19 HARBOR ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards I OR
,h MINA ll'Al l"l f,
Massachusetts State Building Code. 780 CMR. 7 edition USE
t W Building Permit Application To Construct. Repair s'a Or Demolish a Rvi iwd lu1uuu r
r� One- or Ttru-FrunilV D rllrng 't M)N
h`6 1-his Section For -fiflctal Uw ly
v2 Building�Permitmber:
\\ Signature:
Budding Commissioner/ Inspector of Buildings Dat
SECTION 1: SITE INFORMATION
1IgPl'npcc;� dSdM 1.2 Assessors Mup & Parcel slumbers
L la 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 Isq 11) Frontage(it)
1.5 Building Setbacks (ft)
Front Yard J Side Yards Rear Yard
Required Provided Required Provided Require) Provided
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ D' W Y
�pp e� SECTION 2: PROPERTY OWNERSHIP'
2. Iq wFYas6o� weer Coro. Aso C:10in �q �tur`�or S{rt SAIeMt U/1Ar
Name(Print) k*1 pc,);nslCa5 -Jn, �3 Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief(�scription f Proposed W rr� ('J eC w4m
bimyfi-
fora}`✓A q%_ sM o Ks..J �CLAS r•c,5 0.s's& hit l
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Of7lclal Use Only
(Labor and Materials)
NTotal
gHCost:
S I. Building Permit Fee: $ Indicate how tee is determined:
❑Standard City/Town Application Fee
cal $ ❑Total Project Cost'(Item 6) x multiplier x
ngS 2. Other Fees: S
icalS List:
icalS
on) Total All Fees: S
Check No. Check Amount: Cash Amount:
rojS ❑ Paid in Full ❑ Outstanding Balance Due:
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) CS go's—' IR Z ( 2008
D —C t,p J on• &c<4— License Numher F.xpnauon ate
N aic olXl.r_'f^(I ��r/n '1A p, Lt List CSL Type Isee heluwl U
�� (� l Ft'J f, Dcscri non
4d ss U Unrestricted to (o 15.000('u. Fi.i
R Restricted Idt] Fanul Dssellm
iorrree 4 300 7�� M Mason
M Onl
7 . RC Residential Rkwlin Cnvtnn
Telephone R'S Residenoal WulLitm and SiJw
SF Rcsidowal Solid Fuel &onme 1 s ih.mi: In.tallawm
D Residential Demohuon
5.1 Registered Horne Improvement Contractor (HIC)
HIC Company Nainc or HIC Registrant Name Regtstruuon Numhcr
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 1 1506))
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 ..........X No .......... O
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 tit Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the 2ains and penalties of perjury)
NOTES:
1. 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. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS. respectively.
FWhen substantial work is planned. provide the information below:l floors area(Sq. Ft.) (including garage, finished basementlattics, decks or porch)
s living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms i
Number of bathrooms Number of half/bmhs j
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open i
3. 'Total Project Square Footage" maybe substituted for 'Total Project Cost'
Qit�,7v
CITY OF SALEM
3PUBLIC PROPRERTY
DEPARTMENT
12: A\,Iiil:,l!',�NS R1,110S\I! \1, \1,••.,� Itl .! I :•�I'/'_
ThI: 9:8J h9Y)S is F.,A: '1,-8.'i I84o
Workers' Compensation Insurance Affidavit: [3uilders/Contrac torsi Electricians/Plumbers
Applicant Information �l/l_'l l P) `/1 Please Print Legibly
Name t6uamcss ()rgantZanon lndiudunndl`': L�F ^' 1`C/J`i'M+
Address: $1. �aysACtSo� Yue,tlJ('
300
City,Stdte/Zip: fell r� r MA- 0161OL Phone /#: �'7�1 S 17J '9
Are you an employer?Check the appropriate box: Type of project(required):
I.� 1 :un a employer with ri 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. ❑ Remodeling
?,❑ 1 am a rule proprietor or partner-
.ship and have no employees These sub-contracturs have 8. ❑ Demolition
working for me in any capacity. workers' romp. insurance. y. ❑ Building addition
(No workers' comp. insurance 5. ❑ We are it corporation and its 10 ❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work b exemption
right of per MGL H.[] Plumbing repairs or additions
p
myself. [No workers' comp. C. 152, §1(4), and we have no 12.XRoof repairs
insurance required.) r employees. (No workers' 13.0 Other
comp. insurance required.)
•Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information.
t I to neowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l am an employer that is providing workers'compensation insurance for troy employees. Below is the policy and job site
information.
Insurance Company Name:Policy #or Self-ins. Lie. #: tlillZ lf7ggq(�5(_% Expiration Date: p( -40F
Job Site Address: �� �pAs 7r� City/State/Zip: `e
Attach a 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 NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250J10 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invcstie,ations of the DIA for insurance coverage verificalion.
/Jo hereby certrjy under the pain'and penalties'of perjury that the infornation provided above
is true and correct
ljjglrmtre: ITne: 'mob
PhoneC !Ol� 67 -9
Official rise only. Do not it-rite in this area, to he completed by city or town ofjiciaL
Citv or futon: —._----.--- Permit/License
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:---- __ -- Phone #:_.
Information and Instructions
\1:1.<sac Iit nets (;etteraI Laws chapter I�-' requires all employers to provide workers' compensation for their crnofoyces.-.
Pursuant to this statute, an empluree is defined as "__every, person in the service of:mother wider :uty contract of hire,
espress or implied, oral or written."
.\n emploYer is defined as "an indis;dual. partnership, association, corporation or other legal entity, or any two or more
,,I the toicgoing engaged in ajoint enterprise, and including the legal representatives ofa deceased employer. or the
recei%cr or trustee of an indmdual, partnership, association or other legal entity, employing employees. However the
,ns ner of a .hvelling house having not store 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„n the grounds or building appurtemmt thereto shall not because of'such employ nncnt be deemed to be an employer..,
.V(;L chapter l i2, §5(_'(0) 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 eommonsccafth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
:\dditionally, NIGL chapter 152, §2567) states"Nehher 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 till 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 nwnber(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 till in,the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitllicense applications in any given year, need only submit one affidavit indicating current
pol icy;in formation (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.
-File ()tlice of investigations would like to thank you in advance for your cooperation and should you have any questions,
please Jo not hesitate to give us a call.
Hie Dcpurnnent's address, telephone and tax 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
Rey iscd -e-1); Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12C W.N.S1 I]',(;!ON Sil<13]:T 0 SAI I M, M !I I iEi 10 1"
f 1.1 978-745.9;95 4 FAX:978-74C,1)846
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
Debi-is, and the provisions of NIGL c 40, S 54;
Building Permit 4 - - is ISSLIed with the condition that the debris resulting from
T1
this work shall be disposed d0f a properly licensed waste disposal I'acility as defined by MGL c
111, S 150A.
The debris will be transported by:
rCi r c'AeJ
(name it hauler)
The debris will be disposed of in
Ott-,
(came of facility)
(address of facility)
S I g t I at u 10 o/pLYinitapplicant
(late
J MX
b + I
Board of Building Regulations and Standards i
Construction Supervisor License
License: CS 75259
ik ar8 Birtation: 12/14/1965
2008
Expiration: 1y14/2008 Trill 6599
Restriction: 00
BRADIFY.I RQNTZ
7 MCKINLEY RD
MARBLEHEAD, MA 01945 Commissioner
r1
1