7 HORTON ST - BUILDING INSPECTION (2) a The Commonwealth of Massachusetts CITY
Board of Buihiing Regulations and Standards OF SALEM
Massachusetts State Building Code, 730 CMR. Th edition RevisedJw uar.!-
�I_ ! 1, _'LION
[lyla// Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Ttvo-Fumily DtvrffinX
This Section For Otlieia e O
Building Permit Number /I,,,,,,,,�� D Applied•
Signature: " �W
Building Commissioner/Ins or Bu' mgs Out
SE ION IATION
1.1 Property Address: n q / Assessors Map& Parcel Numbers
_ / nr iJYI
-
I.Ia Is this an accepted street?yes �- no
1.3 Zoning Information: 1.4 Property Dimensions.
Zoning District Proposed Use Lot Area(sq Ill Frontage(11)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Rryuircd Provided Required Provided Required Provided
1.6 Water Supply:(M.G.t c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if ycs13
SECTION 2: PROPERTY OWNERSHIP' { —
2.1 Owner'of Record:
Est PlrnL 'Ir� �
Nome(Print) Address for Service:
2�d'- '7VS f332
i atury
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Des iptioja,of Pro osed ork':
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how Ice is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(Item 6)x multipliers
3. Plumbing S 2. Other Fees: S
a. Mechanical (IIVAC) S
List: �� )
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:_
6. Total Project Cost: S "/a`����- ❑Paid in Full ❑Outstanding Balance Due:
� e
SECTION 5: CONSTRUCTION SERVICES
5.1 nsed Consfrucflo ,Supervisor(CSL) is / T� _�J
License Number lis ratio Date
Nm r d "1.- I lul •r
I.ist C'SL kpe(see below)_
:\ rrss fr PC Description
I I t'rimstrictcd N2 to 35.000 Cu.Ft.
R Restricted IBr2 Family ffivellinic
S iuy/natu,(rr�� // At Masonry Onl
RC' Residential RoutingCovering
Ilephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
.2 Iste Ho Impr eme Kontr for IC)
r S �d3O(O
.Al•'C -Pw:- �:.rm., • 07,1Di — — -- ,.vb...:......:.....w,,..e.--
Jres• �r
xpirdtion Date
mature 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 ..........(5 No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property hereby
authorize �P/' /C z�rA to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I. ) , -'g�� r 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.
Pe-T
" atc
Print Name
Signature ot'Awner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
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 Home Improvement Contractor(HIC)Program),will gal 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 I IO.R6 and 110.115, 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.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
T)pc of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted fir"Tidal Project Cost"
CITY OF SIU.E%I, LNL-kss.-kaiusETTs
BULLDLNG DEPARTIENT
110 WASHLNGTON STREET, J3 FLOOR
` TEL (978) 745-9595
FAx(978) 740-9846
KIl®ERLEY DRISCOLL
MAYOR mows ST.PIEm
DIRECTOR OF PUBLIC PROPERTY/BU MLYG COMMISSIONER
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-e-40,-5-54,, — -- — — — --
Building Permit Al 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
111, S 150A.
The debris will be transported by:
(name ofhaulor)
The debris will be disposed ofin
(name of facility)
(address of facility)
signs re of permit applicant
,late
1.AnH,f JAR
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
?a.�o
❑to N:I Y:)Xllt:VI L
At]YI'd 120 WAS INIL;I ON S'JXEkT • SAL p.N,Ms YtsC II .CI-I\3l')7.'.
08•745-9595 • P.ts. 978.7+^•7846
Yorkers' Compensation Insurance :%affidavit: liuilders/Contractors/Electricians/Piumbers
% ) )licant Information
^r J Please Print Le ihlit
Nitlne lliucuwssiiorBmQvatinNlndlviduuq p
: V PICY iJ
Address:Ire( /IP'A�
City,starci/.ip: 4 � 4;0 10) (Jl�/7�_ I'huneii: 7 —7VV�O?34U
:\re you an employer'.'Check the appropriate box: 'type of project(required):
1.❑ I am a employer with 4. ❑ 1 ;fill a general contractor and t fi. ❑ New construction
em to 'ccs full and/or art-time).• have hired the sub-contracture
�...,/ p Y ( P 7. ❑ Remodeling
. 2.pSLI ;Im a�r+vnr partner- lined fin the anachcd sheet.
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'coal insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 tint a homeowner doing all work right of exemption per fvtOL I LE] Plumbing repairs of additions
myscif.tNo workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.) r cmpioyces. LNo workers' 13.001110
comp. insurance required.)
•any.,pphcaur ilia[checks box dl mull also till wn the uctior Wow showing Ihuir w•urkuti cumponsasi.m policy intinnutiun
' I lumauwmn who udlmil this affidavit indicating they arc doing all work also then him outside cuunnon must.uhmit a new al'rdavft indicating awh.
•C'onlrkn'n that check this box mutt altxhcd an additional sheet showing the name of the sub:ontrwton and their wurkers'comp ptdicy infrinnaliun.
/urn un ruy�lu3'¢r tGut&pruvir/ine rvorkers'cuwprnttainn iu rurnurr jar my rurployrrs. Below is the pulicy and job.rite
iojurrrrution.
insurance CumpanyVame: __. .. __.—._---_.----
Policy is or Self-ins. Lis rt: __._.. ... .._ Expiration Date:
Job Site.Address: cay;State21p:
.Utach it copy of the workers' cumpeasati in policy declaration page(showing;the policy number and expiration date).
hailurc to sccurc coverage as required under Section 25A ul'IIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 andlur une-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine
of up u)S250.00 it Jay against file violator. lie advised that a copy of this slatcmunt may be forwarded to the Office uC
Invrangau'nld of doe DIA for insurancc c„varagv tcrificaliun.
/do hereby to ' er the pain•on ulticY ufperjury that the infunnution provided above is true and correct.
tit ':I;Ilin'e: _ � L DatC' �Z/0 r
OQicial nsr wry. Do not write in this areu,to be rumpletrd by city or town ojjicia/.
City or Town: Permit/License�_
Issuing;Aullwrily(circle onc):
I. Board of Ilvallh 1. Building Mparuncot .3.l:iry'i Ibwn Clerk 4. Electrical Inspector 5. Plumbing; Inspector
b. Other
C'nuact I'crsuo; _ .. Phmtc tl:
Information and Instructions
.'%lassachusens 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,
cypress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or tither legal entity,or any two or more
a the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of m 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, bIGL 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 question regarding the low 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 he 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.
Phase 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 pcnniblicetase applications in any given year,need only submit one affidavit indicating current
policy int'ormation(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 file for future permits or licenses. Anew 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 burn leaves etc.)said person is NOT required to complete this affidavit.
I he i)fl ice of Investigations would like to thank you in advance fur your cooperation and should you havc:my 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
Ofiice of Investigations
600 Washington Street
Boston, MA 02111
Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Itcviscd 5-26-05
www.mass.gov/dia