26 IRVING ST - BUILDING INSPECTION ONE OR TWO FAMILY DWELLING
s The Commonwealth of Massachusetts State
(� Board of Building Regulations and Standards
Massachusetts State Building Code
780 CMR
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
O This Section for Office[Use Only
Building Permit Number. Date Issued: l • e& O. O'v
Signature 4' 3 o . o T:>
Bmldi Commission Inspector Date
SECTION 1 -SITE INFORMATION
1.1 Property Address 1.2 Assessors Map+Parcel Number
�6 ICV"/s s f
2vv% uV-l& O 0-70 Mt pNomber ParcdNumber
1.3 Zoning Information 1.4 Property Dimension
Zoning District Proposed the(No.of 5;d Lot Area(sQ Floatage(R)
1.5 Building Setbacks
Front Yard . Side Yard Rear Yard
Required Provided Regairtd Provided Acquired Provided
11- A/A- A/A- IVA V, - 1 y,4
1.6 Water,-SuU"-QI-a-40.S S4 1.7 Flood Zone loformati 1.8 Sewage Disposal Systems �4
Public Ill - Private ❑ Zone /� N/ ❑ Municipal ❑ Septic system ❑
1.9 Special Permit Lt0 Old+Historic Commissiod 1.11 Conservation Commissi
Date Fded N/A .Number N/A Number N/A
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Records
1Q7 t - Address for Service
MA ,;caQTdcpb-
2.2 Authorized Agent
-Tka-0M4.-s A 1 `{ iD'A LN 1�lA!J �j
•fM1nLY /111
Name(Pri Address far Service /� 030r/
I� ?SI- ZSy-y3�� � P,a � �'7S �62 Swn.,OSCeef/ /f�i. al yo7
Signature V Telephone
SECTION 3 CONSTRUCTION SERVICES
.1 Licensed Construction
Supervisor
Licensed Construction Supervisor
Aaa e� /V twt �( /1/y�3 e 7 7 License Nnmbcrl— O Ya
i a-
7g�^ ZS'y^ y?O� Espiratiou Date
Sigrufare Tekphoue 7 .
.2 Registered Rome Improvement Contractor (�
Company Name Registntios Number
Z��u jraC i` lr7�z�l cl%
Add ss
Fapintioo Date
_ �u►-zsy- 93v�
5igmture Telephone
t
ECTION 4-WORKERS COMPENSATION INSURANCE AFFIDAVIT(MG.L.c.1S2.S '
i
orkers Compensation Insurance affidavit must be completed and subml6))
Provide this affidavit will result in the denial of the Issuance of the builidin8 permit this application.
Faliure to
igned Affidavit Attached Yes......
ECTION S-DESCR1pTION OF PROPOSED WORK(check all ap icable)
csr Construction Exisiti❑ ug Building Repair(s)
ccc Altemlion(s) '❑ Addition
ssory Bldg. � Demolition ❑ -
Othcr
❑ Specify:
Brief Description of Proposed Work;
�YysC^tinr. i ' t
`211 n
m 7
- a�
EC11ON 6-ESTIMATED CONSTRUCTION COSTS
Item
I.BuildingEstimated Cost(Dollars) OFFICIAL USE ONLY `
I.0 0-00, (a)Building Permit Fee
.ElecticaI Multiplier
150-0 r (b)Estimated Total Cost of
.Plumbing Construction from(6)
(1� Building Permit W
.Mechanical(13VAC) (a)x(b)
.Fire Protection
.T011k(I+2+3+4+5)
Ufl0 Check Number
ECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -
P//ram' � f r l
hire authorize -jy„I D {hr7J .as Owner of the subject property
re Work autho by this buildin to act on my behalf. In all
g Permit application.
»ate
ECTI 7b-O W NER/AUTHO RIZED AGENT:DECLARATION
Hereby declare that the statements and IMormation on the foregoing applicationas are Owner
I du horkedd gent to the pest
f my Imowledge and belief.
igned under the pains and penalties of perjury.
t�� n
1,0 uvt O r 1 1
am
S�umre of lTvner,p
Date
ECTION B-NOTES AND EXPLANATIONS
Fees: The amount of fees shay be the Work Pert $15/$1000(Building:$10;Wiring:$3;Plumbing:$2)based on the total cost of
Minimum Fee;: $30 and materials used In conjunction with this permit as estimated by the Building Official.
30
SEP-30-2008 12:42 BEN FRANKLIN ACE 16038956065 P.02i02
�.�elR(V rrGR11r6VME G: T.,F1'" LE/RoeLs■ E EEwA7VE�/1e�vw D _ tPJ1lY/Anj
L TNIB ICER7IPICATE 1S ISSUED AS A MASTER OF DUQRMATWN
The Bergeron Agency ONLY AND BONFHR9 NO RIGHTS UPON THE cEFC P"TE:
361 Main Street HOLOM THIS CERTIFICATE t7 GOES NOT AMEND, OM Oft
ALTUR THE C.GVOMOE AFFORDED BY THE POLICIES BELOW. I, j
Nashua,NH 03060
Phone: 603481-7708 Fax:603-880-1722 INSURENB AFFORDING COVERAGE NAIC a
mawt u owLq liw Connecticut Underwriters,Inc-
j DiPietro Contracting mEuane,
Thomas A. DiPietro �sT�FRa
P.O.Box 162 uasuRENa
Swampscott,MA 01907 NuuReeE
ebVeRAGes � I
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a®®uLwaafrr EADNOCCURRENCE a 1,OOp,000
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it
OERYIPICATE HOLD
cAHc9LLATIOR
ONOIADANYOFTNO ABOUS DESEAIIIOa POUCIBE eECANCELLBD OEEmlE 71a_
'l:iq'of Salem DATe TNepitoF.TNa uNRANp
Public Properties Dept. O�ONr�LONDEArDR TO DAE_ 20 DAYs 9DUTTEA
NOTTC81DtINTOwm`"T NOLOMN411ED110 THE Lv%0Drl'ZouETO DO:EOENAI.L
,12D Washington Street a1F0EENG OOLNyT OR MMIL"T OPANT'aaD UPON TMWSU Salem,MA 01970 RnEFaENrnTAe6 Imti"ASOMOR
A OIN P
4CORD 26(atlm1 'h
®ACORG CORPORATION 1368
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_�� CITY OF SALEM
(, PUBLIC I'ROPRERTY
a' r� DEPARTMENT
I'Y:)I(Is(Oli
�lEstto 12t:'XIM1F1INGIoNSra6h'I' S.su s(,Ms>ssaa it.l'IsGI`i7�
'1'1a: 778-743-9595 • I'vx. 978-741--9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please P nt Lei
A i llicant lnfarmulion Qt � /0 TT /pJ Niln7t: lnuciaesv(1r8a/ni'rttinNlndl\'�Iluoll: \ n �7. 03o-27 (L V, Date 1(62,
Addl-Css: "1 Q L N ICfti .� rid /ll l
City,Statc,%ip'
Phone i': :7,;7/- 25 y -
:\rr you an employer? Check the appropriate box:
Type of project (retuired):
4. ❑ I am a general contractor and I 6. ❑ New construction
n —
I-' -r;u a employer with- have hired the sub-contractors
employees(lull andlur part-woe).` 7. []v R odeling
2.❑ 1 ran a sole proprietor partner-
listed on the attached sheet.
ship and have no employees These sub-contractors have K. Demolition
Workers' comp. insumnce. 9. ❑ Building addition
working firs me in:my capacity. 5. ❑ We are a corporation and its ,�
[No workers' comp. insurance 10.L,.1 electrical repairs or additions
officers have exercised their
required]itho right of exemption per MGL I 1. Plumbing repair or additions
3.❑ I ant a homeowner doing all work c.152, j 1(4),and we have no 12.❑ Roof repairs
myself. e r aired.sf comp. cinployees. (Ko workers'
insurance reyuirtd.J - 13.❑ Other
comp. insurance required.)
•-1ny apphcaut that cl:ccks box DI muss also till nut the Seclien txluw showing their vorkui cumpunvnion policy inlivnwtioo.
t I h>meuu men who submit this t noniit indicating they am doing ull work and then him outside eontrnetors mmt nuhmir a new atfdava indi.Iing ouch.
that i •'k this box mtbt 3owhed an additional.Sheet h g the tame of the
sub-contractor and Ihcir wurkur•comp.policy informarion.
I ma all employer that is providing workers'c•umrpensm ann ur.curauce for my employees. Below is the pulicy and job site
infurrrmli'rm' �Ty
n C
g r
huumncc Company Vmne: -� J _ e,
qZ Expiration Date: 7 Lr e 2
Policy S or Snlf-ins. Lic. t': ®�!/l9L1..--. .
(� C _ _---cif istalcizi S�Lti list Ike o r%7d
Job Site Address: 2 to Y Pa
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 ur>IGL C. 152 can lead to the imposition of criminal penalties of a
tine lip to S1.500.00 and/ur one-year nlplisolonent, as\yell as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violator. Ile advi.icd that a copy of this stutcmcnt may be lorwardcd to the Office of
III\"i PII�a1191U oil the DIA (or inrorar.cc covcrage \eriticallntt.
l Ju hen•by certify under(h pair s and qjlt es a perjury that the information provided above is true and correct.
Dar• —r
I:lalul e; _..
Gt-1 _-7T/- _2015
O/Jicial use only. Do nat na•ire is this area, to be completed by city or(allies official
City or'1'nw•n: Vermit/License 8_
Imaing:tulhurily (circle one):
1. Board or lle:dth 2. Iuilding Department 3.CiIJ/rossu Clerk 4. L•'iectrical luipector 5• plumbing; Inspector
6.Other _ -- -
Phone tt:
Contact Verson: -
Information and Instructions
Massachusetts Gencral Laws chapter 152 requires all employers to provide workers' compensation fix their employees.
Pursuant to this statute, in empforee is defined as "...every petxon in the service of another under any contract of hire, ICI
repress or implied, oral or written."
An employer is defined as "an individual, partnership,association, corporation or other legal entity, or any two or more
„t the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of :n Individual, patinership, 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.,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.%1GL 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. NlGL 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 accepetble 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) namc(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
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.
Please be cure to till in the penniNicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicemse 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he t)tlice of lovestngationY %%ould like to thank you i1 advance for your cooperation and Should you have;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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or I-877-MASSAFE
5_16-05 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC. PROPRERTY
= Y% DEPARTMENT
1M
. ",ll illr � l\il V, \t \ \I .. I .Ir
111 I'3.'4 S. I'•r5
construction Debris Disposal Affidavit
(rc\luircd Ii)r all demolition and rcnovation work)
In accordance it11 the sixth edition of the State Building Code, 780 (AIR section 1 1 1.5
Dcbris, :Ind the provisions of MGL c 40, S 54;
Building Permit f! is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will he transported by:
.-►-,1� � D\��,�.�.-mil:
1 name of ham-,
he debris will be disposed of in
I n.�lnr ul laulny)
1:Id\Irra. of I�clllrvl ///^J
\Il'llal UlC Uf�fi I1111[ .Ih I111CaIlI `
,�]IC