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8 GLOVER ST - BUILDING INSPECTION The Commonwealth of Massachusetts g > Board of Building Regulations and Standards CITY OF T a Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Fancily Dwelling This Section For Official Use Only Building Permit ber. 4 1Date Applied: _/// Building Official(Print NaaneV Signature Date SECTION 1: SITE INFORMATION 1.1 Prty Addresss�C 1.2 Assessors Map& Parcel Numbers 1.1 a 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 It) Frontage(II) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Zone: _ Outside Flood Zone? Private❑ Check ifyes8-� Municipal 0-On'site disposal system [3 SECTION 2: PROPERTY OWNERSHIP' 2oO�nRr�ofRecord: M� �l+ �.V'Ct� l I v Name(Print) City.State,ZIP V GC S a C9-w) 609 ,2(37 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work': b eeuznr� at lot C A'M_ rcf1l r ce< t' SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1. Building $ C7M 1. Building Permit Fee: $ Indicate how fee is determined: �. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier -x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ _ Suppression) Total All Fees:$ Cy Check No. Check Amount Cash Amount: 6.Total Project Cost: $ ! 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 ConstructiqLi Supervisor License(CSL) 1 i,h.el License Number Expiration Date Nami of CSL Holder List CSL Type(see below) No. d Slree[ hE Type Description I, M� e2or--% U Unrestricted(Buildings tip to 35.000 cu. fi.) Cityll'own,Slate,ZIP R Restricted 1&2 FamilyDwelling M Masonry RC Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances I I Insulation Telephone Email address D Demolition 5.2 Registered H e Improvement Contractor(HIC) '/ 19� Z —�1.f..11�� a. i HIC Registration Number Expiry ion Date HIC C��ppyyn N:kue or F41C Re Mtn dame �`iA w�BKtRa �y�,gCA X 2kG _ cSR64re11 x No. Z)S eet A aln` Email address City/Town, State,ZIP '_l•ht'— "�/� Tele hone 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. 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. CARS R, LovoiF— raR. ,- e S G 20// Pnnl Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information c atned in this clattiion is true and accurate to the best of my knowledge and understanding. wA Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 can be found at w•ww.mass.uov octt Information on the Construction Supervisor License can be found at www.nrvss.LovldL 2. When substantial work is planned, provide the information below: Total floor 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 # �r PUBLIC PROPRERTY a �r- DEPARTMENT ,�eu::a:rY;1MIXanI \I e1e Nt 1 2^\r/A%ffVNlilts\51'xEkl•t SAII!.N,MAN.S.w.111 it I IsJ1'97� 11:1: 011-7.I3-9393 o P ex. 979-740.9346 Workers' Compensation Insurunce Affidavit: Builders/Cuntracturs/Electric)ansiPlumbers ifunlicunt Inform'rtion Pleaxe Print Leeibly Vd171O l nuankvs/1)r;lanu�linrvindlvlduul l:_����r�,(�K��1( Address: I CC�--�hl ,r� City,Slarci%ip: C � d Phonert: 1Are to an vmployer:' Check the upproprlote box: Type of project(required): 1. 1 am i employer wish_.� a. 31:on a general contractor and 1 fl• 0 new construction employees(full ind/ur part-time).• have hired the suh•cunuactors 2.0 I ant a solo prnprictflr or partner• listed on the amachcd.heat. 7• ❑Rernodeling ship and have no employers These subcontractors have g. Demolition working for me in any capacity, workers' comp. insumnce_T __q_0_puiWing-nldiriun )k'nwnrkcn'eoinp, lnyu�ance 5.-- lYe arc u rnrpernhnn and its required.) officers have exercised their 10.0 Electrical repairs or additions ).0 I ant a homeowner doing ill work right of exemption per 'M 1 I.0 Plumbing repairs or additions myself.(no workers' comp, C. 152, §1(4),and we how no 12.0 Rouf mprirt insurance required.) t - arpluyecs, too worker' comp. insurancemqui Ld 13•OOther \n).glpheatd Ihas Rucks boa to mass also rill uus the reeuon buluw dwwine IMir awkeu'cumptnuuiun polity in6umuCien 'a Cutrluttwnan whe wlhmll Chill smdavif indicative Ilw•y aw Joint all work and deco him alnfids cuuracron mass oulanil a new al'ndsvif inJiulina atuh. -('anerxfun Thal check this box mums anwhed an addifiunal..lava deuwine Che nanw of rho sofa enjracaaof,and their wuritan'comp.("they inRemlasiut. /run un eugalloyer,bur Is providing ivorkers'cutnpenrtaion insaraace/br,City a op/uyeex. Br/owls the puW�y cant/cab a'ib ia`ornfu,ion. Insurince Company Valve: � �- -� ©sue �...._.��'�`_�_►�lfay Policy A car Scif-ins. gqL,,icc.�.y: ._ . .._ Ex iralwn Date: Job Site Address:S..JC�l.,jei —��— - I„_- L..l C'uy,State/"Lap:_ °L 1 V� Attach it copy of flat workers'wmpvnsatlon policy declarallun page(showing the policy number and explratlun date). FaIIafC W 1eCU,C e0 ge as rcq cd under Scctiun 25A ul'JIGL c. 152 can lead to the imposition of criminal penalries of a Foe kill n)51.500. and/or one•y i ilnprlxnlllnl:fl(,J.Y well is civil penallle:a in the form of a STOP WORK ORDER and a fine of kill rn i250.001 Jay aguinst file v Anor. Ire advised that a copy of this slulcmcnl may be furwirdcd to Iha Office uC I'll' -NllgJlmns of ill• UTA IOr I.)SII ; ice covcfa�e 1 e1'itic Jilern. /Ju hereby earlify It, ♦the ttinv and penult/ex u/per/ary Chip,the injurrnatlon provided above is true and correct il-,;rlturc. W p) 0)7 -K21 cl f41"Clul Itre wr/y. Ou,m 'wr ite in Nair area, tube completed by airy or town o//ieiuL i I Citv Car'Dawn. Permit/LieenSetl- Issuing.\uihurify (circle one): I. ltl,urd 'f Ileallll 1. llufldinq Ilvparmcnl .1. (:ilyi funm Clerk J. Electrical Inspector S. Plumbing Impeelor I 6. Ol iwr C.,141Jcl I'erwit: _ . . Phone l: information and Instructions .Massaehuseus Uencral Laws chaptcr 152 requires all eery erson in the service of anothers to provide workers' e ndetr+ally c ntrict of hue far their cillpi s 1'ursuaiii to this astute, in rmpluyrr is debited as"...every p - avpresx or unplicd, oral or written." hip,association,corporation or other legal nifty,or any two or more An employer is Jefincd as"an individual,Partners a the tbregoh+g engaged in a)wm enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of.m Individual, partnership,sssoc atioa or other legal entity,employing employees. ItaweVCr the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant el the or on ire goose of another r who employs urtenantersons to do thereto shall notnbecause of such construction employmnt be deemed tit on o an employer or on the grounds or building app MUL chapter 152, @25C(6)also states that"every state or local licensing atteney shag withhold the issuance or renewal of r license or permit to operate a business or to construct buildings In the commonwealth for any ;renewal who has not pro educed'•acceptable evidence of cumpllanie with the insurance coverage required:' appliadlicant w �IGL not r 152, a25CM;rates"Neither the commonwealth nor any of its political subdivisions shall rater into say contract chapter the pertormance of public work until acceptable evidence of cumpliarrce with the insurance have been presented to the contracting authority." requirements of this chillier Applicant please-Gll out-the-workers' compensation affidavit complew -p by checking the boxewith thaeir-erttificatc(s)ufour on and,if —— necessary, supply sub•contractor(s)namc(s),ajdiesa(ea)and hone numbers}along insurance. Limited Liability Companies(LLC)or Limited Liability (If aa)with or L employees does other than the members or partners, are not required to carrycompensation employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial %ccidents for confirmation of insurance coverage. Also be sure to gig"Bad dale the of idavlL The affdavit should be returned to the city or town that the application for the permit or license is be ing requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' t the number listed below. Self-insured companies should enter their compensation policy,please call the Deportment a self-insurance license number on the appropriate line. City or'rown Offlelaq Plensc be sure that theaffidavit is complete and printed legibly. The Department has provided u space at the bottom of the affidavit For you to It out in the event the Office of Investigations has to contact you regarding the applicant. Pl.ase be sure to till in the permit/license nwnbor which will be used as a reference number. In addition,an applicant that mmt submit multiple penmitllicmtse applications in any given year,need only submit one affidavit indicating currant policy informatitin(it necessary) and under"Job Site Address"the applicant should write"all"lucBtiuns 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 nut each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture t i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he t)i tice of Investigations would like to thank you in advance fur your cooperation and should you have,my questions, please do nut hesitate to give us a call. The U:partlnciWi address, telephone and fax number The Commonwealth of Mtiltsachusettil Department of Industrial Accidents OMCS of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 x:•. . d 5-]o-ns www.mass.gov/dia CITY OF Smym. NL-kss kcFiUSETTS • BUIIDIING DEPARTM&NT ' 120 WASHNGTON STREET,3 °FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KISCBERLEY DRISCOLL MAYOR THo.+c►s ST.PtERas DIRECTOR OF PUBLIC PROPERTY/BUtMNG CO\DnSSIONER 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 I l 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit # 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 l 11, S 150A. The debris will be transported by: (name ofhau r) The debris will be disposed of in Cc (name of facility) (address of facility) signature of permit applicant date .Icbnvlf J•k