319 JEFFERSON AVE - BUILDING INSPECTION (3) GK -70/ / S
l The Commonwealth of Massachusetts
Board of Building Regulations and Stan���� RECEIVED CITY OF
Massachusetts State Building Code,786'�NIRCTIONAL SER ICESSALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Reno tz O�Drplelisl�a' S v
One-or Two-Family Dwelling 77 A b LL JJ ;tao
ILI
This Section For Official c Only
Building Permit Number: - .Date A pried:
_ 8
Building Official(Print Name) signature Date
ISECTION 1:SITE INFORMATION
1.1 Prope dd 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
I1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fit) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Requ'ved 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? Municipal❑ On site disposal system ❑
Public❑ Private El Zone:
if yesO P p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own n��,t///(��A R.seeccord: v n -/
Name(Print) b ��6� City,State ZIP ,.��
No.and Strett Telephone —T Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(cbeck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s)V I Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work:
7
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1 Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ El Standard City/Town Application Fee
[3 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: �A�—
5.Mechanical (Fire $ Total All Fees:$
Suppression)
> Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 5 6 ❑Paid in Full ❑Outstanding Balance Due:
m�»� $131 1-0 C.(O� T-1 .
SECTION 5: CONSTRUCTION SERVICES ;
5.1 Construction Supervisor Licen ( SL)
License Number Q Expumi on Dame 1
Name o CSL Hol
List CSL Type(see below)
No.and S^tre t `r,yr, I Description
Unrestricted uildin s up to 35,000 cu.ft)
Cityll'oUwn State"Z Restricted 1&2 Fami1 Dwelling
M I Masonry
RC I Roofing Covering
WS I Window and Siding
�/ �• / �/� SF I Solid Fuel Burning Appliances
CI d /i I 1 Insulation
Telephone Email address D Demolition
5.2 Registered mejmp vemen C ntractor(HIC) //,F6' '
G FB1�2 V l)lJ
C Registration Number Expiration Date
HIC Compan r am or C t ,me
NNo.ant eef7 �_.
j Z i, /�C `
/1 n —) (, / Email address
Ci ow/ ✓� State,ZIP �'V / Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(b))
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 .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OIL CONTRACTOR APPLIES FOR
,/tBUILDING PERMIT
' u q '
I,as Owner of the subject property,hereby authorize ( f�A
to act on my behalf,in all matters relative to work authorized by this building permit application.
Or)- �6 f/<:) LrzJ-I( 7,
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and a curate to the best of my knowledge and understanding.
Print Owner's or Aulhorized Agent's-Name(Electronic Signature) Date
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
n2ny im govlml Information on the Construction Supervisor License can be found at www.mass.gov/dam
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
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'
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Wxvorkers'Compensation Insurance Affidavit:Builders/Contractors/Electiicians/Plumbers.
TO BE FH,ED W1TH THE PERMITTING AUTHORr1'Y.
Applicant Information Please Print Ledlil
Name(BusinessiOrganiration/Indind al
Address: /�/(t//Y
City/State/Zip: z / w) ,p✓� Phone M14
Are you an employer?Check the appropriate box: Type of project(required):
1.6ran a employer with employees(full and/mpart-time).' 7. ❑New construction
2-Q 1 am asole proprietor o partnership and have no employees working fm me in g, Q Remodeling
my capacity.INo workeis''comp.insurance required] .
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9• El Demoutiori
4.n I am a homeowner end will be hiring contractors to conduct all work on my property. twill 10 Q Building addition
creme that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with m employees' - 12. Plumbing repairs or additions
5.❑I am a general comeetor and I have hired the sub-commenr th s listed on e attached sheet.
act.
sub-contractors have employees and have workers'comp.inswanxl ]3-EIRoofrepajrs.
6.0 We are a corporation and its officers have exercised their right of exemption Per MGL c. 14. Other
152,§1(4),and we have no employees.[No workers'comp:insurance required.]
-Any applicant that checict box#1 must also fill out the section below showing their workers'compensation policy information.. .
t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such.
1Contractors that check this box must attached an additional sheet showing the came of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their.workers'-comp.policy number..,
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job-site
information. n ,�
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date: 4expiWilt,
Job Site Address: � - �iity/StatelziAttach a copy of the workers'compensation p la
cy decrationp m
age(showing the policy nober and date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true an ifcor`L�
Sip_nature• '� �� --��—�� Date: ��-/ / �)
Phone#: L
Official use only. Do not write in this area,to be completed by city or town official,
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
.Information and Instructions
Massachusetts 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,
express or implied,oral or writtep."
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 construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL 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 fill 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
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 dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
aCITY OF SALEK MASSY musE m
Bu iLDINGDEPAR7)&NT
120 WASt w=xSTREET,3'mRom
I L(978)745-9595.
FAX(978)740-9846
KIIv18ERLEYDRIS�LL
MAYOR 711CUM ST.PIEBRE
DIRECTOR of PUBLICPROPERTY/Bum DWG axeasgomR
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 00, S 54; Building Permit is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of fa ility)
P k/ V ,
(address of facj ity)
Signature of applicant
Date
• Z"Usf'r
l
i
14-1 B8B >< A.C. CASTLE CONSTRI
MEMBER Telephone (800) 505-LEAK(532
Brian LeBlanc, P
Please mail accepted proposal
9 Tibbetts Avenue • Dan
Unrestricted Mass Builders License No. 054882
PROPOSAL SU94TTED TO PLJ
STREET JO
CITY, STAT AND ZIP CODE JO
DATE WOfTK IS SCHEDULED TO BEGA DATE WORK IS SCHEI
Ve prop 6¢ hereby to furnish material and labor - complete ' accordance with
Paym t o be as follows:
113 down, the balance due upon comi
NOTICE: All home improvement contractors and subcontractors engaged in home
improvement contracting unless specifically exempt from registration by
provisions of Chapter 142A of the General Laws, must be registered with
the Commonwealth of Massachusetts. Inquiries about registration and
status should be made to the Office of Consumer Affairs and Business
Regulation, Ten Park Plaza, Suite 5170, Boston, MA 02116.
WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR:
A ROOF STRIP
We will cover the siding, bushes, and grasses with Blue Tarps in order to
We will Strip up to 2 layers of roofing and remove all nails, screws and staple
The Ice and Water Shield will then be installed at the bottom of all Edges, and
around all Chimneys, Skylights, and into all Valleys, in heated,areas only.
We will install 30 lb. Synthetic Deck Protector Underlayment to all other are
The 8" Dripedge will then be installe to II roof e�f&
existi
The roofing material to be used will be
The bottom of all roof edges will have a Pro Starter course with a gluej edge fo
All the Debris will be cleaned and Dumped by us on a daily basis. We will cleanoui
extract all nails from your property. We will protect your property as best we ca
We cannot accept responsibility for possessions inside of the house, or debris f;
EXTRA WORK IN WHICH A COST WILL BE ADDED TO THE ABOVE F
Replace Rotted Roofboards Inc
Relead Chimney(s) +-11J Y In;
Replace Facia Boards
Install Ridgevent Rc
Install Roof Louvers Gt