52 GALLOWS HILL RD - BUILDING INSPECTION (2) t The Commonwealth of Massachusetts
Board of Building Regulations and Standards
FOR
Massachusetts State Building Code, 180 CMR, 7n MUNICIPALITY edition USE
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised January
One-or Two-Family Dwelling 1, 2008
Th' Section For Official Use Only
Building Permit Number: Date Applied: vc7
Signature:
Building Commissioner/In pee or of Buildings Dates
SECTION 1: SITE INFORMATION
1.1 Property Address: q 1.2 Assessors Map&Parcel Numbers
v
l.la Is this an accepted street?yes no Map Number Parcel Number
13 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSIIIPt
2.1 Owner Record:
Name(Pri) 71 Address for Service:
Signatu Telephone - -
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : thl�r tG �L_e e L-Y�st�] d�';#J 6,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing 1 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
a� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ fs;; @�t ❑Paid in Full ❑ Outstanding Balance Due:
D %/io
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed`Construction Supervisor(CSL) I(72�1j-� 0 O �2+
` et License Number Exptio11n ate
lAddres
-Holder List CSL Type(see below)1!
y
T e -Description
vKf- Unrestricted u to 35,000 Cu.Ft.OD
Restricted 1&2 Famil Dwellin Mason Only
(01� 2��C+o Residential Roofin Covering
Telephone Residential Window and Siding
Residential Solid Fuel BurningAppliance Installation
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) I&n 0'�
,Tait a,� CR^A�'�161A !-
HI Com ny Name or Re istrant Name Registration Number
Address
(Olt 10 Expiration atc
Si a Telephone
SECTION 6 WORKERS'COMPENSATION 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.
1.
Signed Affidavit Attached? Yes .......... ❑ No...........
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AaNT O CON RA TOR APPLIES FOR BUILDING PERMIT
NZ
as Owner of the subject property hereby
authorize 7_�ot�i J ji^n�I to act on my behalf,in all matters
relativeo work authorized this building permit application.
Si ature of Owner Date
SECTION 7b: OWNER OR AUTHORIZED AGENT.DECLARATION
,yt!4DLA 1D 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�Ta
lo
Si to o ner o Autho d Agent Date /—
Si ed under t1wimffris and penalties ofperjury)
NOTES: .
1. 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 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.R5,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"
_n7l?
CITY OF SALEM
PUBLIC PRUPRERTY
l � DEPARTMENT
.Nut;N:1'Y:1x ISC, I
vl.lr,as ILC Wd{HIM;l on STx ELT a SA P.M.MASSACI II if.1-1101')7.^
11•a.:V8.7 4i9595 is p.sx. 978.74C-f:146
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
%imlicant Informalion /� r/ Please Print Leeihly
Name llhtutkss/t�r;;anir:ttinNl�ynJiv uluul): C_ �•kf�T-1LI -0 �" ' � '� 1 •� �
Address: ^d `li/� t9 CS )
City,State,Zip: Yy I ' Phone (CJ �� �� � l � 0
:\re you an employer?Check the appropriate box: 'Type of project(required):
1.❑ I tun a employer with 4. ❑ lain a general coutractor and 1 6. ❑ New construction
t
cal lu ecx full and/or J[Plllle).• have hired the sub-contractors
P Y ( p 7. �Retnodeline
2.'� I ;tin a sole proprietor or partner- listed on the attached sheet. :
ship and have no employws These sub-contractors have S. ❑ Demolition
working Air inc in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'comp. insurance 5. ❑ We are a corporation and its required.) of 10.❑ Electrical repairs or additions
officers;have exercised their
Y❑ I ant a homeowner doing all work right of exemption per NICL 1 LE] Plumbing repairs or additions
myself. (No sgorkers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t cinployces. (No workers' 13.0 Other
comp. insurance required.)
-:city e,phcaut atat checks boa 01 muse also fill out the w:cuau taauw flowing their work tit campenamiun pulicy influmativa
'I lumaowran who udtmil this affidavit indicating they ate daing all work and then hire outside cNunwicu,must.uhmif a new af'fdavit indicating wwh.
d'.mnru;u,ra that check this box must auachad.m addiliunal Acel+hawing flit name of the sub-contracto6 and their warkurs'comp.rmlicy infurmation.
f ant an anployer that&providing Ivorkers'c•nmpcnrntioli hisarance fur uty eurpfayees. Before is the policy mrd job.rite
iuforatusiam
Insurance Company Name; _.. _
Policy 4 or Sclf--ins. Lic. N: __.. _._.__ Expiration Date:
Job site.-address: City;Stateizip:
Attach it copy of ilia workers' compcnxation policy declaration page(showing;the policy number and expiration date).
Failure to secure coverage as required under Section 25A ui'1IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/ur one-year imprisonment, as well as civil penalties in the lbirn of a STOP WORK ORDER and a fine
of up in 5250.00 if day against the violator. Inc advised that a copy of this smternent may be forwarded to the Office of
Ina'rsngations ul'thc DIA for insurance coverage lciitiullon.
f da hereby certify rur,Aa 11 .-pr� ricer'. Id penuhies oflierjrtry that the infurinultion provider/,above is t tie and correct.
tii�•:runrc' Dale l(�t�Z�
F
ial use nary. Dd nal write in this area, to he completed by city or town ojJirial
or Tneyn: Permit/License X._ng;Authority (circle one):ard of licallh 2. Building Department .1. Cilyi fmsu.C'lerk 4. Llectrical Inspector 5. Plumbing; Inspector
her
Contact I'cnuu; _ .. Phoned:
Information and Instructions
�lassachusets Gencral Laws chapter I52 requires all employers to provide workers' compensation for their employees.
111irsuam to this sutu(e, an empluree is defined as-...every person in the service of another Under any contract of hire,
cvprcss or implied. oral or written."
An einployer is defined as"an individual,partnership,association,corporation or tither legal entity, or any two or more
.d the t0regouig engaged in a Joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of in 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."
:`lGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewul 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 fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub•contractor(s) namc(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 dale the affidavit. The affidavit should
be retuned 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 time affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
111case be sure to fill in the pennitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pcnnit/licetse 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 "rill locations in (city or
town)."A copy of the affidavit(hat has been officially stamped or marked by the city or town may be provided to the
applicant as proof chat 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.
I he 01,61ce of luvestigations would like to thank you in advance fur your cooperation and should you havc,ny questions,
please do nut hesitate to give us a call
"fhe Dcparunent's address, telephone and fax number:
The Comrnonwealth of Massachusetts
Departrilent of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. N 617-7274900 ext 406 or I-877-MASSAFE
Fax N 617-727-7749
Kcvi>ed i-26-05
www.mass.gov/tile
CITY OF S.UE.NI, .L1SSACHUSETTS
• BI:ILDLNG DEP1RT%t&NT
120 W.ASHLNGTON STREET, 3"FLOOR
T L (978) 745-9595
PAX(978) 740-9846
Kl\IBERIEY DRISCOLL
'I
MAYOR >:to.�us ST.PIF.RRS
DIRECTOR OP Pt:BLIC PROPERTY/13EMMLVG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 .
Debris, and the provisions of MGL c 40, S 54;
Building Permit At is issued with the condition that the debris resulting from
this work shall be 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 hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
ig u re of par 't applicant
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-\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR {
Registration; 162014 {
�apirtiBon 12/26/2010 Tr# 279220 ¢
Type fidividual
j JONATHAN SANTILlO {`t
JONATHAN SAN71LL0
48 FAIRMONT ST -.t.wQ+
�. MALDEN, MA 02148 Administrator