42-44 HARBOR ST - BUILDING INSPECTION p The Commonwealth of Massachusetts — —
q t` 130a111 oI Budding RCgula(ions and Standards I ( IR
Massachusetts Slat • Buildina Code. 7S1) CMR. 7"' edition Mt NII'll'.\I fl 1
1 tuildirig Per III II Appf at ion Tr ('oilsuuct. Repair. Reno%ate Or Demolish a k ' i l.huui u
t� Oile- or ru-1 iunill. Otrrlling
' (� Is tiuun For Official Use Only . o ----------- - __—�
V Building Pcril m Number: Date Applied: _
I3mldoif C nuntNNiou•r/ Inape i o &uldiuEs Dale
n 'UTION 1: SITE INFORMATION
`d\ 1.1 Property :\ddrit s: D 1.2 Assessors Map & Parcel Numbers
I.la Is this an accepted street? \es no %lop Number Parccl NUnIhCI
1.3 Zoning Information: - 1.4 Property Dimensions: ~
Zoning District Proposed Use I Lot Area Ise 1t) Frontage t 11 t —_
1.5 Building Setbacks (ft)
_ Front Yard Side Yards Rear )'aid
Req,,,L Provided Requited Provided Recoiled PI...ided
I
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public ❑ Pncate❑ — Check if yes❑ :\lunicipal ❑ On cite dislxwal Nvsieni ❑
SECTION 2: PROPERTY OWNERSHIP'
' 2.1 Owner'of ecord: -
,u<< 4Z-s� �1�1ov- Ft. ,d
Name ( rino Address for Service:
t enam rc Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New C�.mstruction ❑ Existing Building ❑ Owner-Occupied ❑ Repans(s) Alteralion(s) ❑ Addition ❑
Demolition Cl Accessory Bldg. ❑ Number of Units il Other ❑ Specify:
Brief Description of Proposed Work': b �¢
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only I
ILaburandbtaterialsl _ _
I. Building $ 60oe I. Building Permit Fee: $ Indicate how tee is Jelennme•d:
❑Standard City/Town Application Fee
'_. filectrical $ ❑ final Project Cost' (Item 6) x multiplier x
1. Plumbing $ -1. Other Fees: $
1. Mechanical tH�':\CI $ List:— _----
i. !vlechanical (Fire _
Su cession) fetal :\II Fees: 5
dp Check No. Check Amount: _ ('ash \nnaun:
0 rotal Project Cost: PdDd �j f 0 Paid to Full 0 Outuandtng B,J;mce Due:_-___ -
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed CConstructioii Sfuperviiso�lr (CSI'I p
— Luinx• `L nlhrr I`.\pn.w a 7.n: r h
Nanm of CSL IluWrr q
i Lu( CSL l\Ix I,rr hi IorN I
� \JJrr,> — __— ) hr. �• Ue,ili noon �
(till to1�.IXIU Cu I1.
Re,Initcd I.F_' F.mnh lines_
MiLso
i Sienat -- 11 ldnn On 1,RC i—t RcoiJ:ntial Root ime (lircn ny
I clrphmlc wS j I<_iJiulf.J llr.:J:"I .uiJ_�iJiiy_
sohd furl Buinin_ \ �I r�
l( l6� D Rr.iJ:nli.il Ilnn��liiinn _ _ --_i
5? Registered Ilorne Improv nt C emeuntractor (IIIC)
NIC Cungi;ury .Name ur III Registrant N me Regi,uauou .Numher
�.!
Addres,
LIUErp:rat rm Date
Slgnan,; :e:cphune I —
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (NI.G.L. c. 152. § 25C(6))
I
Workers Compensation Insurance affidavit must be completed and ,uhmitted w:th this application. F:mare to pair Ide I
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... O No -._._.-`.. ❑
SECTION 7a: OWNER AUTIiORIZATtON TO BE COM1IPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Kr/5 Y' as Owner uY the subject propetty hereby
a,.uh; rize _ -- sewer /✓ to ait „n any be h;,lf. il: ar Irlaaers
Ielauve to '.cork authorized by this building permit application. - �-----
_ ___
taturc of Owner __. Dale
SECTIION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
aen 4/G !!e Z ;Is Owner or Authorized :gent her ehy declare
that the statements and intitrmation, on the foregoing pplfcauon are true and accurate. to the best of my knowledge and
behalf. e4 rA
Pont Name
Signature of Owner or Authon zed Agent Dale
(signed under the 2ainN and penalties of per tl )
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an uni egi,lared contrae 11.1
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the :ubitration
program or guaranty fund under M.G.L. c. 112A. Other important information on the HIC Program and
Construction Supervisor Licensing ICSL)can be found In 780 CMR Regulations 110.R6 and 1 IORS. resperuNel)
i
When ,ubsiamial work is planned, provide the Inturmauon below:
Total flours area ISq. Ft.l lincluding garage. finished ba,emen UatticN, decks nr porch)
Grohs living mea ISq. Fr.) Habitable room count
Number a•f fireplaces :Number of hedromn,
Number of h.lthmortts NUrriber of hall/bath,
vpe of he:mmg ,v,tem Number nt decks/ pot,he, __- -- --------__
fype of cooling N),Icm _ Iin.haod _-
3. Total Project Syuurc Footage" may be Nubsnwlnd tic "ioml Prolert Co,t"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
, •,I 12. p. 11 ,. N racrr • �.v I M. %I.\.,�, r • _1 +
Debt-is Disposal l Af iclaVlt
Construction Dcb p
� ,
(rerluired lilt all demolition and renu ,tion work)
In accordance \%ith the sixth edition of the State Building Code, 7S0 C•MR section 1 1 1.5
Debris, and the provisions of'viGL 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
I11. S 150A.
The debris will be t
ra
nsported
by:
(name of hauler
I he debris will be disposed of in : t
wQ
(name P
Ilacilily)
y �
'ef
luddres. ul 16cililyl
,+gauturc oP permit .ytplicam
/os'
.I e
CITY OF SALEM
,
PUBLIC 1 ROPRERTY
DEPARTMENT
.I,nf:A:1'1':)KNC,It 1
12C WMIrll\t;ION S-txLLT • S:st ea+,MAL S.\CI It i1:'1'1 N 01970.
978-743-9595 • P-Ax. 978-741Cd18ih
Workers' Compensation Insurance Affidavit: Builders/Contractors/El Please Pnnt Lebers
,\ ) )licant Information
Naine l0usiousvOrganiratioNlndro uluall: e,"/4'I
Address: 1 ' /city; QQ
stale,zip!ir
Mono I;'- in- G pz l/X f
• ,mu tin era iloyer'! Check the apprupriute b
'Type ur project(required):
\n I
I 4. :tin a general.,Duct:,.,tor and 1 G.an,a employer with - ❑ New construction
I ❑ I P have hired the sub-contractors
en,ployces(lull antL'ur part-lime).` 7. ❑ Remodeling
on the attached.sheet.
2.❑ I III,,a sole proprietor or partner- These sub-contractors have S. ❑ Demolirion
ship and have no employees 9 ❑ Building
working for me in any capacity. workers' comp. Insurance. . +g,addition
5. ❑ We arc a corporation and its ME] Electrical repairs or additions
IKn workers' sump. insurance ofticers have exercised their
required.] 1 1. PI in'repairs or additions
right of exemption per IvIGL ❑ b P
3.❑ I am a homeowner doing all work c. 152, §I(4),and we have no 12. 'or repairs
myself. e r workers'a»np' employees. (Ko workers•
insurance required.] 13.❑ Other
coop. insurance required.]
-:any u,phcaut thus checks box fit must also till uw the suction Isauw slwwioy their work=*'cumpensatiun puticy inlirrmatiun-
'I Wma,w nett who submit this n17iJavir indicating Ihcy are doing all work and then hire outside conlrxton must wtnnil a new alf:Javi1 inJivaling nmh.
(' I 't nth I i 'k this box must atiwhcd an additional.,hoer h a 1110 mote of tho sub-contractors and their workers'cun,p:policy infortnadun.
Belmry is the puhcy and/mb ore
/an, au employer that fs providing workers'c•or»peflsnnnn uisurmrice jar ray eurplo)eca.
information.
Insurance Company Name: -. ._ ... .
I'ulic_v S ur Self-ins. Lie. *: PRC 67S96�2, _ p. .. -- Expiration Dam:_ D 2
Job Site Address:
�L ,rl Citylslatei"Lip: /�¢+, AlAr
\ttach itcupy or the workers' compensation policy declaration page (showing;the policy number and expiration date).
I;ailure to secure coverage as required under Section 25A of}IGL c. 152 can lead to the imposition of criminal penalties of a
rinc LIP to S1.500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up m S250.00:t day against the vlJlator. Ile advised that a copy of this siatcment Inay be iurwarded to the Office of
-ncra.,u ,cri ticaliun.
la Lill 10 urnts ul'thu UTA :or invmar.cc �,
/Jo hen•by cerrijv iuider the pnine'wid r u s of perjury that the mljurinatlon provided above is true and correct
��� � D,t.. o9aa oe
OQiciul m.se o ly. Do flat Ivrite in this area, to be completed by city or town o/Jiciul.
Citv or fawn: _—
PermittLicensc N.- _ ..
Issuing; :\uthurily (circle olic):
1. Iloard of Ilcalth 2. Building, Department ].Citvi rows Clerk J. Electrical Inspector 5. Plumbing Inspector
6.Other -
Phonc M:
Cu nlacl Pcnon: .._ - --
Information and Instructions
,Aiassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplgree is defined as"_.every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is detined as"an individual, partnership,association, corporation or other legal entity, or any two or more
,tithe t0regoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of :at individual, pattnership,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
renewul of a license or permit to operate a business'or'to construct buildings iti 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(his 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(ban the
membersor 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 confirnmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he retuned 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 ouf in the event the Office of Investigations has-to contact you regarding the applicant.
Please be.sure to fill in(he pennitflicense number which will be used as a reference number. In addition,an applicant
that must submit muliiple permit license applications in any given year,deed 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 tl4affidavit (hat has been officially stamped or marked by the city or town maybe 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.
The t)t'tice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The Deparnnent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents.
Oflice of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
www.mass.gov/dia
✓!t¢70Nnv�na�¢tuea�t� a�./Vtad�aclladed i .. ,
Board of Building Regulations end Standards .f
HOME IMPROVEMENT CONTRACTOR-'
Registration: 158319
Expllgtion::(tl9/2010 TI# 265100
Type::`Individual
CHUN WA NG
CHUN NG
14 WENTWORTH ST
MALDEN,MA 02146 Administrator I
J
A
�DMINItlNtfl O�✓and SttlIJP.I.�D
k� Board of Building Regulationsandards
Construction Supervisor License'
j License: CS 69640
Expiration: 2/19/2010 Trlt 17307
Restriction 00' .,
o �
CHUN WA NG
72 W WYOMING
MELROSE,MA 02178 ' '` Commissioner
i
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