28 GROVE ST - BPA B-2009-173 aka B-9-185 _ The Conunonwealth of Massachusetts
t Board of Building Regulations and Standards It W
MassaehusettS State Building Code. 780 CNIR. 7 edition I �I
Building Permit Application To ConSttuct. Repair. Reno(ate Or Demolish a Rri,,,/hmmi,
(her- or Torr-Fm,ril) [)itdlin,q 'r
i, � — This Section For Official Use Only -
-7
,13u�tkdfingermit Number: Date Applied: _� '•
Signature: -- V� --- ----- -.
Rwld(ng('uuumsswned Inspector of Buildings Dale
SECTION 1: SITE INFORMATION
1.1 Propert,�ddmbs: �� S 1.2 Assessors Nlap & Parcel Numbers--— --- -- - -- --
C7Y
I. la Is this an accepted street.' ses II0 Map Numher. Pound Nun(hcr
1.3 Zoning Information: 1.4 Property Dimensions:
_ I
Zoning District Proposed Use Lot Area(sq it) Fronwge(lit --
1_5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
! Required Provided Regm red Provided Required PI'oVdcd
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''
Check if yes❑ Municipal ❑ On site dislwsal ey+tein ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnert of Re rd:
�i „� M." d Z y tiro •� ST
Name(Print) Address for Service:
PDemolition
ure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
onstruction ❑ Ezisti ng Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ AJditi� 1 ❑
❑ Accessory Bldg. ❑ Number of Units Other ❑ Specily:
Description of Proposed Work'': L 2 =
bFlL 2fziA. /�ryfYVV/L� I
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
!rem tl_abur:md Materials) Official Use Only
I. Building 5 ��'pqr oo I. Building Permit Fee: 8 Indicate hose tar a determu)eJ:
❑Standard City/Fown Application Fee
2. Electrical $
❑Total Project G)at (Item 6) s multiplier s _
I Plumbing S 2. Other Fees: S
J. Mtchaniad (HV:\C) $
List:
i. Mechanical (Fire $Su, ressiont rotal All Fees: S
Check No. Check :\mount _ Cazh :\nnnurt -- -- -
bFotal Project Cast: S ❑ Paid to Full ❑ OublanJmg Balance Doc:
LL, 1� {64 a�6�
SECTION 5: CONSTRUCTION SERVICES _!
5.1 Licensed C list ruction Supervisor (CS I.) -
�I='ZrJ-_D I
.Vninhrr I!�lu r:uln I):na
Name IIISf.sl lulder _ w (f l
. ^ LmI CSL I\pC i�ri hilal
a Dish ,Ilan
\JJIis �� l t in'so''Ltid in
It,
75.0 IU
-- / L-. --- R Resmic!eJ 1,1:2 F.untls
1lgnatw • \I >l:uunrs Onf.
_ ___ _ RC Rca&IIIIal Ruululg l'usinn
i lcplu mp \U IL:.IJi nil cal
Q • /�- r. J (J ^ _^ lF Ki,idi , SnhJ I 1. l IBilllli n, �„I s.'Iinlall.il
�iJi In i.11o"J Un iiulilum I
ed Il i 5.2 Registered n proveme Con
tractor onractor (1110
j r , times
HIC Comp:ut) Nalne or HIC Registrant Name- RcLutiauun Number
— 72 (.�i Is C r-"T 2, d SA Gam•, 7- / l -
\JJrns
- awle --- l'clepinnti
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT INI'.G.L. c. 152. S 2506))
Workers Compensation Insurance affidavit must be r,,mplcted .md submitted with tins appbi:ti:,n. F:ulure to pmu Ide
this affidavit will result in the denial of the Issuance of the b!.rilJ!ne permit.___
Signed Affidavit Attached? Yes .......... ❑ .vo .. .... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED 1VHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. - _---- as Owner of the subjecl property hereby .
authorize _ _ _____ to act on my behalf. in :JI ma([ern
relative to work authorized by this buibfing permit aoplic.;tion.
Signature of Owner -- - --- --- Date
SECTION 7b: OWNER( OR AUTHORIZED AGENT DECLARATION
1 __ , as Owner or Authorized :Agent hereby decline
that the statements and information on the t'oregoing application are true and accurate, to the best ut my kno\viadge and j
behalf.
Pont .`Jame ---
Signature of Owner or Authunzed Agent Dale
(Signed under the pains and penalties of er u )
NOTES:
I. An Owner who obtains a building permit to du his/her own \vork. or an owner who hues in unregistered conmik-,T
(nut registered in the Home Improvement Contractor(HIC) Program), will not here ❑cress to the arhioation
program or guaranty fund under M.G.L. c. 142A. Other important intitrmmiun on the HIC Prngr:un and
Consouaion Supervisor Licensing (CSL) can be found In 780 C MR Regulations I IQ.R6 and 1 I0R5. rcspeiusely.
' When ,ubsiantl:d work is planned, pn>vlde (he information below
Total flours area ISy. Ft.) (indudtng garage. finished basemen Uaulcs. Jecks or ponhl
Gross living area ISO. Ft.) Habitable room count
Number of fireplaces Number tit hedroums
Number of h.uhnuims Number of halt/hash.
1'vpe of heating system _ Number utdeika/ poiLhcs
I\pe utcooling s),tem
1. "1'ued Project .Square Footage" maa be subs(ituted for Total Project Cost.
' CITY OF SALE:M
>
r � PUBLIC PROPRERTY
DEPAK"I'MENT
�,..,...
UA"dnV,.,
('construction Debris Disposal Affidavit
(required li,r all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Code, 780 CMR section 1 1 L5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit tf is issued with the condition that the debris resulting from
this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
- I name of hauder) - -
I'lie debris will be disposed of in
C (name of laciluy)
(address uflacility)
t�-
. . ,ignmur prnnit applicant
plate
CITY OF SALEM
' PUBLIC PROPRERTY
'a` r DEPARTMENT
:�`.�p�
\1Xs(Ia fZC WAsill."610N Sl'<M' • SAtby+,MANS., la it.I.Is01`)7C
71•.1.: 778-'l5.9595 • P.sx.97x.74C 9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
\ t yltcant Information Please Print Leeiblv
slalnl lliu<incss qr anu:uinlc`Indivuluufl: l S
1(Idreis: 7 �r 7�i� l
City,State,Zip: 5�q lee-x, m 0/ 1 W Phone I
I Are you an eat ploycr? Check the appropriate box: Type of project(required):
4. ❑ I am a general contractor and 1 6. New construction
I.❑ I am a employer with have hired the sub-contractors ❑
elployces(full and/or part-tints).• 7. ❑ Remodeling
2 I :ua a sole proprietor or partner- listed on The attached sheet.
ship and have no employees These sub-contractors have ti. ❑ Demolition
working for me in any capacity. workers' comp. Insurance 9. ❑ Building addition
No workers'comp. insurance 5. ❑ We arc:t corporation and its 10.❑ Electrical repairs or additions
1 required.] officers have exercised Their
right of exemption per MOL I I.[] Plumbing repairs or additions
3.❑ I ant a homeowner doing all work S 12.❑ Roof repairs
myself. iNo workers' comp. c. 152, S 1(4),and we have no
insurance required.] r employees. [No workers' 13.❑ Other
comp. insurance required.] 11
-.4m:�,pbcanl Ihul checks box AI ma>I alYn IIII oil, he tiCIIJn know sbowina their werkmll'cumpenf lion hullcy information.
' tlomnlwnon who submil this affidavit indicating Ibuy are doing all work and I I him ooKisk caarxtun must.,uhmit a new a1LJavi1 indiwong ouch.
-C,,niraclur,Thal check this box must aaachod enaddinimal..,heel.hawing the"ante of The sub+ontracton and their workers'comp.Policy infurmaton.
,it, an emplayer that ix pravidintf workers'c•untpetrsadon insurance for illy employees. Below is the pulicy and job vile
information.
Insurance(.'ontpany Name:
folic., 8 or Self-ins. Lie. t: Expiration Date:
Job Site Address: __ _ Cityrstate/Zip:
Attach it 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>IGL 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 up to S250.00 it Jay against the violator. lie advised that a copy of this statement may be lur,xarded to the Olitce of
Ineesngamns ul'the DIA for iniurar.cc coverage (cnlic.11ion.
l du hereby certify wider the ttins and pentdlics of perjury that the informution provir/crp/above iiss tru ate!correct.
w„v Date'57
O(lfciaj list only. Da not "•rite in thir area, to be completed by city or town ajJiciuL
City or fawn: --- .. Pcrmitil.icensc 9._ ..
Issuing .\whurily (circle line):
1. DourJ of Ilcahh 2. liuildin:; Dcparunent 3.City.'I ossn Clerk 4. Electrical Inspector 5, Plumbing Inspector
6. Other
Contact Person: _ __ Phone th
Information and Instructions
,Vassachusetis General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an einpluree is defined as"...every person in the service.of another under any contract of hire,
Ctpress or Implied, oral or written."
An employer is defined as"an individual,partnership, associatiou, corporation or other legal entity, or any two or more
of the toregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of all individual,paltnership, 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."
\1GL 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, S25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomhance 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 nuniber(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 Depurtment of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he retunhed to the city or town that the applicationfor 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
111oase be.sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple perniUlicetse 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 niust 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he t)Rice of luvestigations would like to thank you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call
The Depernnent'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
R:viscJ 5-_'G-US
Fax # 617-727-7749
www.mass.gov/dia