26 HOWARD ST - BUILDING INSPECTION ` } r to
The Conunonwealth of Massachusetts
IOR
i Board of Building RCgulalionS and Standards Nlt:NIl'IPALI'Il
Massachusetts State Building Code, 7811 C'MR. 7 ' edition
I'SI[
l3uildim, Permit Application To Construct, Repair. Renovate Or Demolish ❑ H,'i'is�'l.Luu, ,r,
PP One- or Two-Fmnih- D yelling 'urns
This Section For Official Use Only
Building Permit Numb Date Applied:
Signature:
Building Cunt n since/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property' :Xddra 1.2 Assessors Map & Parcel Numbers
1,la Is this an accepted street'? yes nu Nlap Numher — Farrel �Numhrr
i.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq to --- Frontage I It) -----
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
I Required Provided Required Provided Required i'nroided
1.6 Water Supply: (M.G.L c. 10. §51) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone:'
Public ❑ Private ❑ — Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
e (Print) qe Address for Service:
Si azure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied Repairs(,) ❑ Alter:dion(s) ❑ Additwn ❑J
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:_ J
�Hrief Description of Proposed Work
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) _
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
3. Electrical $
❑Total Project Cost' (Item 6) x multiplier
3. Plumbing $
2. Other Fees: $
J. Mechanical (HVAC) .$ List:-
S. Mechanical (Fire Total All Fees: $
Suppression)
Check No. Check Amount (Wash
j 6. 'Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due:_..____
0
Yy\ca� o6 mt��i�� i'
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Il, r.-1 on Dale
Nanx•of CSL- Ifolder
, M M List CSL"fNpc Iscc heluwl
"I"• . Us.n Ilion
\ tress
C UnrcsulcleJ (Lill to 35.010 Cu. Pt.i
R Rcstrict.d I.c'_ Fumil ' Dw.11ine
Signature M >lasonry Only
RC Residential Kaoline '.'utenne
T.lephone \1'S Ro,idnuial \\`mdmc 'ind S:d:n;:
SF Residential Solid Pucl liurnine \ t tlian.r In51.111JW.1
D Residenu:d Uewohuon
5.�? Registered Home Improvement Contractor (IIIC') 7�g
" aa111�C��panyNam.u r I11' C 11cgi vant Namtistration Number
ass
O
dress :.xpiratiun Date I
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. J
Siened Affidavit Attached? Yes .......... No........... ❑ --
SECTION 7a: OWNER AUTHORIZA LION TO BE COMPLETED WHEN
OWNER'S ACENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT___ _
1.
_ e as Owner of the suNcc: property hereby
authio
v x� to act on my hehalf. in all matters
relati wcr, authorized by this building permit application.
Signature L-1,Owner -- — --_—
SECTION 7ir: JWNERt F[OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby de,:lare
that the.statements and mforma?io�no�te ;oregoing application are true and accurate, to the best oP any knowledge and
be alf.
P( t Name
Signature of Owner or thurizcltl Agent D'to
(Signed under the pains and penalties of egurv)
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 (he arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Prueram and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS. respectively.
' When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage, finished basement/attics, decks or parch)
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"
CITY OF SALEM
r� PUBLIC. PROPRERTY
DEPARTMENT
Construction Debris Disposal .-affidavit
(reyuircd liir all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 ChIR section 111.5
Debris, and the provisions of'b1GL c 40, S 54;
Building Permit it is issued with the condition that the debris resultinu front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
(name of hauler) �—
I he debris will be disposed of*in :
(name�uf l'auliry�
--- laddreas ul'Invlilvl -. -
�iguatu'c of pr nntt
6
laie
CITY OF SALEM
-16� PUBLIC PROPRERTY
DEPARTMENT
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71:1.:978-715-9595 • 1'.,x.978.I41^.7846
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers ace Print Leeiblv
:\ ylicant Information
Vdtnt, l0u�wc vgr„an tw >.``Ind Iu011 y
Address: D-1 \`rodCoC
CityiStatc;%ip�^\ ���� Monc
I :itrc ,nu an employer? Check the appropriate box: 'Type of project(required):
4. ❑ I am a general contractor and 1 G. New construction
I.❑ I an,a cmpluyer with ❑
�/c 1ployccs(full and/ur part-tinic).• have hired the sub-contractors 7. ❑ Remodeling
2.u I ant a sole proprietor or partner- listed on the attached sheet.
These sub-contractors have 8. ❑ Demolition
ship and have no employees
working for me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
INo workers'comp. insurance 5. ❑ We c11'c a corporation and its ME] Electrical repairs or additions
I required.) officers have exercised their
right of exemption per MGL I I.Q Plumbing repairs or additions
3.❑ I Yscl - LNO workers*
doing all work S s O 12.Q Ruuf repairs
myself. LKo workers' comp. C. 152, s l 4 .and we have no
insurance required.] t alnpluyecs. Lno workers' 13.❑ Other
comp. insurance required.]
'Ally .ipphcaill that checks box fit muse a15u rill Otto the sccriou Ix IOw showing their w•Orkcrs'cumpenvlion poet y inlinmalioa
'I Wmauwmn who snbnid this of idavit indicating they are doing all work anal then Ain outside cuNrxlon must auhmil a new atC,lavil indiul�ng
(' I, dmpsbeck this box mu61 aaached do additional%heel showing Itte name of that sub ontracton and their wvrlocm*a p.policy infurm:n t,on
/tun an employer that is pro vidiag workers'c•oatpensation insurance for rtty employees. Below is the policy and job rile
information.
lr..%tiranee Company Name:
Pulicv i!ur Scif-ins. Lic. *: . -.. Expiration Date:
Job Site .-\ddress: -_. CilyrStatelzip:
Attach it copy of file workers'compensation policy declaration page(showing; the policy number and expiration date).
failure to secure coverage as required under Section 25A of.>lGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or une-year rnprisonincnt, as well as Civil penalties in the form of a STOP WORK ORDER and a fine
-25 violator. Ile adviwd that a copy ofthis slntement may be forwarded to the Office of
of u t to �_�0.Q0 a day a uins tlhe >
I Y b
Invrsngaunns of the MA fur insurance cot crags teificalion. _
I do hereby certify uncle rr dies urrd penalties of perjury that the irrforinulion provider!above is true anal correct.
�i:gaomre: Dat
F�ely. no not n•rite itr this urea,to be completed by city or lot o/Jiciu/.: —rily (circle one):
lcallll 2. Building Mp:lrunent 3.C.ily.`fonu Clerk 4. Electrical luspector i, Plumbin>: Inspector
--
Coutacll'cnou: _ . .__. Phone0:
Information and Instructions
Massachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an rmpluree is defined as"._every person in the service of another under any contact of hire,
express or implied, oral or written."
An employer is defined as"an individual, partnership, associatiou, corporation or other legal entity, or any two or more
of the loregomg engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of :ar 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(rouse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on n71 grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
S1GL 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, :NIGL 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 connpliance w ith the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors)nanme(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
he 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 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.
('lease 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 perniulicerse 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
(i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I h.: t)ffice of Investr.gatnon9 would like to thank you in advance fur your Cooperation and should you have any questions,
pleat 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. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
R:viseJ �-2G-u5
www.mass.gov/dia
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