38 HANSON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OFSALEM
n , Massachusetts State Building Code, 780 CMR. 7N edition
ResisrOJuntrun•
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 20W
one or vo-Fomily Dwelling
s Section For Official Use Only
Building Permit um Date Applied: 2 O
Signature:
Building C imionoj Inspector of Buildings late
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map dt Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dlmeosirns:
Zoning District Proposed Use Lot Area(sq Il) Frontage(11)
I.! Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
n/i9 A///i- n/r7
1.6 Water upply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage a posal System:
Public Private O Zone: _ Outside Flood Municipal On site disposal system ❑
Check if es�
SECTION2: PROPERTY OWNERSHIP'
L
rtof Record: , - ,'1j: tt- 49r'70L 9UC1Gf 7-f 3�' On/ �'. S.9-4,ot Address ror Service:
/>iue�eri� 97iF- ?YS- �9� L/
Telephone
�XION 3: DESCRIPTION OR PROPOSED WORK'(check that apply)
xisting Building Owner-Occupied O Repairs(s) Cr I Alterations) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. O 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': AEP.•//d-e r rr(A-'tl t701.eiA/ /D
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials y
I. Building S �R SO W I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
). Plumbing S 11 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
5. Mechanical lFire
Suppression) S Total All Fees:S
Check No. _Check Amount: Cash Amount:
6. Total Project Coat: Sll e'S 00 0 Paid in Full 11 Outstanding Balance Due:
SECTION !: CONSTRUCTIONSERVIICES
5.1 Licensed Construction Supervisor(CSL) I0 2132/ y ?013
J'sM FS l�jrrC� /-) License Number I:sptralion Dare
Name of CSl.- I lolder List CSL rype(s. below)
a GUl9 L n/ui—" Jr sue,r� i 6
r Ikseri ion
:Address U I Unrestricted(up 1035.000 Cu.Ft.
Restricted 1&2 Familv Dwelling
Signalu M M Onl
RC Residential Roulin C'overin
telephone WS Residential Window and Sidin
SF Residential Solid Fuel Buming Appliance Installaliun
D Residential Demolition
5.2 Reelsterets Home Impprovem��st Coatnefor(HIC)
6g A/ 23JQTN l J a n/1't>,VrTl�a✓
I IIC Company Name or f IIC Registrant Name Registration Number
Ad ss ddD-1
.11— 9 7!�-� z—��Z pirati Date
Signature Telephone .
S ON 6: W ERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 1S2.f 23C(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 011ie building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 b70l4 �&UC L/Z�=y as Owner of the subject property hereby
authorize hACnA/ fin/(T/1Ur MD ✓ to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si ure of Owner D01e
SECTION 7b:OWNE//R��t OR AUTHORIZED AGENT DECLARATION
I )1� h��fCn J IgCJA/ C8 ✓S1= as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf. /
c lA�+�,is S O O h✓
Print Name
Signature at net uthori A Date
Si ntkr the aim and natt es of 'u
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 zQj have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 I0.R6 and 110.R5,rcspectively.
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 hall7baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Fswlage"maybe substituled for"Tolat Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
r
DEPARTMENT
,Nm; a:I :)xti(:VI I.
\Lss"a 12^.W)NtaXGION 514 EL•T • 5Atl'.]t,M.(SS.walt il:l IS 5197Z
fla.:WS-743-9595 is, 1'.sx.9711•740.1346
Workers' Compensation Insurance Affidavit: Builders/Contractors/.Electricians/Plumbers
konlicaut Information �7 / //1 / Please Print Leeibiv
Vane l0usutcssiori a nirltiontIndividual): / tit' 10 rJ fT711�C77�1
Address: 027 G!/ A/l/T— ZT
City,State,zip: Phone :;: 971t'S32-1,qp
Are v u tin employer? Check the appropriate box: 'Typo orproject(required):
1. 1 ant a with w employer ( 4. ❑ 1 tun a-eneral contractor and t
6. ❑ New construction
employeex(full and/or part-6111C).s have hired the sub-cuntracturs
.❑ 1 :can a sole proprietor or partner-
listed on the attached sheet. : �• ,®'Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
I No workers'comp. insurance 5. ❑ We arc a corporation and its
required.)
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I ank a homeowner doing all work right of exemption per MGL 11.❑ plumbing repairs or additions
myself. (Ko workers' sump, c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] r employees. 1Ko workers' 13.❑Other
comp.insurance required.]
•soy.,pplrcanl that chucks box ill must:dso fill out the section 41ow showing Ihoir w•urkurs'wmponartion policy inliunwtiun_
'l lomeuwnen who sabmif this affidavit indicating Ihcy are doing all work and Ilten his outside cauraclon must auhmil a new alydavil indicating such.
-C',mtrKuw,that check this box must!mmahcd.m additional slwet.hawing Iho name of the sub-conuxton and their worker:comp.policy information.
l star on employer Iitat Is providing workers'compensation insurance far ury employees. Befafv is the p ilicy and jab.vile
infarmutiam
Insurance Company Name:
�9G )( / jtlLif E_-a-p—ira-t-
n DattPolicy Is or Sclr-ins. Lic. N: ,1 y 3d I/
Job Site Address:^Fr A&Alk / - _ C'ity;State/Zip: Jgtt" Ln-f e7-"
.\nosh it copy of Ilia workers'compensation policy declaration pale (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ul'.MGL c. 152 can lead to the imposition of criminal penalties of a
line tilt to S1.500.00 and/or one-year imprisonincnt, a.i well as civil penalties in the form of a STOP WORK ORDER and a fine
of III)to S250.00 al day ayralnst the violator. Its:advl.icd that a copy of this slutcment may be lbrwafded to the Office cat
Ill\Ynlhanu115 ul the DIA i'or io.urarcc covcra.c'%c1'Illcataln.
d do hereby certify under the pains a ud penaddev of 'try that the infortnullon provided above is true and correct
Uf/ie•iuf use only. Do tint-sprite in this area, to be cuutpfeted by city car town o/Jieiul.
(:ity or'four n: Pcnnit/l.icume
Issuing Aulhorily (circle one):
1. Board of llcalth 2. Iuilding DcparFmeut 3. City:Town Clerk 4. Llectricad luspcctor 5, Plumbing Inspector 1
6. OI hur
Cuulact fcrsun: __ -- Phone n:
Information and Instructions
.V assachusetts General Laws chapter 152 requires all employers to provide workers' compensation fix their employees.
Pursuant to this,natute,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 cntiry,or any two or more
,i the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of :m 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 in employer."
`IGL 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. tvIGL 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 ufcompliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors) 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 returned to die 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 u 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 u 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.
Plcasc be sure to fill in the permittlicense number which will be used as a reference number. in addition,an applicant
that must submit multiple pennitilicense applications in any given year,need only submit one affidavit indicating current
policy information lif necessary) and under"Job Site Address'the applicant should write "all locations in (city or
town)." ,it 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he 0Ilice of lnve,tigatlon s would like to thank you in adV:mCC for your cooperation and should you have any questions,
pleu,e do nut hesitate to give us a call.
'the Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfHee of Invesdgadons
600 Washington Street
Boston, MA 021 l 1
'ref. lib 17-7274900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
CITY OF SALEM
, i PUBLIC PROPRERTY
1-4
'��''�-�� DEPARTMENT
-„. .
M 120 W,%iI IIN(11 ON S r8 rrT • SA I r V, MASiAt'I It SI I'i i j f 4".
'frl: 978- 4 9595 • ISix:978-74).9846 -
Construction Debris Disposal Affidavit
(required fur 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 # __ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
Iname of hauler)
The debris will be disposed of in
(name of faci ity)
(address of facility)
signal of 1h' tt appli ant
� 'date