13 HAZEL ST - BUILDING PERMIT B-11-731 I The Commonwealth of Massachusetts CITY
I Q„p Board of Building Regulations and Standards OF SALEM
�I Raj+ Massachusetts State Building Code, 780 CMR, 7`h edition Revised January
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One-or Two-F y Dwelling
This'Seed For -fficial Use Only
,Bpilding Permit Number: a D teAp lied:"
Signature:
Building Commner/Inspectorrof Buildin Date
SECTION 1:SIT INFORMATION
1.1 Pro eVA ress= .2 Assessors Map&Parcel Numbers
Lla 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(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yazd
Required Provided Required Provided Required Provided
r
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 ClCheck if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own of Re4ordc a
Name(Pri t) \ ��•t/ Address for Se�T
Signature Telephone 9CIO �1_-/
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) [IAlteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of U its Other ❑ Specify:
Brief Description of Proposed Work:
f
SECTION 4:ESTIMATED'CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1.Building $ 1. Building Permit Fee: $ � Indicate how fee is determined:
❑ Standard City/Town Application Fee.
2.Electrical $ ❑Total Project Cost'(Item 6)..x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
pj CheckNo. ' Check Amount: Cash Amount:
6.Total Project Cost: $ OV 0 Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licenseq Construction Su isor(CSL) 1(� 8 S 1 I 7
( �J fj)/ License Number Expira ion ate
Na�e�o.�) CSL- Ider
r List CSL Type(see below)
Address 6111 T e' 'I _ Description
Unrestricted u to 35,000 Cu.Ft.
Signature Restricted 1&2 Family Dwelling
761 _��(o M Mason Onl
Telephone ✓ RC Residential Roofin Coverin
WS Residential Window and Sidin
SF Residential Solid Fuel Burnin A liance Installation
D Residential Demolition
5.2 Re 'stereo FIome Impg� e e t Contrp or IC
r.
HIC Company N r HIC Re i r t N n Reg umber
Address -l /
70( Expiralion Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(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 ..........ek, No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Eauthorize
as Owner of the subject property hereby
to act on my behalf, in all matters
rk aut o�building permit application.
ner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
r
pbehalf.
tL4 as Owner or Authorized Agent hereby declare
ments and information on the foregoing application are true and accurate,to the best of my knowledge and
(ftI �` G . �
Print Name
�l � glll
Signature of Owner or uthorized Agent Date
Si ned under the 'ins and malt' of er'u
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. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
FTotal
n substantial work is planned,provide the information below:
ors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)ing area(Sq.Ft.) Habitable room count
f fireplaces Number of bedrooms
f bathrooms Number of half/baths
eating system Number of decks/porchesooling system Enclosed Open
al Project Square Footage"maybe substituted for"Total Project Cost"
i
4-o* CITY OF SALEM
' PUBLIC PROPRERTY
-' DEPARTMENT
.1w::a:I Y:,xMI'll
\I Intel
I!:WAHll.Nti It^Slxll:T a SA P.M. M.\9.)t.III it I Is3197•^,
I'm;08•7I5-9395 a P.sx. 97N•74C•')346
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
V)nlicant Information Please Print Leeihly
Vi11T10Illuoia.ssi Qr;lanlratioNlndt)uluall: _ vvwr I C Q�I t/ /li/l� /�
Address: % 0 tf�
City,Statci/.ip i'huneP:_
Are)4111 an eay)loyer?Check the ap]WIld"Wow
x: swwkwecvnipvnYjOj
Kinhirmajon
project(requlred):
I 1,0 1 and a employer with_� mn eral contractor and 1 ew construction
colployces(full ancVur part-time) ave the sub-cuntracturs
0 1 :un a sole proprietor or partner- stede artachcd.sheet. : emodeling
%hip and have no empluycashesecontractors have Clemolition
working for me in any capacity. orkmp,insurance. Wing addition---—---- INa workcts`cuinp. utsurancee arporation and itsrequired.) Ticee uxereised their ectrical repairs or additions3.0 1 and a homeowner doing all workht omption per MGI. mbing repairs or additionsmyself. ino workers'comp. 132, ),and we have no of mpaininsuranco required.) r - plaino workers'mp. nce required.1 er
-bt)-,pplivai l thwe checks blis III must aliu rill wl a ivili lg teir w'wkwe cvnlpenYWOn puli inin6ammion
'I lummtwnun who"damn this smdavit indtuling They ao doing all wurk and'hen hire outside cuntrncson mul.uhmt a new'Indarit indicating rich.
•r'.minchtn$hat Ihcck this box most alnchod,m addiaunal.dwvt.h„wing Ill¢name of the suls�ceniracwn and their wurkan'comp,ptdicy inrormanun.
/ran an ewp(uyer that G prav/Jing workers'rumprnrnNon inrunritca/br my coop/uperr. Be/nry/r the pu//�y and/ub sih
i,r/annafirrn. .�
Insurance Company Vmne: •� '
I'ulicy 4 or Sclr•ins. Lic.#: C -Y �-/ Z 2 — Expiration Date:
Job Site Address:_ / 3 , pp 2pal ) C ily'slate/Zip:
Altuch it cupy of the workers'eumpen.latlun policy declaration pug@(showing the policy number and expiration data).
Pailurc to secura coverage as required under Secliun 25A ul'.%IGL e. 152 can lead to file imposition of criminal penalties of a
rinc up nl SL5110.00 and/or one-year imprisonment, is well Jx civil pcnalbu in the Amin of a STOP WORK ORDER and a fine
of up to i?sa.00 it Jay aguinat the viol itar. Ile advi.ed that a copy of this stulclnu t may be-lurwardcd to the 011ice uT
III\'�.sIhJllniti ul the UTA lof 1n111r:mee cOveragC)cl'Iticilion.
/du hereby rcnijy cruder rho groin tu/r' . ofPCIIJUIX that the injunnullon provided above is true urn/correct.
;I1 R:Iliire: U //1 /1
O lieu/acre dilly. Od ant write in this area, to be ruinp/eted by city uptown r)/J/eiuL i
i
City or lnlrn: Pcrinit/Lieensa 0
Issuing Authority(circle one):
I. hoard of Ilralth 2. Iluildinq I)cpartmvnf I. GO/Tulin Clerk 4. Electrical inspector 5. Plumbing Inspector t
6. Olhcr
O,14t Jcl l'cnuu: _ .. Phone'!•
•
tntormation and Instructions
\I:us.ldw:ctts Gcnerai Laws chapter 132 requires all employers t in the service workers'
compensation
om another sationny contract of tor their oyc i.
Pursuant to this statute,in emploree is defined as"...every pc"
apress Jr implied, oral of written."
.fin employer is defined as"an individual, partnership,association,corporation ti other legal entity,or any two r t more
,a the loregoing engaged in a Joint enterprise,and including the ICgaI repfesC11t1rves Jf a deceased Cn1pIUye4 Jf the
receiver Jr trustee ut an individual,patmcnhip,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,cunstruction or repair work on such dwelling house
or on the 2roundv or building appurtenant thereto shall not because of such employment be deemed to be in employer."
MGL chapter 152, Q25C(6) also states that"every state or legal licensing agency shag withhold the issuance or
renewai of a license ur permit to operate a business or to construct buildings In the commonwealth for any
ho has not produced acceptable evidence of cumpllance with the insurance coverage required."
applicant wa coupler l 5_', a25C(71 crates"Neither the commonwealth nor any of its political subdivisions shall
Additionally, has
enter into any contract for the performance of public work until acceptable evidence of cu/mpliauce with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
-- —please flit out-the-workers'compensation affidavit completely,by checking the boxes that apply to your situation art if
necessary, supply subcontrretor(s)name(s),udihess(es)and-phone numbers)along-with-their-cert�catcLs)Pf
insurance. Limited Liability Companies(LLC)vorkeor trs't comped ensationility ilroisurance rshiwith
an)LLC or LLP dots haveer than the
members Jr partners,are not required to carry P
employees, d B
a policy is requiree advised that this affid the ufndavtt Thite affidavit should.
avit may be submitted to the Deportment Industrial
\ccidents for confirmation of insurance coverage. Also be sure to sign and date
he retumed to rile 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 low 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 Omits
please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the buttorn
Of the affidavit for you to till not in the event the Office of Investigations has to contact you regarding the applicant.
ht:usc 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 pennit/licmise applications in any given year,need only submit one afiiduvit indicating current
policy int'otmation(if necessary)and under"Job Site Address"the applicant.ihould write"Al locutions in (eity Jr
town)."A copy of the affidavit that has been officially stamped or marked by the city or town tnay be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business Jr commercial venture
(i.c. a dog license or permit to bum leaves tic.)said person is NOT required to complete this affidovit.
1 hC t)t lice of Invcsrigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us it call.
The D:paronent'i addreis, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofllce of Invadgadons
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.mass.gov/dia
`b CITY OF S'U.E.N1, L DiSSACHUSETI'S
• 3L:imLYG D EPA RT.%MNT
130 WASHLYGTON STRm, 3i0 FLOOR
T EL (978)743-959S
FAX(978) 740.9&M
KIJBERLEY DRISCOLL
T
MAYOR Tlouns ST.PtFnRB
DiltwroI OF PuaLic PROPERTY/SUMDLNG CONNISSIONER
.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
Debris,and the provisions of MGL a 40, S 54;
Building Permit At is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11,S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
d Te
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