 a day against tilt vh)letnr lie advised that a copy of this Statement may be lurwarded to the Office ut
I u\.atigati�.ms ofthe DIA for insur;uxe covcragc cciiticatiun.
l do he c wader tine Paine and enalties ufperjury that the information provided above is true and correct.
Dar '
Sicaowrc: __ - -
I'hl�nc 7: �o-7�• �'�
OQicial use only. Do not tvrie in this area,to be c•umpleted by city or tolvn official.
City or Town: -- Pcrmit/Licensc'4___..._.
Issuing ioulhurily (circle one):
I. ISoard of health 2. Building Department .S.City/town C'Ierk 4. Electrical Inspector 5. Plumbing Inspector
6. Other --- -
Contact Person: _-... -.--_ Phone th
Information and Instructions '
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their cnmployees.
Pursuant to this statute,an emphgyee 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 ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of:m individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house havingnot more than three apartments and who resides e' t p therein.or he 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."
`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, ,lv1GL 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 aft-rdavit 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 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Phase be sure to till in the penmitllicense 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 burn leaves etc.)said person is NOT required to complete this affidavit.
l'hc Office of Investigations would like to thank you in advance fur your cooperation and should you have ;uty 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
Otflee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
itcviscd 5-26-05
Fax #617-727-7749
www.mass.gov/dia
. Id
•BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 092960 a
Birthdate: 12/08/1969
j Expires: 12108/2009 Tr. no: 92960 1
i
Restricted: 00
? KEVIN M OKEEFE
397 LINEBROOK ROAD
IPSWICH, MA 01938 commissioner F
• � �� 29PYILIRS+R(6/a�- 6�•.•��Q.kaLf.�ll(JCCCd
• Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 149742
Expiration: 2/6/2008
Type: Private Corporation
OKEEFE BROTHERS CONSTRUCTION INC
y KEVIN OKEEFE
1 397 LINEBROOK ROAD �_.,,emu✓
IPSWICH,MA 01938 Administrator