6 HAZEL ST - BUILDING INSPECTION (3) / a 111c CUI1111'on'%eldth of Massachusetts
Bu;trJ ol'Building Regulations Standards CI'I'1'OF
r sl iJ Massaclttuctts State Building Code, 730 CMR tiALl:hl
R��ri,rrJ.l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
(hrr-or Tnvr•Fumi1 1)mt/11 1if
thisAWa
Building Permit Number:Building 011icial(Print N;une) Out,
SECTION 1:SITE INFORNIATIO
t.l Property Address: 1.2 Assessors.Nap di reel Numbers
6 .H+3 2 6-, S-T , s LEA L
I.la Is this an accepted street?yes V no Nlap Number Parcel Number
1.3 Zoning Information: t.d Property Dimensions:
Zoning District Imposed thic Lot Area(s4 It) Frontage(11)
I.i Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Re4uircd Provided Required Provided
1,6 Water Supply:(M.G.I.c.4U,§54) 1.7 Fload Zone Information: 1.8 Sewage Disposal System:
Public It Privotc❑ Zone: _ Outside Flood Zone? Municipal® On site dis sal s,tun ❑
Checkil' yes❑ p W' )
SECTION2: PROPERTYOWNERSHIPt
2.1 Owners of Record:
�' Hr7Z�/ .S-t 2���� y 514Lew � H� OI P �
Name(Prinq Uly.Slate,LIP
Fi /lla? E L s-r R "t -O"O V- /�� rEK y � CorvC�s , Nv 7
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building)dl Osvner•Occupied ❑ Repairs(s) V Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Grief Description of Preposed Work':
�LJ� dli TCNt✓NS -7r/.eoOMs
SECTION 4: ESTIMATED CONSTRUCTION COSTS
item 02.
OMctul Use Only
I. Building I. Building Permit Fee: f Indicate how t'I is determined:
'. lilccirical ❑Standard CilytTusvn Application Fee
❑Total Project Cost l Item 6)x multiplier _ x
J. Plumbing 2. Other Fees: S
4. >Iccha11ical ill\.%') S List:_—
---------
5. \lechulic;d I ire
Su m nessiunl Total .\II Fees: S -
Check No. _Check Amount: l'.uh \mount:
Total I'rnjcct Cost: S 5 pp 0 Paid in Full 0 Outstanding Btllmce Duc:
SECTION S: C'ON5'I-RUCTION SERVICES
5.1 Construction Supenisor License(C'SL) GSfI/} 066r.6 —�-�-_
I ic.nse Nwnhcr I viration Date
Name of C'.SI. I Folder
I ist CSI. I)Ile Isce hclunl
-S [-iK�sQ ���".___ N—_ .I.ypc Description
No, and Sued -
`� /� ll IInrestricicJ IIhIiIJin�s a ut 1S,IItI)eu. II.)
y)�LC".�,,V� 414 0 11? (, ICnuictcd ISU Tamil Dsscllin
Co4o„n..Slate.LIP 1 Nlasoiiry
RC Rtwlin Unerillit
._.—. µ'S Whidow;mdSidinit
SF Sulid Fuel Burning Appliances
47e 7 1 ✓ ZtL0O1" I Isolation
I elc hone Ifntail addrusy D Demolition
5.2Ister Ilonle-CwtrovementContractor(H1C)
ti�G� V� z IIIC Registration Number Iispirution Date
I IIC Compan) Name or IIIC Ftagistrant Name
No.mid Street Email addrass
City/Town,State,ZIP rete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 ..........M/ No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize I
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print 0%wer's Nmne(Electronic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
costa' d in this application is true and accurate to the best of my knowledge and understanding.
7J�Nl -Z701UC `/ 1- 31 - lZ
41" r'soh.\uthodicdAgent's NomeIElectronicSignaturol Date
VOTES:
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 Hume Improvement Contractor(HIC) Program),will nu have access to the arbitration
program or guaranty fund under M.G.L. c. la_'A. Other important information on the HIC Program can be found at
m.r., 1;o, i,, i Information on the Construction Supervisor License can be found at„ 10% ,III,
2. \Then substantial work is planned,provide the information below:
filial tloor area(sy. It.) - __.._)including garage. finished bascntent;attics,decks or porch)
Cross Iising area I sq. 11.1 ._-_- Habitable room count _._.
Number of fireplaces .._ Number ol'hedrooms
Number tit'bathmunls - — \'umberofhalfhalls
I')pc of heating iy:lenl N'tunher ut'decks, porches
I I\lie of COUlmig i\(lelll FIlelosed ..(teen
1. "loi.il I'rojat Syuate Footage"im;w be Suhstiulted lilr"I'oial Project Cost"
LAJ
CITY OF 5i`r2m, NWs.ICHUSETTS
t BUILDING DEPART',W—ST
120 WASNLIIGTON STREET, 31e FLOOR
e`b•' Tit. (978) 745-95435
P.kx(978) 710.9846
KI%IBERLEY DRISCOLL
I'LAYO.q T"miats ST.PIERu
DIRECTOR OF PUBLIC PROPERTY/SUrl DING CONMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractorv/Electricians/Plumbers
Amilicant Information /^1 Please Print Legibly
V;1111C lnusiiwsu Urylaniratianindividual): fr1� / ill/ '"7 Oi11 �2 `!/C
Address:
City/State/Zip: P4 (0 LG-7-QA/ Nl4 none lt: PI& 7�—O L/0,0 (�
Are you in employer."Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a gonrral contractor and 1 6. ❑Now construction
employees(full andlor part-time).• have hired the subcontractors
2. I am a sole proprietor or partner- listed on the attached.rhecl. : 7' ❑Remodeling
ship and have no employees These subcontractors have V. C] Demolition
working for me in any capacity. workers'comp. insurance. 9, C] Building addition
(No workers'.comp. insurance 3. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.C]Plumbing repairs or additions
myself.(No workers'Gump, c. 152, §1(4),and we have no 12.C] Roof repairs
insurance required.)t employees. [No workers' 13.C]Other
comp. insurance required.)
•Airy'uppliuunt flat chucks boa rI must afws fill uul thv sectim below showing thou wotken'compensation policy inrutmotion.
'I r1"euwrrns who.uhnrtt this Al ldnvit indicating ihry an doing all work and then hire outride contncton mtut suhmir arm alr.davit indicting rack
$limrxton that chuck ibis box most anwhod an additiurwl.heft showing the mm9e of the suba0mncten and their workeri rump.policy infennodon.
/um an employer char is pruvfding workers'compensation insurance jar my etnp/oyeem Below iti the policy and fob slle
information.
Insurance
Policy A or Self-ins. Lio.N: Expiration Date:
Job Site Address: City/State/Zip: S L��i
Ainch a copy of the workers' compensation policy declaration page(showing the policy number and explratlon data).
Fail=to wcuru cuvenge as required under Section 25A of MGL e. 132 can lead to the imposition of criminal penalties of a
fine up to 5I,50.00 undlur one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
Of up to 52SO.Oo a day against the violator. Ile advised that a copy of this.statement may bu:forwarded to the Office of
Invcstigatiuns of the MA for Insurance coverage vcrlfic.diun.
l do hereby certifjy us a the pains and penalties tPerjury t/rat the f'fonnatlart pravfded above is true and correct.
ll"T t Di1fJ: CJ 7 I Z
I'httne,i'
Official use July. Da nor write he 1114c area,to be crompleted by city ur town offiria, I
I
Cif or l'
Y — _ Permi"Ic
uwo; cme.i
Iss uiug,�wlmrily (circle arse):
1. Board of fleallh !. Iluildim, Department .1. Cilyaom, Clerk J. Electrical lnspcctor 5. Plumbing htspector i
G.Odwr --- _-...
i
Contact Person: Phone rh.
Information and Instructinna
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,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 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,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 an 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, MGL chapter 152, §25C(7)states"Neither the commonwealth not 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 rill out the workers'compensation atTdavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)nume(s),address(es)and phone number(s)along with their certifrcate(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 Deparanent of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he 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. Sclf-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town omelets
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 rill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permittlicense 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 Lila 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Off ice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of ladustrlal Accidents
Omce of Investigations
600 Washington Street
Boston, MA 021 l 1
Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE
5-_6-IIS Fax#617-727-7749
2t;iscd
www.mass.gov/dia
L_
CITY of SALEN(, AksS.kcuL:sETTS
9LILDLYG DEP.IRTLLVT
120 WASHLYGTON STXW, j'O FLOOA
rM (978) 745-9J9S
K AMER1 Y 01MOLL FkX(978) 740.9846
,tiG1YOJt THoxus ST.PM Uls
DIRE CCO R OP PL BEIC PROPERTY/at:MD LNG Co.aIf,S(ON EIt
COnstrUCHOU Debris Disposal Atfldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section
Debris, and the provisions of MGL c 40, S 34;
Building Permit M i
I I I. S I JOA.work shall be s issued with the condltion that the dcbris resulting from
1 disposed of in a properly licensed waste disposal facility as defincd by NIGL c
The debris will be transportcd by:
..Di Sao
(M+me uf'haular)
no debris will be disposed of in :
(name o— r�l.) --
l+ddress arr+aihty)
�iAn+Nraofpermrrrppli nt
late