4 HAMILTON ST - BUILDING INSPECTION The Conurtonksealth of Massachusetts
i Bowd of Building RcUulations and Standards FOIL
MaSS7CI7t1SIOUS State Building Code, 730 C'MR, 7 edition
o Building Permit Application To Construct. Repair, I2enoeate Or Demolish a Krri,r,Lliuu„u r
One- or Tit o-Fumil v Duelling 100S
' ion For Official Use Only
Building Permit Nun bee Date Applied:
Somaure: 60/� 6p
Building nnmiesiuoeOln uildiugs Date
SECTION 1: SITE INFORMATION
I1ropt y� Address: S 1.2 Assessors Map & Parcel Numbers ;
l FA O.� I
i.Lt is tf-pis :ui a�c_�!zd �t_..et'r y.es_ nu _ Map Number P:arcl \'umho
!.3 Zoning loformatlon! t IA Property Dimens3onc!
Zoning District Proposed Use Lot Area(sq It) Frontage Uil
_.�
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:
}.disposal Zone: _ Outside Flood Zone'? Municipal ❑ On site dis l s stem ❑
Public ❑ Private ❑ Check if yes❑ P I
SECTION 2: PROPERTY OWNERSHIP[ )
2.1 Omer'etf Rtr Uo (rd^ o f 9A et,
y Lq f zt, ( Lo., S
Name(Print) J Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) LA' Alteration(s) ❑ Additikm ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units Other ❑ Specily:
Brief Description of Propose Work'': -- -- --- __—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and_Materials)
L Building $ I. Building Permit Fee: $ Indicate how tee is determined:
❑Standard City/Town Application Fee
]. Electrical $ ❑Total Project Cost}(Item 6) x multiplier�l x
3. Plumbing $ 2. Other Fees: $ `
4. Mechanical (FIVAC) $ List: (�
5. Mechanical (Fire $
Suppression) Total All Fees: S
ezy Check No. Check Amount: ('ash :\mount: __
6, Total Project Cost: S $250w ❑ Paid to Full ❑ Outstanding Balance Due:__ __
, J
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) 6gi 7q-5—�L
License Number F:apiruiun Date
Name ol'CS L- 1 older .r
List CSI_'I')pe (see btlowl y
26 Ira S �F
Wdres. f' e Description
_ C Cnresricted tap to 35,000 Co. Ft.)
It Restricted I&_ Fa nu lv Dsselhne
Sign/gtur•
r' �� q01 ^ ��� RC Rcsidrnlial Routine Cu\en ne
Telephone K'S KrsJrnuul \V mdulc':rr! S�Jine ___
SF Ri sidrntial Suhd Poet Burnnie \ l llnmcc lust.illaW u
D Re>idenli:l Demolition
5.2 R1�gtstered Ilome Improvement Contractor (HIC) �� /
hi rt.f a\\ r f J a P l
HIC Compan Nmne or HIC Re isuant Name Registration Nullifier
zs J s el. 0f- , Mfg lot y
Address `z. ( �—
Fy,pirnLm G):0.0
Signature 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.
Signed Affidavit Attached? Yes .......... Ulm 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.
Signature of Owner Date _
--� r SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, II n- Iz--v, 4ellf-^- am-1 . 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. ��\\
:30 L v 1 1 A f vt.. a.t,._ � —
. Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of edu )
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut 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 750 C•MR Regulations I IO.R6 and 110.R5. respectively.
2. When substar ial work is planned, provide the information below:
Total floors area ISq. 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 half7ba(hs
Type of heating systeri) .. Number of decks/ porches -- --__—_--
Type of cooling system - Lnelo::ed Open _ _ __-
3. "Total Project Square Footage- may be Substituted for "Total Project Cost-
CITY OF SALEM
PUBLIC PROPRERTY
�•;o / DEPARTMENT
. ... \Ls.. It _ --I'_ \\ s.i�: .�,.,,� il!:ii1 ♦ i,. : st. \I tom.t� !.• ,i '� . :I I�:
8--t3.;at; • P\I, I-S.'1..'IS all,
Norkers' C'ompensation'Insuranc :V'fidatit: Builders/Contractors%Electricians/Plumbers
Please Print Leyibly
\ ) tltcant Information
�.11I1i inc.rlc., I Ir__.Ill v.m.In In.11s idualC ��'�- �, .�'1/l-iz� b "• f 1•^L (.-.ry`f �
\.Idf\a,:
2(� QN�V\ t6— r
('ity State.Zip: 1°1C0 "\ trVt CRISt Phone 4:
\re you an employer? Check the appropriate box: 'type ofproject (required):
I.❑/run a emplo)'er ss ith __L— 4. ❑ 1 and a general contractor and 1 6 ❑ New construction
employees(full and'ur part-time).' have hired the sub-contractors 7. ❑ Remodeling
listed on the attached sheet. t
2.❑ I :un a sole proprietor or partner- I hose sub-contractors have S. ❑ Demolition
;htp and have no employees workers' comp. 9
insurance. ---
working for me in any capaci(y. . ❑ Building addition
No workers' comp. insurance 5. ❑ We are a corporation and its Iq ❑ Electrical repairs or additions
required.) officers have exercised their
11. Plumbingrepairs or additions
3.❑ I am a homeowner doing all work right of exemption per NIGL ❑ y
myself. (No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other. _-.
comp. insurance required.]
•;\uy.Ipplicant that checks box NI moat also rill out the section below showing their workers'compensation policy information.
t I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
't',romoors that.heck this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp. policy information.
/ow an employer that is providing workers'compensation insurance for my employers. Below is the policy and job site '
information. I/
Insurance Company Name:_ �i�'`� -5
u ��/nt ) / r� /
kv u ��),{� 04 4 6"(QD Expiration Date:
Policy q or Self-ins. Lic. q: 1� /
Job Site Address: Lt I to" �I City,State/7-ip: �LEAan
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
I,ilure to secure coverage as required under Section 25A of NIGL c. 152 can lead aI the imposition of criminal penalties of a
tine up to S 1,5io ot) and'or one-year imprisonment. as well as civil penalties in the Bann of a STOP WORK ORDER and a fine
nl Itp III i__150 00 a day against the \lolator. lie ad\'Ised that a copy of tllls statement may be forwarded in the Office of
I rI%csn•s;uums of the DI:\ for insurrnce :o\erage scrilicanon.
l,lit hereby rertilj•under the pains and penaltiev of perjury that the injitrmtutiott prnei,led ohoee is true mtd correct.
450 - -
- t)% ,teal use onll•. Do nor Icrite in this area, to he completed by city or town officiuL
( ih or fawn: ..—
Issuing; \uthority (circle une):
I. Board of Health 2. Building Deparhticn /
t 1, ('itsfossn Clerk J. Electrical Inspector S. Plumbing Inspector
6. Other -..--- - -- - ----'---
Contact Person: _—_-- Phone --
Information and Instructions `
lulseus (ieneral I aIw, chaptcr I s' rryuirr> AI crop Io%crs Io pro\Ide workers' connpcnsauom low Iicif ernplo\ces.
I'm,II.III t to Ihts ,Ia I ute. .ut emplur're is JQ I!li ed .Is cl cry per,on in the ,cn ice of .nwlhCr under Juts contract of hire.
yac,s or impll d. oral or wnncn."
:nydoter Is dc1mcd .0 ".ul inJr\;dual. p.utr.crnhip. .Isoct.uton, :orporatlon or oilier IeL:al acute. or Jul} Iwo or more
,•I ]lie 6nc_outg crraagcd in a Bonn enterprise. and including the I,al rcpresentan\cs of deceased cmplo}er. or the
c:n\er or trustee Of.ul Iudr\(dual, parncr,htp, .I,,oQLmon or other Ic�al cnmy, cnlplo)nIg cnlplosces. IIo\se\er tale
, •ener of I o1\\cllu u lg house hang not snore than three tilarmwnts and who rc•stdes Ihcrcm, or Ilse occupant of the
.Iw ci!ulg hou,e of another who enq,Io-Ns pernons to tit) I13al1lmlance, construction or repair work on such d\sellmg house
,,, ,it the --rounds or building Allpwten,lnt iherew ,hJll not he..wse of,ueh cnlplo\mcnt be deemed to he .m employer."
\1(iL :impicr I5?, j'S('It,) also states that 'cscry state or local licensing agency shall withhold the issuance or
reness at of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable cs idence of compliance with the insurance coverage required."
\dduionally, NIGL chapter 152, �25('(') states `\either the conunomvealth nor any of us politic Jl suhdi%i,ions shall
cuter into any contract for the pert ornlance of public work until JCCeptable e\Idence of compliance with the Insurance
rcquireolents of this chapter hate been presented to the contracting authority."
Applicants
I'lease fill uuf the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) mmne(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
Ile 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 he 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.
]'lease be sure to fill in the permit,license number which will be used as a reference number. In addition,an applicant
Ihat must submit multiple permiulicense 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
10w11)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
:Ipplicant 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 i.c. a Jog license or permit to burn leuvcs ctc.)said person is NOT required to complete this affidavit.
the ()tficc of In\esligations would like to thank you in advance fur your cooperation and should you ha\e any questions,
please do not hesuatc to give its a :all.
I lie Dcp.unncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
{ y CITY OF SALEM
PUBLIC PROPRERTY
�� DEPARTMENT
\t �I: I '� \\'.UIIIM.:i-',\$I'R I-IT 1 "AI I M. \I.\ii.\t ;It
I rl: 978-74i-9595 ♦ FAN: 9,8"174,0)846
Construction Debris Disposal Affidavit
(icyuired li\r 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 4 is issued with the condition that the debris resulting front
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 of hauler)
I'he debris will be disposed of in
(name ul facility)
pr
(address of facility)
---- sipnature of permit applicant
-- date - ---