21 HEMENWAY RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
/ USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pplied:
Building Official(Print Name) Signatur Date
SECTION 1: SITE INFORMA N
1.1 Property Address: 1.2 As s s Map & Parcel Numbers
1 4-eM�„_,� , 4 � � 63t-r(,
1.1a Is this an accepted street? yes V no Map Number Parcel Number
1.3 Zgging Information: 1.4 Prop �y�Dimensions:
Zoning DVis\ttiict Proposed Use Lot Area(sq(8)D Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Publi ` ( Private El Zone:
if yes❑ Municipal.& On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
(1te tk + Kf) 0 2 4e dZJ 7p
Name(Print) City, State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s)X Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work 2: r 0 tr S - �' '-+7)^
1.✓ jtJ K e�1 s�.m nA ,s �1ct 3 l c.r trjc l ¢ Ke, fs
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ J 3,VOt) 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ElStandard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees:
4. Mechanical (FIVAC) $ List: /
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 13,000 ❑ Paid in Full ❑ Outstanding Balance Due:
C
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)ca�41fLllf-1� License Number Expiration Date
Name of CSL Holder
1',� In"c / List CSL Type(see below) (/
No.and S J Itreet (� Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�-r /�r� SF Solid Fuel Burning Appliances
CJ 78- S3� 56�/ Cn �dcrw I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
B P 1 L'I y 797 2 12
NJ,( HIC Registration Number Expiration Date
HIC�}ompany Name or HIC egistrant Name r- Q
,`J (a�V,—,,L 4) `t,"
NSLa1tLnS , �7� 83d-69G� Email address
City/Town, State, ZIP 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 .......... kC No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize co�,.k r cA o
to act on my behalf, in all matters relative to work authorized by this building permit application.
�rySfl ✓i i O (P /-2t
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that al I of the information
contained in this application is true and accurate to the best of my kno ge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.sov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(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
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1 C. \Vn MIIAG I U,\jIYCt:r • 5.1I1-M. h1.111.11.11i V I I%JI'77-
Ihl. 77L713'93 3 e h tt v7M•?Q-9,446
Workers' Compensation Insurunce .ttOdovit: UuildersiContractors/Electrlcliinwpiumbers
\ 1 lllcant In ormulion
ge Print le 'bl
V:I In1:111uu�le,Nl)raani ratinN I nJ.r nlual l:
City,.Starc.Zip- �w� s y�q G�S7c�Phone0:_ '57-7 3�^J;5� g
Are I y n ou a uinployar"Check the approprlule boa:1.❑ I and J umpluyur with 4. C] I :on a guneral couoaetor and I 1)M nrpro)act(required):
L04Ik1r4'1ft64VJ
uycus(full uad/ur putt-finie).• huvu hired the.+uh-cuntracwrs 6. ❑New construction
a ale prnpricnx or partner- lisfcd on the anached.vheet : 7. ❑Remodeling
nd have no umpluycva Micas subcontractors have
ng thr one in any capacity. workers' coinp. insurance. a' nemolirion
orkurs'cutup, insurance J. 0 We are a cni 9. ❑ OuiWind addititrrs
cJ.) pontinn anJ itsorJ4ccrs have uvur:iswl their IO.C]Electrical repair$or additions
homuuwner doing all work right Orctunption per fv1U1, 11.0 Plumbing repairs or additions
(N•o Ivorkun'cunlpe. 1S2,¢I(4),and we have no
c°required.) r clnpluyuus.(N'o workers' 12.0 Ruufrepairs
etnnP, insurance squired.) 1 J•❑Other
•4nr.yglhcull Ilia ba fl mus':Jw Ifll uW IN,echan below Jwwul r u , n
'I l.rm,mwrwn whe"Amlif this snWsvit inakwin lill ,vurk a Mir wwAnd iticM hire"1140 yli u11l.rt iiuliuy miirrmWitit.
f.minwbrn lha thvck this bee mum aoxhed.m aJJiMiin'unsrl.Awn,howita IM nanM tl/lM Subw.4 Nr raeNn and h@W uuAen� .brif inJiuJina,Iw�h.
/lour mf tmrplayfr thus If pro rfdlntf workers'rurnpfnroddho Luurnnce or ru ern o• Came.pJlcy mfhrnatius.
i ilarruNdws I y p/J rfls Bf/uw li Mhr po/ky unr//u1 aiN
Imuranct:Company Name:
Ihllicy 4 or Sulr-ins. Lic.M;
EApiraiton Date:
Job Situ.\dares:
C1ty1 Slate/zlp:
.\ltach it easy of 1111 workers'cumpentafloe pulley duclaraNun purse(showing the policy number and etpiratlun date).
"lluru to vccuro awerugs as required under Secliun?Sr\ OI'JIOL c. I)I oats lead S to the im
fin. up of S LngiM anJ/ur uue-year nnprisomncnt av wc11 as civil pt:nalllu in Ihd turn Ora STOP WORK URGER and a fine
position of criminal penalties of a
,Ifup lot i2S(1.rM a Jay lgainat the violamr. Ile advi.lcJ thus a copy urlhin:
v alutemum may be Iurw urJOJ Wthe Ullice ut'
Incangaumms ol';hu UI.\ Or in,urancc auvcragc tcr ilicalarrl.
/du/rcrrhy t,rri/y mrdar Ihn print, nuhicy u/yer/nry MINI the hi urinuNon/� yrvridrfl ubovf is star and carrot
78 - '3 --G AG
Irl//1riNt ielf aii/y. nJ nor Irrirf in rhi.f urcu. ru Ie go
Ay sirs ur rows n//7ciuL
('i fr ur Town:
PennirMl.leentr it
I„ulnq .\W hurily (corclo noel;
I.
6. 01hur IL,arJ .I(Ilvalih 1. Iluddin� Ilvp.lruotvd I, Cily. l'u,vuC'Icrk J. Llccfric.11fu+ a:rrur i,
I Plumbing Inlycclar
I
( u11.N1 I'tr WIC --- l
information and Instructions
r s to the service of another un.ler Ally cun1r, of hire,
�IaSsadlusetts l;enenl Luws chayfer I i2 rcywrcs all euyrloyen o provide workers' wmpensauon tar tt r.cc of hires.
I'ur.u.nit to gills.could. an trmpl iVee is dcrined as"_.every (>`
,press or ❑nplied, oral Of written' two or more
�n ernpluyrr rs derineJ as"an individual.parmenhip,.Issoelallao,corporauon or ocher legal entity,or any
r.
J. lu m �m loyees. However the
f ,he rareg,vnJ clifwdJ m a individuaoint pnso, and ir>`IuJinJ the legal represelltalives of a deceased :mpluy\% v t t
,,I the l dl filmed of.w Iudivlduol, ptumershtp,assoclalled or other le al aunty,emp Y a ' D
non,w Jo maintenance, cun,,truction or repair work on such i dwelling house
owner r a dwelling house having{not more than three aparvnents and who resides therein.ur the occupant of
,Iwcll,nt huusd of anothdr who employ. pe _
or on the Jruunds or building appurtenant thereto:hall not because of such employment be deemed to be m employer.'
�IGL chapter 132, g?SC(6) also states that•'everY state or local lictnslog agaaeY shall withhold the Issuo any
or
ce Of Uanee with the Insurance coverage required.'
-,jGLrene of of a license or permit to operate a business or to coastrutt buddang,In the commric I subdivisi s+h,ll
uppilcant who has not prod u;ad CSC+P��b�lewlNeuher he ommonwcalth nor any of ill p
Additionally, %lGL chapter I S_, �_ l
requirements folily
of this act for t have been p euntedbo the cony ct g authority ible "'
ul'cunrpliarlce with the insurance
Ayylicants to our situation and.if
Completely. checking the boxes that 2DPIY Y
ns)and phone numbers)slang with their certillcutaUl of
Ple:rsa lilt out the worker,' compensation atlldavit ges)and
by LLP)with no amployres other than the
necessary,supply+ub-eontraetor(s)nameW.address(
worker' compensation insurance. If an LLC or LLP does have
insurance. Limited Liability Companies(LLC)or Limited Liability Partner P�
strial
members or partners. are not required to carry Of
employees,a policy is required 9e aJvixJ chat thi,�lso be sure to salgo affidavit nay be laid Jute he ttendavlt.fttTllela�irdav t should
Accidents for ontlrmation of insurance coverage unit or license is being requested, not the U,pavement of
he lettrntdd to file city or town that the applic for the regarding the low or if you are required toa obtain
should enter their
lndustrial,\eciddnts. Should you have any questions ant st the number th el below. Self-insured comp
compensation policy. Please call the Dept I it
Self-insurance license number on the a ro riato line.
city or Town officials
rfa.s be ifidurc that the you to fill out tutit sin the event the Orli a complete and printed loth nlvestig{rtions has ty. The oe contact yuu regarding the appt ha a provided a space at the licane
Phase bd sure ro till in the permit/license nwnM r which will be used as a reference number. (1 addition, is applicant or
dint must submit multiple Peonio'licarrsa applications in any given year, need only d Write ono:all ire provided oehaent
policy information t if necessary) and undar"Job Site Address"j f marpkedrbyS 1114 coy oraown tnayelocations o l' Y
town).••,%copy of rho affidavit that has been ofticiully stump'
each
applicant as proof that a valid affidavit is on file for future permits or licenses. to any new a urines must m Riled out venture
°.'.r t�JR errot not r
rr permit to burn Naves ice ) `ld Pers 3 license as VOTrreyuired of complete this affidavit.mrllercial venture
I he )tticc„t Iuvesfigatiuns tvuuld Ilk*w dwnk you in.oil is Nnce fur your coupdration and shuuld you hat a any yuesuoos,
plea,: do nut hesitate to Jive us a call.
f he Ucp:unncnt's addre+s, telephone and rax This Cn m�tnnonwealth of M=40Use1111
f]epart cent of Industrial Accidents
of ice of InvaUgatlans
600 Witshington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617.727-7749
wWw.may.gov/die