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3 HENRY ST - BUILDING INSPECTION (2) e AA The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR, 71h edition MUNICIPALITY USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January One-or Two-Family Dwelling 1, 2008 This Se to For Official Use Only Building Permit mber. Date pplied: Signature: Building Commissio r/Inspector of Bui w gs Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers Ate SA , L l a 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 Yard •�� Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 O ner' f Record: I 1 A t 1, _ 3 Ne►�r� si . �r. (e g. / 17oS7 4 Name t) - Address for Service. 1-0O2- spy -5-)L16 Sign ure Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Workz: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building s 3 -� 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 $ OUO 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ `Q0 _ ❑ Paid in Full ❑ Outstanding Balance Due: 3jChr�t-� �a SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 1 _ [Gi' /ti 9 p J 11 2 LPrj^Q 1 lqre�rL License Number Expirat io Name of CSL-Holder) �' �G:n�C.,�,/' List CSL Type(see below) C� Address - G198S T e Descri Cu. U Unrestricted u to 35,000 . Ft. R Restricted 1&2 Family Dwelling Signature C' ^^ M Masonry Only �17g— S 3��`57� / RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 ];egistered Home Itttprovement Contractor(HIC) ,a , jy (/ere: ed C`�� r o I'c , J°a9Lg�_�,� , $ HIC Comp y ame or HIC R istran Registration Number e A. OtvGo q Addres -ExpirationDate 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 .......... 9� No........... ❑ t: SECTION 7a: OWNER AUTHORIZATION.TO BE COMPLETED WHEN , 4 OWNER''SS/AGENT OR CONTRACTOR APPLIES FOR,BUII,DING PERMIT as Owner of the subject property hereby authorize' " eGt, I i Q tr,Z _ to act on my behalf, in all matters ,relative to work authorized by this brlding permit'application. �s 40 Signauke o ner - `' + Date ' .. o .. .. SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION L 1, tq AA,I P2Pe.`rL , 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. nn Le0� Y I k Jr Print Name� ,_ _ . . r"- /, - Signature of Owner,or Authorized Agent Date . (Signed under the pains and penalties of perjury 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. 2. When substantial work is planned, provide the information below: Total floors 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" t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): y0 1 e t Address: r ' City/State/Zip:_ j^)- -A//A;h� �f✓!A' ' Phone#: f-7'IY-S -S7/7 Are you an employer?Check the appropriate box: Type of project(required): 1.LJ t am a employer with___12—_ 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).- have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These subcontractors have 8. ❑Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition - fNo workers'comp.insurance 5. ❑ We are a corporation and its - ficers have exercised their 10.❑Electrical repairs or additions required.] of 3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions _ myself. [No workers'comp. a 152,§l(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑Other - comp.insurance required.] .Any applicant that checks box HI must also,fill out the section below slowing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractms that check this box must attached an additional sheet showing the name ofthe sub<ontracims and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information s Insurance Company Name: Policy#or Self-ins.Lie.#: 6 K CiYS it I 0i -Jo Expiration DateC Job Site Address: 3 Netselt Si, City/State/Zip: ,.Xtt- Attach a 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification_ I do hereby certify un he pains and penalties ofperjury that the information provided above is true and correct Signature. Date: Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions 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 ajoint 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." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shalt 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 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 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-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 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 Officials - " -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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license 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)."Ai 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. The Office 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 Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26 05 www.mass.gov/dia J i I _ J 1 + CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT 1 V/ Ial4.e.lay.,\IV�Irl:.relell el. \L\\{\1111V1.\•1'1 • \I .n'le rrl•y7•%1}'/yI! �1°ex:•%71•i r.}'1111a Construction Debris Disposal A110davit (m.4uired ,or all demolition:uxl renovation work) In accordanec with the sixth edition of the State Buildin`Code, 730 CMR scetion 11 I.s Debris, and the provisions of MGL c 30,s issued ns It e Ouilding Permit '*' • _ is issue d with the condition that the debris resulting Item This wink shall he disposed of in r properly licensed waste disposal tbcility as defined by 111. s 130A. The debris will be trunsportcd by: 511, 1:�rel i3� 1�1a � � uo�✓� (its of hauler) Ilia dcbris will be disposed of in CG (11anm Vr lax Ilp (0 ullaclhly) .Irnalurf of Irermir apylieant 6-�r - Ilale y I•u.al.L. - J �S�ISTI `�J 1 zoo 1C,`A, +© aC-k ,etie. a G �� v�.'�'�oh a 31 `�� R,'c��e I� 2 Ad R, c�ge .2 )(10" R-44ers /G " O.000 ', aX/�� Il�c�ye l3oarcl .2 X/O ro �-� �xy" 16 a.0 mi-I i)cfer ar' Oormtt wall aK4 160GC. Knee wall Ex;s4 :erg axg" EG " o.0 . ? x5/� L-xferiu� wall o? y „ "'tef;'Gr (�jtar,'n5 w� I 1 E�KrS�;vej ex/5�,1� .