4 GALLOWS CIR - BUILDING INSPECTION The Commonwealth ol'Massachusetts
t Board ol'BuilJing Regulations and Standards CITY
y j Massachusetts State Building Code, 780 C'MR, 70 edition OF SALEM
Nevised Juin4ury
Building Permil Application To Construct, Repair, Renovate Or Demolish a /. _rNAY
One-or Two-Family Dwelling
This Sqd1lon For Official Use Only
Building Permit Number: Date A d:
Signature:
Building Commissioneq Inspector of ful)aw f}ate
SEC ON 1: SITE INFORMATION
1.1 Properry A dress: 1 '� 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Informatlo 1.4 Property Dimensions:
_
j fee
Zoning District Proposed Use Lot Area(sq 11) Frontage(tl)
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: 1.3 Sewaga Disposal System:
Zone: _ Outside Flood Zone?
Public O Private O Check if es0 Municipal O On site disposal system O
SECTION2: PROPERTY OWNERSHIP
2.1 Owr�rt of R o `
gels I I1711ecdc, L/� _� V Cr//d yl/S cl� rc(
Name(Print) Address for Service: C
9 V Ze k
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) ❑ Addition 0
Demolition O Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work':
i O
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S g-Q Q(� I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S O Standard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier x
J. Plumbing S 2. Other Fees: S
4. Mechanical (iIVAC) $ List:_ "
S. Mechanical (Fire S
Su ression Total All Fees:f
Check No. Check Amount: Cash Amount:
b. Total Project Cost: S ? a D D 0 Paid in Full O Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 101 LZ Q /6 1 L
I.icense Number I:tpiratiun Uale
Nam C'SI.-I lgldcr S, I.is1 CSL Type tree below)
n
f 17escri ion
J ss — U I Inrestricted u to 75,000 Cu.F1.
R Restricted Id2 FamilyIhvtiling
Si aturc M M Only
RC Residential Roolin Coverin
I'vleplrme WS Residential Window and Siding
SF Residential Solid Fuel BuntingAppliance Installation
D I Residential Demolition
5.2 Reeblereed-Horr/�e_Imp vementvC n#p[tor(HIQ /f�! 7 7
lS 4C /RAG/.ri dJ� �K t .6,7 ,Z1J e
I IIC Company Name or IIIC Registrant Name Registretion Number
s a s ; z
ddsAL /O LELYXSS/ E.Apiratitin Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. I52.S ZSC(6))
Workers Compensation Insurance atrtdavit 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...........0
SECTION 7s: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,�I /!n m TY i—
� J 12 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of(honer or Authorized Agent Date
Si under the sins and mities of 'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L.c. Id2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.116 and 1 IO.RS,respectively.
? When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage, finished basementlattics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfhaths
Type of heating system Number of decks'porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may be substituted for"Total Project Cost"
^. CITY OF SALEM
s
141 . lr PUBLIC PROPRERTY
DEPARTMENT
IJ�n::'RLISI'DNIK:ULL.
12C.W AS&II w I ON S'rxet:T 4 SA ua3,M.tssnra n-%I ISO 197.^
Ti i1 978-745-9595 o Pas: 978.740.984E
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A 3 ilicant Information nn Please Print Legibly
Nametl3usiii"s/OrganizatioNlndividuu4:/ /q TOC4/1!'A �� (ton S1tL
Address: a��
Cily/slatc Zip:�h n Phone h: W-1 so Lly y
Are you an employer?Check the appropriate box: 'Type of project(required):
I. 1 :I i a employer with 4. ❑ I am a general contractor and 1 G. ❑ new construction
employees(full and/or part-time).' have hired the sub-contractors
?.❑ i :un a sole proprietor or partner-
listed on the attached sheet. �• El Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. - workers' comp. insurance. 9. ❑ Building addition
To workers' cum insurance 5. ❑ We area corporation and its
� p• 10.❑ Electrical repairs or additions
required.] oftiecrs have exercised their
3.❑ 1 ant a homeowner Doing all work S exemption right of per MGL 11.❑ Plumbing repairs or additions
P P'
myself. [No workers' clmtp. C. 152, j 1(4),and we have no 12.0 Roof repa s
insurance required.] t employees. [No workers' 13.0 Other Oar
cmnp. insurance required.]
-Ally o,plicaut thot chucks box fit must:dam lilt out the sechun lxlow showing their workers'cumpens:aion policy m i,rmulium
' I lumcuwnen whu submit this affidavit indicating They are doing ull work a.us then hire outside conunctom must eubmil a new affidavit indicating such.
C omr.,ntun dial check this box mast anwhcxl on additional shut showing rho name of tho sub�contraetom and their wvrkan'comp.policy informatiun.
l am am employer that it providing workers'c•ainpcnsrttiorr insurance jot•aty employees. Below is the policy and job.site
io/orinatiUn.
IltiUfaI1CL•Company Name:
policv 4 or Self-ins. Lie. t•': � U w� d�—Df Ill.O_ L Expiration Date: J j
Job Site Address: 7 ��6WU rs S7 City/Stateizip: �
Altach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
I-'ailuic to secure coverage as required under SCChon 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up m S250.00 a day against die violator. lie advised that a copy of this suacmcnt may be forwarded to the ODice of
Investigations of the DIA for insurance coverage verification.
/r/u hereby certij tins r hr.,win.' Berta/t' x uj//p/rip drat the iujorinatlon provided ab per
true and correct.
Si :taturd. /� Datc. ���/ y
r
Plrmc +:
OJJic•iul use only. Do net sprite in this urea,to be completed by city or town aJJiL al.
C'ityorTown: Permit/l.iccnse'd--_. --
Issuing(Aulhorily (circle one):
1. Board of Health 2. Building Department 3. Citiffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
G.Other
Contact Person:___ .. _._-- Phone 0:
1�a Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree 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,pattnership,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."
NIGL 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. NIGL 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 rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors names , address es)and hone numbers along with their certificate s)of
PPY• O O ( P O g ( -
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 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 fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and tinder"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 tilled 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.
The 011ice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Dcparnnent'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
Revised 5-26-05
Fax f#617-727-7749
www.mass.gov/dia
CITY OF SALEM
y, r>
PUBLIC PROPRERTY
DEPARTMENT
IVP+. nMIPI 9a, i'!I
�d �� �r I?C,A'�;u1%,.:ON s nud r \,;.\, ,u iis
.I.ri, I'.\s: 978..74_9546
Construction Debris Disposal Affidavit
(required lbr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Cv1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
-- (name of hatder)
The debris will be disposed of in
(naine of facility)
(addre.s of lacilityf
J
denature of pcnuit applicant
FS 3 1 a
date --