7 HERBERT ST - BUILDING INSPECTION (3) I` ZZ, The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
y j Massachusetts State Building Code. 780 CMR, 7o'edition OF SALEM
�r Rvvised Aunaun•
Building Permit Application To Construct. Repair, Renovate Or Demolish a /. MAY
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I D e Applied: �y
Signature:
Building C * issi r/Im it ' gs Mee T—
ECTION 1: SITE INFORMATION
1.1 Prope Address* 1.2 Assessors Map& Parcel Numbers
m� 57"
I.I 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 11) Frontage(11)
1.3 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 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: 7
�Z O,I'fY J, �i, GZJC(sA�lfi 4 Ham& ti�
" Name.�(Prim) � Address for Service:
!` Yb- L6/Co� `Es =G�/1Gt�rl W - - q?�'-.���-/rZ��
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(chock all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
X i M I Su it)
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:f Indicate how lee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost(Item 6)x multiplier x \
3. Plumbing 5 2. Other Fees: S � yV
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:f
Check No._Check Amount: Cash Amount:
X6. Total Project Cost: Stb 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ZA5A Yz /2
�T St I.icensc Number Fxpintlon Date
Name o1(>I--I/lold r ` List CSL fype Iser below) u
f I Descriplion
:Address U I I Imestricted(up to 35,000 Cu.Ft.
R I Restricted IA2 Family Dwellin
Signature M M Only
ro 93r-no). RC Residenial Roudlina C'overin
telephone WS Residential Window and Sidin
.5F Residential Solid Fuel Bumina Appliance Installation
D Residential Demolition
5.2 Regb%H01 r0vementCootnctor(HIC)o 76 y�
I IIC Corn am"HIC Registrant Name�"v� Registration Number
/r, ' Ivry., I Mom--- a
xAadtja} , y i W7:31r2A6 ,pitation Date
Siwud re I ' rrleplwne
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 ..........O No...........O
P11RAN 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
e to act on my behalf,in all matters
o work authorized by this building permit application. -
of owner Date
SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
tatements and information on the foregoing application are true and accurate,to the best of my knowledge and
e
Signature of owner or Authorized Agent Date
Fwn
der the ains and penalties of 'u
NOTES:
wner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
registered in the Home Improvement Contractor(HIC)Program), will aI have access to the arbitration
am or guaranty fund under M.G.L.c. Id2A.Other important information on the HIC Program and
truction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5.respectiv2. n substantial work is planned,provide the informationbelow:
rs area ISq. Ft.) (including garage, finished basement/attics,decks or porch)
ng area(Sq. Ft.) habitable room count
f fireplaces Number of bedrooms
f bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SALEM
,, i PUBLIC PROPRERTY
" DEPARTMENT
V.Vm,`KI.I1Y i)nISCVt.L
M..WASHIXC:TON S I It ELT•SALEM,MASSACI H SE I'ISO 1970
'11.1.:978-745-9595 • Pax:978J40-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
implicant Information Please Print Leeibly
Nime l0ucincss/OrpanizatinNlndiviclual): i /�R� Nt7fl� (J(�W
Address: �J "C407z R�
d Iq ii 1 Phone it: IJ — 5�
cllystaraZ�n: SIruPP� Y �M ,�: A 96
:kre you an employer'Check he appropriate box: 'Type of project(required):
1.❑ 1 am a employer with 4. ❑ I :un a general couxaelor and 1 6. ❑ New construction
employees(full and/ur part-time).' have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 ant a sole proprietor or partner- listed on the attached sheet. :
Ship and have no mnployc es These sub-contractors have 8, ❑ Detnolition
working for me in any capacity, workers' comp. insurance. 9, ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of excnt tion Per NIGL l l.❑ Plumbing repairs or additions
3.El I um a homeowner doing all work g P '
myself. LKo workers' comp. c. 152, gl(4),and we have no 12.❑ Roof repairs
insurance required.] t cmPloyces. Lko workers' 13.0 Other
comp. insurance required.]
•,Any v,plica it tbut chucks box ill must also lilt out the scclion bcluw slowing(heir worked compensation policy inlormalium
r l lumuuwtwn who submit this affidavit indicating they arc doing all work and(lien him outside cuntraoton must submit A new al'rdavit indicating such.
,C.'ontmcon(than check this box must anSchod an additional sheel showing the name of the subcontractors and their wurkurs'camp.policy information.
I nor an employer that is providing workers'compensation insurance fur my eniplayees. Below is file policy and job.site
injunnatiun.
Insurance Company Name. _...-_._...
Policv 4 or Seif-ins. Lic. >r: __ ._.. __ Expiration Dater
Job Site Address: '1�nJ � S Cay'Slate/Zip: 3 819M
Attach it copy of the workers' compensation policy declaration pale (showing the policy number and expiration date).
I-'ailure to secure coverage as required under Section 25A of�1GL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. He advised that a copy of this siatl'rnenl inay be forwarded to the Office of
I m'estigarinos ul'the [AA t"or insurance c(,vcragc vcrilicatiun.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sic:muttro: Dat•t
Phul:c?:
official use only. Do nol write in this area,to be conhpleted by city or town official.
City or Town: _ Permit/License -
Issuing Authority (circle one):
I. Board of llealth 2. Building Department 3.Cityffowu Clerk 4. Electrical Inspector 5. Piwnbing Inspector
6. Other .
Contact Person: __-- Phone q:
r .
Information and Instructions
;;\lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplaced 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."
MGL 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 coustruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, &IGL 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 till 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
towril."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. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I"he Off icc ot'lavesitig7ations would like to thank you in advance fur 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 021 t 1
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/lima
CITY OF SALEM
j �
a. PUBLIC PROPRERTY
DEPARTMENT
I r1I , !'KPv ' :l
TO• $.VIM, Nhl\ A: I1'. :1 1 ,1 I _
Construction Debris Disposal Affidavit
(retluired li r all demolition and trnovation work)
In accordance with the sixth edition of the State Building Code, 7S0 Ch9R section 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 9 is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as detined by MGL c
1 11. S 150A.
The debris will b/e�traansported by:
(name of hauler)
The debris will be disposed of in
(name ut laclhty)
laddiess u(IScilhyl
sign❑ rc oCl er tit applicant
V
date -