22 HORTON ST - BUILDING INSPECTION (2) The Conunonwealth of Massachusetts
i Board of Building Regulations and Standards I'c llz
�Il'NIl'll'.\I.I'I1 I
�.' Massachusetts State Building Code, 780 CMR, 7"' edition I SI'.
Building Permit Application To COnSIRICL Repair. Renorate Or Dcnu,lislt a Krri,c,/./<,nm,rr
One- or Trr unih, Dn ellin,q
Thi , ectio Ft r Official Use Only
Building Permit Numbe . ate An
Signature: � '� �� 0
Building Cenunissiener/ Inspector o'Bu di , s Date
SECTION 1: SITE INFORMATION _
LI Property Address:e Z Ho/G Tb.ri 3 r— 1.2 Assessors ;11ap & Parcel Numbers —
1.la Is this an accepted street? yes_ no_ Map Number P:urcl ;Numhrr
1.3 Zoning Information: 1.4 Property Dimensions:
i Zoning J::trici ...—. Proposed Use Let Area(sy to frontage (11)
15 Building Setbacks (ft)
r'
j Front Yard Side Yards Rcar Yard
! Required Provided Required Provided Required Pruvidcd
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 —/
System Private❑ Check if yes❑ W On site disposal systc ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
)'
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTI N OF PROPOSED WORK'(check all that apply)
New Construction ,;sting Building Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition
Demolition y I Accessory Bldg. ❑ Number of Units Other ❑ Specily:
Brief Description of Proposed Work-: !FX
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials) _
I. Building $ dt1t� 'M I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
3. Electrical $ CAN . L10 ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ O fvp 2. Other Fees: $
4. Mechanical (HVAC) .$ s9fl List: t �/
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Chick Amount: Cash :\mount: _
Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due:_ ._
M lei
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) —8/Z X)
/OA,l License Number Fxpicaion Date
Nance of CSI.- Ifolder
List CSI_T)pc(see hclowl _
Address Al.17 Type oon
OJ�J 6 Dcscn l
11-� L Unrestricted (u�to 3?.000 Cu. H.)
�-y R Restricted INc_ Family Dttclline
Si�nutt Vt Masonn Only
!22f rpy-6Z,,f RC Rrsidenlial Rooline ('uscrute
Telephone \\'S Resid.mial \Vindw,jnd Sidme _
SF Rcsidenoal Solid Fuel Burmue \ t th:mce Insl.dlauon
D RCMdenlial Dentohuun _
5.2 Re is"tered Flonne Improverent Contractor(IIIQ
--
HIC Company Nano ur HIC Registrant Name ' Registration Number
Address
Expiration 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 pro\ide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached" Yes ......... Ci No ........... ❑
SECTION 7a: OWNER AUTHORIZATION U BE COMPLETED WHEN
OWNER'S AGENT OR CC'NTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building Permit application.
S,mature of Owner --— Date
SECTION 7b: OWNER' OR A VTIIORIZFD AGENT DECLARATION
ee— �+���`'� �. v�� ` , as Owner or Authorized Agent h7knowledge
that the statements and information on the ` egoing application are true and accurate, to the best of my
behalf.
Lp/ .
Print Name
Signature of Owner or Authorized Agent Date
(Signed under Ilse pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program ur guaranty fund under M.G.L. c. 142A. Other important information oil the HIC Program and
Construction Supervisor Licensing (CSL)can be found in 730 CMR Regulations 110.R6 and I IO.R5, respectively.
'. When substantial work is planned, provide the information below:
Total flours area (Sq. Ft.) (including garage, finished basement/attics, decks or porch i
Gross living area (Sq. FL) Habitable room count _
Number of fireplaces Number of bedrooms _
Number of halhroums Number of halt/baths
Type of heating system Number of decks/porches j
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12, IN Sr+r.ri • S.0 ni,
1t78-'4;a;115 ♦ 1:nx:97874_-9846
Construction Debi-is Disposal Affidavit
(required lur all demolition and renovation work)
fit accordance faith the sixth edition of the State Building Code, 780 Ch1R section 111.5 T
Debris, and the provisions of MGL c 40, S 54;
Building Permit f is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
v
The debris will be transported by:
�. L No..a �v/�N �✓rvti�sfj�.. Go.
(name of hauler)
I lie debris will be disposed of in
(name of laeility)
_ la rc of permit applicant
-21 Z�,Os
,late
13uilding Bnldi"g
al' ltc�ul ivan�and SW nJ:�d��a
Construction Supervisor License
License: CS 86200
t zzpiration: 8/2/2009 Tr# 13027
Restriction: 00
JOHN E HOWELL
107 HARANTIS LAKE RD !_
CHESTER. NH 03036
('o to issioner
CITY OF SALEM
x (r�ii PUBLIC PROPRERTY
DEPARTMENT
\y r
'.wt\W;K:If l':)RI\C111.1.
X l2C\VAtiHl.1,G l U\STREET 1 SAL.E.M.M.\ss.\a it'iii I'I s 0I970
Ti-.r;978-745-9595 • 1':\X:978.741C-1846
Workers' Compensation Insurance Affidavit, Builders/Contractors/El arise Print Lee Builders/Contractors/Electricians/Plumbers
Y yheant Information
iblv
ft
Volpe: (Business/or8aniv:uiordlndivldual):� --/61 f(( (n A
Address:
G&1rt /I ,/f 07a76
Cityr'Statcizsip:
Phone ;': ` W o� —6 2 J
Are you an employer' Check the appropriate box: 'Type of project(required):
I.❑ 1 a t a employer with 4. ❑ I wn a general contractor and 1 6. ❑ construction
nployccs(full and/ur part-time).` have hired the sub-contractors 7. �inodeling
2. I ;un a sole proprietor or partner- seed on the attached sheet.
ship and have no employees These sub-contractors have 8. Demolition
capacity.
workers' comp. insurance. 9. [:] Building addition
• for me in an working Y 0
bon and its
S. ❑ We are a corporation Electrical repairs or additions
(ko workers' comp. insurance 10.❑ P
officers have exercised their
� repairs or additions
required.] 1 I. Plumbing� lc air
3.❑ I am a homeowner doing all Work right of exemption per NIGL b 'P
myself. LKo workers' comp. C. 152, j 1(4),and we have no 12.[1 Roof repairs
insurance required.] y employees. tiro workers' 13.0 Other
comp. insurance required.]
-buy:pvplicanl Ihot d:ccks box fll must also till um the,eclian inauw showing their%-ofkcfs'cumpcnculioft policy in(ormatioa
' I bmcuwm:rs who submit this affidavit indicating they ate doing all work and then him outside cotlffaCtON must sulmlit a new arRdavit indiuling such.
•C' rxt rs th 1 chock this box must unshed nn addiliunal she•1 howing the name of tM suA:ontrxwn and their workers'comp.policy information.
l our an employer that is providing workers'compensation hisurance fo•oy employees. Below is the policy andlob site
information. ./
Insurance Company Name:„2I�/LC/.f.�-+^-t__ //L,y✓2'4'>„'[ ._.._..--_-....-----_----
_,
Policy isor Sclf-ins. Lic. Expiration Date:_,
t': - �-- -----
7 ��9�� p y 3� City,,Slatc/Zip:
Job Site Address: _L
Attach n copy of the workers' compensation policy' declaration payee (showing; the policy number and expiration date).
Attachalkirk; to secure coverage as required under Section 25A of:vIGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 lip to S230-00 a Clay against the violator. 13c advised that a copy orthis statement may be forwarded to the Office of
111 ,ligatiuns ol'the DIA for insurance awcragc vernicadon.
Ida hereby certifµ under the pains and penaltirs of perjury that the information provided above is true«ad correcr.
Date'
SiT:nuure: __
G�7P 1P/>V-oz/f ,T-
Official use only. Do not write in this area,to be completed by city or tmvn officiuL
City or"town:
Issuing:\ulhority(circle one):
I. Board of Health 2. Building Department 3. City/rocyn Clerk 4. Electrical inspector 5• Plumbing Inspector
6. Other __.--
Contact Person: --_-' _ ..___. Phone th
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for thrar employees.
Pursa:rlmt to this statute, an errtplgmvee 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 uf: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."
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 construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, bIGL chapter 132, 525C(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 time boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone nunmber(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 Offleials
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.
Please be sure to fill ;n 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)."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
t i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Office of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Departrnent'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
ae%;.ed 5-26-05
Fax # 617-727-7749
www.mass.gov/dia