16 HAWTHORNE BLVD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
J , Board of Building Regulations and Standards CITY
Massachusetts Stale Building Code, 780 C'MR, 7m edition OF SALEM
Revised Junuun•
Building Permit Application To Construct, Repair, Renovate Or Demolish a
11 I One-or Twu-Family Dwelling
This Section Fqr Official Use Only
Building Permit Nu r: Date Applied:
Signature:
Ruilding Commissioner/Ins •ioru uildings Nate I
SECTION 1:SITE INFORMATION
1.1 Property Add ess: 1.2 Assessors Map d Parcel Numbers
I.l a Is this an accepted streel?yes no Map Number Parcel Number
1-3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Ld Area(sq 11) Fromage(11)
1.5 Building Setbacks(R)
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 Sewege Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if es❑ Municipal D On site disposal system O
�e SECTION2: PROPERTY OWNERSHIP'
2.1 (7 Gr r" t�ord�
XName(Print) Address thr Service: �7 q
t /7a .7� r
Signature Telephone
SECTION 5: DESCRIPTION OF PROPOSED WORKS(check all that apply)
X New Construction❑ Existing Building O Owner-Occupied ❑ Repairs(s) Iterations) O Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-: zed
IF
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 0111clal Use Only
Labor and Materials
I. Building Is y'J� 1. Building Permit Fee: S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
1. Plumbing Is 2. Other Fees: S
4. Mechanical (IIVAC) S List:
S. Mechanical (Fire S
Suppression) Total All Fees: S
�/�*l Check No. Check Amount: Cash Amount:
X 6. Total Project Cost 5 7 J"V 0 Paid in Full 0 Outstanding Balance Due:
c
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed onstru oo Supervisor(CSL)
l.icicccrise Number lupiratiu I}ale
Name uyMl- I Iy.IJer �1, -// _ I.ist CSL Type(see below)
�} AD
Oescri ion
Address unrestricted u to 15,000 Co.Ft.Rearicled l32 Famil DwellinSigna re M Onl�/O a./� V //fResidential Routin CoverinTelephone Residential Window and SidinResidential Solid Fuel Bumin A liance Installation
Residential Demolition
5.2 Registered Home Improro,��sme Co(�t,ractor(HIC) �a� Sol
Y�Z r�1 ' "� "-" Registration Number
111C Company Name or l S7gistrum Nam
A dre �5/ �� Espimtion Del
t Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. f 2SC(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 ..........O 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. -
Siansiure of Owner Date
SECTION 7b: OWNER'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 Own"or Authorized Agent Dal
tSiwicd under the pains and penalties of 'u
NOTES:
FOwner r who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
tered in the Home Improvement Contractor(HIC)Program), will rsgf have access to the arbitration
or guaranty fund under M.G.L.c. IJ2A.Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.116 and 1 IO.RS,respectively.
stantial work is planned,provide the information below:
ea(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross vngarea(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
tic
it PUBLIC PROPRERTY
DEPARTMENT
:,I\II1:'RLIiY UMIiC01.L
54.\% rn C2C WAsru u�io�SI X ELT• SALf.\4,1VIASSACI Har:I IS 01970
11,1.:978-745-9595 • P:\x: 978.740•9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A ) 4licant information yam/ Please Print Le ibly
Varnt; l8usincsslOrBanizatioNlnJiviSuulY. �� "
Address:
City/'Statcizip: 1VK-Oa2a7-? Phone t.-: 9�
Are you an employer' Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 :un a general contractor and 1 fi. ❑ New construction
el lo 'ces full and/or put have hired the sub-contractors
y ( P' 7. [3 Remodeling
2 I am a sole proprietor or partner- listed on the attached sheet. :
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
5. ❑ We are a corporation and its
ITo workers'comp. insurance 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per rvIGL I 1.❑ Plumbing ropain or additions
3.❑ I am a homeowner doing all work g P P'
myself. (No workers' comp. c. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. (No workers' 13.0 Other
comp. insurance required.]
'Any L;ppllcattl that chucks box#1 must also till out the\lction h0uw showing Ihetr wurkws cumpumation policy infiunnatiun.
' i lomeownen who submit this affidavit indic:uing Ihcy are doing all work atd lien him outside contractors must submit a new afRdavit indicating such.
�Contractun that check Ibis box must anachcd an additional sheet showing the name of the sub�contraclon and their workers'comp.policy infurmatiun.
I nor on employer that is providing workers'compensation insurance for ray einployeec. Belo),is rite policy and job site
information.
Insurance Company Name:-.--.. ._.....
I'olicv 4 or Self-ins. Lie. >:: Expiration Date:
Job Site Address: City/Staleizip:
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�1GL 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 [he form of a STOP WORK.ORDER and a fine
of up to S250.00 it day against the violator. lic advised that a copy of this statement may be torwarded to the Office of
Investigations of the MA for insurance coverage verification.
I do hereby certify out the i mud penalties of perjury that the information provided above is tare and correct.
Oflicial use only. Do not write in this area,to be completed by city or town afficial.
City or'fown; Permit/License Al_
Issulnu Authority (circle one):
I. Beard of llualth 2. Building Department 3. Cilyi fowu Clerk 4. Electrical Inspector 5. Plumbing Inspector
G. outer . -----
Cn mach l'cnou: _..._. .. . -. __-- one
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an empfgree is defined as"...every person ;n 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 entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,parnership, 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."
1 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, bIGL chapter 152, 325C(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 counpliunce 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-contractors) name(s), address(es)and phone nunmber(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 Off7clah;
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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till ;n the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 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.
I he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do nut hesitate to give us a call.
The Dcparnnent'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
Revised 5-2fi-us Fax #617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'd 12, A.N,11[Nt.;0NS1S1J T # SAHNI, \I\li%( :11
Construction Debt-is Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 9_., is issued with the condition that the debt-is resultin.- 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:
(name of hauler)
I he debris will be disposed of in
(name of facility) V
vaef/fi/r-
(address of facility)
signut c of porn t;111plicant
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
IM ^�0( L
DATA
July 20, 2010 wf �U59
Ms. Sheila Lawler
Hawthorne Blvd.
Salem MA 01970
We hereby propose to furnish labor and materials to:
Replace existing bulkhead with 2'X 4' construction, T1-11 siding left side, salvage aluminum siding and install on
the right side, steel entry door with locking handle, and install roofing.
Replace existing deck with materials to match the front porch.
All permit fees and disposal included.
Total materials and labor. $4,500.00
Terms: One half down and one half upon completion.
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications
involving extra costs will be executed only upon written orders, and will become an extra charge
over and above the estimate.All agreements contingent upon strikes, accidents or delays
beyond our control. Owner to carry fire,tornado and other necessary insurance.
Thank you for the opportunity to present this proposal. Please feel free to contact me with any
questions or concerns. I look forward to working with you. �U /
This proposal is valid for 30 days.
Respectfully, d 51
Todd Duffy
Acceptance of Proposal
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Regiettalloh: 123801
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! F; EzPlreNon: 411W2011 Tr# 284640
— Type: IndMdaal
Todd Duffy
Ny c Todd Duffy
629 SOUTH ST
WRETHAM,MA 02093
Administrator
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