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29 GRANT RD - BPA-16-13 REPLACE TUB . NECEIVEO CES C-K I OZ 8 The CominonwCiLitwloltklaisaclitisetts CITY OF W Board of Building Regulations a d d rte SALEM Massachusetts State d' - , �aC'de 80IR Revised,t)ar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For-Official Use O -I Building Permit Number: Date Applie / L building Ol)icial(Print Name). Simalure,: ' Date 1 SECTION It SITE INFOR+NATION t.l Property ►dd�ss: 1.2 Assessors Map 3r Parcel Numbers 1.1 a Is this an acce led street9 yes no_ Map Number Parcel Number 1.3 'Zoning Information: 1.d Property Dimensions: "Coning District Propose)Use Cot Area(sy R) - Frontage(Il) - - 1.5 Building Setbacks(R) nSupply: - Side Yards Rem Yard' Pro, -Required - Provided. Required - Provided c.40,§5d) 1.7 Flood Zone Information: I.S Sewage Disposal System: Zone: Outside Flood Zone? oOdisposalsystem ❑Cluck if es❑ SECTION2: PROPERTyO�VNERSNIP!' ?2.1wjner'ofRccord: Q -7 ) City,State,ZIP S�IiNSdAl IFd At ` L Nu.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK4(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) 11111 Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION 4:ESTIMATED CONSTRUCTION COSTS Item - Estimated Costs: OfRclal Use Only Labor and INIaterials - - I. Building $ "�Q�� 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Costj(item 6)s multiplier s 3. Plumbing S 2V?plher Fees: .S d.iMcchanical (HVAC) S - List: . i\Iachanieal (Fire $ "total All Fees:S .3 ressiwt) ` Check No. Check Amount: Cash Amount: 6. Total Project Cost: S ]It`�C3© ❑paid in Full 0 Outstanding Balance Due: sENr t [ I2 SECTIOiV`5:"iCONSTRUCTION SERVICES 5.1 Construction Supervisor License(6SL). CS--io 1 L{ 7 Z 2 Z ZO 17 l�l�lAa.� 6 .P r04Q 'Pr License Number E pi tiun Ua e N;mie of CSL Holder p 1 List CSL'rype(see below) JZ No.and Shea Description . -et n TY. ' . •, . Unrestricted B;Minas tip-to 35,000 cu. 11. �C" . Restricted 1&2 Family Dwelling Cityfrown,State,ZIP M Masonry RC Roolina Coverinit WS Window and Siding rb%s ;c4A'�cr`laro CD SF - Solid Fuel Burning Appliances 97Y- �6( -�'I(.�(• L O\o C or, I 1 I Insulation Telephone Email address D I Demolition 5.2 RegisteredHoome Improvement Contractor(HIC) L 0 1 1 Z 1 5 U i /✓Ik" U 'd- SD�1 �-EY\ HIC Registration Number npi tion Date HIC Company Name or HIC Registraftl Name �^ - �Z G >- t G 1 1 l . Nd treet Email address mr Ci/Town State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G.L.c.I5;.g 2SC(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 ..........IN No...........O SECTlON7a:OWNER AUTI{ORIZATION:TO BE COMPLETED WHEN OWNER'S AGENTOR CONTRACTOItAFPLIE9 FOR BUILDING PERM1IIT' 1,as Owner of the subject property,hereby authorize ASS t9 act on my half,in all matters relative to work authorized by this building permit application. - rat Owners ant ectronic Signature) C n Dale ECT[ON 7b:OWNERt OR AUTHO IZED AGENT DECLARATION By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in t ' application is true and accurate to the best knowledge and understanding riot Owncr's r Au ro 'zcJ Ag•nt's Name(Electronic Signature) O ate NOTES: I. An ner who bt ins a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in_the H0, mprovement Contractor, (HICPProgram);will our have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other tm ortant information on"the HIC Pro gram can 6e-1ou`nd al www rnass.cov.'oca Information on the Construction Supervisor License can be-found at www.mass.^ov/Jos 2. When substantial work is planned,provide the information below: "total floor area(sq. R.) Co' r °L(I 's (including garage, finished basement/attics,decks or porch) Gross living area(sq. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths 'rype of heating system Number of decks/porches 'rype of cooling system Enclosed- Open .3. "Total Project Square Footage"may be,ubstituted I'or"Total Project Cost" V The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERINIITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): SS � ZAddress: Ccd I—V i Lw t / r City/State/Zip: tz ` /" `fir Phone#: U 8`— Are you an employer?Check the appropriate box: Type of prJCdd quired): 1 I am a employer with employees(full and/or part-time).' 7. ❑Newtion 2. I am a sole proprietor or partnership and have no employees working for me in $. Rem any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Dem 4.❑1 am a homeowner and will be hiring contractors to conduct all work on m roe . I will 10 ❑BuildtionYP P �tYensure that all contractors either have workers'compensation insurance or are sole I L❑Electairs or additionsproprietors with no employees. 12.❑Plumairs or additions5.❑1 am a general contractor and I have hired the subcontractors listed on[he attached sheet.These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer,that is providing workers'comp sacton insu once for my employees. Below is the policy and job site information. Insurance Company Name: L// V C\ I 7 1 Policy#or Self-ins.Lie.#: B G D(Y M L Expiration Date:— Ll t Job Site Address: 4'4� City/State/Zip: J S Q/� / Ir, Q/� •70 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance CoverageMlifAyderthe Tdoherely ai penal s of rju y that the information providd hove ' trueandcorrect. Date:Pone#: � "' G Q /'— , Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• 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 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,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 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 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. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 -Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15, www.mass.gov/dia Q-I Y OF SALEA MASSAGiLISEM BmDnaG DEFARTAeNr 120 WAgmgGxNSTREET,3IDFLooR TkL(978)745.9595. BDvJBERLEYDRIS FAX(979)74D.9846 �LL MAYOR TYIrAS STREW DntEcrcat oFr[1BLTcFRomm/BuaDm ooIIssromit 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 c40, S 54; Building Permit d is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: W (name of hauler The debris will be disposed of in: (name of facility) (address of facility) 7 S'gna ure of applicant Date q i , /J I f Office of Consumer Affairs and Business Regulation n �.' 10 Par k Plaza - Suite 5170 Boston,'Massachusetts 02116 Home Improvement Cad' tractor Registration �,: t Registration: 181929Type: DBA - f Expiration: 5/12/2017 Trp 266179 DIMAMBRO & SON CONSTRUCTION ROSS DIMAMBRO 32 CEDARVIEW ST SALEM, MA 01970 inC a ;� juY` Update Address and return card.Mark reason for change. scn t c, zom-osin - Address ❑ Renewal ❑ Employment Lost Car �• �N�mnmwyun«cl��6`vLawJG�Lude/ta - �_ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before!the expiration date. If found return to: egistration f81929 Type: Office of Consumer Affairs and Business Regulation Expiration; 5/12/2017 DBA 10 Park.Plaza-Suite 5170 DIMAMBRO&SON OQKSTRIJGTION Boston,MA 02116 - ROSS DIMAMBRO 32 CEDARVIEW ST SALEM, MA 01970 Undersecretary Not valid without signature Massachusetts..:.bepar I I 1 rnervt of PUb�i^ Safety r oard-ot Buiiding,i2ec ulations ari,4 < "Constructinit ktpire lco i4 ° . License:-CS-107473 .. ROSS DIMAMBR9- 32 CEDARVIEW"STRE„E,T - Salem MA 019W cxpiraban Commissioner 05/22/2017 -