20 KOSCIUSKO ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'"edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Nu er: Date Applied: O
Signature:
Buililing Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
'Z � 5T 3�- �-lol -f�I
I.1 a Is this an accepted street?yes Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(@)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Fled Zone Information: 1.8 Sewage Disposal System:
Public fides Private❑ Zone:` Outside Flood Zone?
Check if yes❑ Municipal WOn site disposal system ❑
.1 caner'of Reco SECTION 2: PROPERTY OWNERSHIP'
' /—
- + n _l<o (sko sr
Name(Print) Address for Service:
��8- -Y+4+-0-7bs-
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building . Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief,Description—off Proposed Work': ( Cit3s�C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
p Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
P/5( �`,� .� License Number Expiration Date
Name of CSL-Holder S List CSL Type(sec below)
2" T Description
IdsU Unrestricted u to 35,000 Cu. Ft.)
Restricted 1&2 Famil Dwellinre Masonry Only
Residential Roofing Coveri�
Telephone fWS Residential Window and Sidin
Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Imp ovement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephorr,
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
.. Workers Compensation Insurance of idavit 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"'HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Signature of Owner Date
SECTION 7b: O ER' OR AUTHORIZED AGENT DECLARATION
SidWio
as Owner or Authorized Agent hereby declare
that the statements and information o�tthiprfor goin application are a and accurate,to the best of my knowledge and
C.
_ -
Signature of Owner or Authorized Agent / D e
Si ned under the 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
(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 and -
Consiruclion Supervisor Licensing(CSL)can be found in 790 CMR Regulations I I O.R6 and I IO.RS, 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.) - Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms_ Number of half/baths
Tyne 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"
10/02/2008 09:20 FAX 978 291 8675 FAVAZZA JOJPISON 10002
uTE MAwwYTYr)
ACORQ. CERTIFICATE OF LIABILITY INSURANCE 1o�oz/zooa
PRODILCER 978)233-o0J6 FAX (979)231-b675 THIS CERTIFICATE IS ISSUED AS A,MATTER OF INFORMATION
Favazza-7oMSon Ins. Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
218 Main Street MOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P. 0. Box 930 ALTER THE COVERAGE AFFORDED BY THE POLICIES OW.
Gloucester, NA 01930 INSURERS AFFORDING COVERAGE NAIC 0
INSURES 07 S Painting & Carpentry INsuRFEA Norfolk 8--Dedham Nutual 23965
22 Perkins Street NStwDts
Gloucester, NA 01930 NEURMC!
INS~a
INSUAMe
THE POLICIES OF NSURAN:E LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI JD INDICATED.NOTWITHSTANDING;
ANY REOUIRETENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEPTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUiIONS MID CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN RexcM aY PAID CLAIMS.
INERJim TYPE OF NSUMNIE POLICY NUMOEN POLR:Y EFP[STIYF WUDT'nmmA N LIMEE
GI]LIAAL LIALNIm S09743A 06/01/2008 06/01/2009 FACIM ocuIERENCE s 500,0
X COMMEACIALGEA'ERALLA&UTY DAMAGE Tf-RI:NTEO i SO
CLAIMS MADI OOCCUR MWC(Ptpaym pH ) I S 000
A PERSONAL A ADv INJURY a 500.000
GEN9NLAli2!4EGATE f 2,000.00
GENT AGGREGATE UNDT APPLIES PIER: PRDOUCr9 COMPIUPAGO I 1.000
POLICY ,E f M LOC
AUIOIgWLE UABILITT COMeIH®iNSTLELAMR
ANY AUTO mb MxMP,I' f
ALLOWNEOAUTo:: 8000.Y ptIIIRY ~
SCHEDULEDAUTO; (PWP I I
HIRED AUTOS
ImOLYINA,RY f -
NON-OYYTEDALITCS (ParaCddaN!
PROPERTY.WAGE I x
(PIN mvidenl
GARAGE LIASIUTY AMTO ONLY-E,,ACCIDENT f
ANY AUTO OTHER TNA.I E ACC I
AUTO ONLY AGO I
FXCEeeNYMELIA LASR.m EACH OCCURRr=E I —
OCCUR a CUM3 MADE AGGaIRiATI I
_ f
OEDIICTISLE I
RETENTION I i
LYORIIERS COMPENSATION AMMO rYC ,4TU- OTN.
EMPLOYEES UARM1 MD
ANY NiOPRETORIPART 8W KECUTNE EL.EACH N LNIENT i
OFrICERDI9ASER EXOLUDED' el pSpiLSI -fAEMPL f
SXEH AL PROVNRON`=unear
SIMIw EL OISEABI:-POLICY IIYR f '
WKIR
OeSCAI►TXIN aF OPERATR)NS/ld:ArNNded VptlCLE91 FECLUSIOMe AOOEDeY ENOOIISENBT/SPFDML PRDAegN9
CER7IFtCATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE OFEORWO POLC14e Me CANCELLED eEFME TEE
.eR VIILtrt/1OEAVOREnY W L
GAY@rYR/TIBIMBNSeR@THOC9LTIRI:AiE�10LDBi.YA�EU Tp THE LEFT.
Nancy Swain eursARAme rowlge.&IgA .aHAFI.t�TH JIS)"LJOA?Iau ORUAeILrn
20 Kosciusko Street DP ANr NmD iNoKtNE" 1r3` �"jb`R•T�Aiwes.
Salem, NA 01970 AUT A -A
Favazz oiler`_
ACORD 2$(200IMDB) FAX: (973)745-2371 0tOORD.CORPORATION 1988
CITY OF SALEM
r s
PLBLIC. PROPRERTY
DEPAR'I'VIENT
III 'r'3.'J i.
Construction Debris Disposal Affidavit
(required Ior all demolition and rcnovaiion work)
In accordance ith the sixth edition of the State Building Code, 7S0 CMR section I I I.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
l t 1. S 1 50A.
The debris will be transported by:
�G y Or� pst L-r�s
1 name tit hauls)
The debris will be disposed of in '
�� hlamr ul laellny)
IodJrrs,ul Ixllln'1
�IL'llal Ul l' OI I1CII111[ Jt I�nl djl 11
V
date
Massachusetts- Dvin rtment of Public SJct%
Board of Building Rc_ulations and Standards
Construction Supervisor Specialty License
License: OS SL 101084 .,s.
Restricted to: RF,WS,DM
DANIEL DEFREITAS
22 PERKINS STREET
GLOUCESTER, MA 01930
Expiration: 10f312011
('ommiysiow,�. Tr#: 101084
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.1Vt11 Mf I\''JNI�(�4 t
\Iw:w xt 12:W,suoM ;loN SIALLI • SAI 1'If,M-W%'ti.III it InJ197�-
fi.i. 978.7$3.9595 • 1:s.x 9711-74C.'ia46
Workers' Cumpensation Insurunce Af6davir: Builders/Contractors/Electricians/Plumbers
l ylicant Information Please Print Le ibiv
S Al
V a lnt: l Bu.u,evy t�r;;anv:uinNl nJt�uluan:
/l
City,Scacc,Zip:
I'hunc
Arc \ou an employer'!Check the appropriate box: I')pa of project (required):
with 4. ❑ 1 :un a general contractor and 1 6. ❑ New construction
1.❑ I 1p oce.semployer . have hired the sub-contractors
eny\la sole(lull antor part-one). listed on the anachcd sheet. � 7. ❑ Remodeling
� - m a sole proprietor or Banner-
_' l •i P P These subcontractor have S. ❑ Demolition
ship and have no employees
working for me in any capacity. ,workers' comp. Insurance. 9. ❑ Building addition
INo workers' comp. insurance 5. ❑ We are it cntporation and its 10.0 Electrical repairs or additions
I required.] oBieers have exercised their
right of per NIGL 1111 Plumbing repairs or additions
3.❑ 1 ::till a homeowner doing all work exem ti g Pon P'
myself. INo workers' comp. c. 152, ¢1(4),and we have no 12.❑ Ruuf repairs
employees. [No workers'
insurance required.) g 13.❑ Other 'r CAS
ctanp. Insurance required.]
6l{5
•Any apphwaut 111a crccks box pin mac,abu rill uw the.ccnmt hcluw chuwing their wurkui cumpuna:aiou pu si ol hmiljiutiun:
' l lomcuumer,whu atbn,il this 3111davit indicating Ihe).tie doing act work ami(lien hire outside ewurnctun tear.uhmil a new alydavit inJiuting•uwh. ��-s•-+��
that Itcck this box muting-ooh vl In]dd lionAl nIKyl.huwiny the nano of the subKontraeto6 and their wurkcrs'comp.pulicy Infurmanun. p s W,GCg
an employer dour is pruriding rvurk-ers'cuntpen vation/nsaranceJar my entp/gpees. Below is tire•pulicy and fob.wite
information.
Insurance Company Name:--- _ .._____..---------
Policv is or Sclf-ins. Lic. n: _-.. .. . .. ___ Expiration Date:
Job Site Address: ___. City,Slateizip:
Attach it copy of the workers' compensation pulicy declarulion page(showing the policy number and expiration date).
hailuro to secure coverage as required under Swiun 25A uf.%lGL c. 152 can lead to cite imposition ofcrintinal penalties of a
risonment, as%%ell as civil penalties in the ILtm of a STOP WORK ORDER and a fine
firer up to 51.5110,f)n anJ,br one-year imp
Of op to i230 00 it day ,Igainsl the violator. Ile advowd that a copy of this slutcmcnt may be torNarded to the 011ice of
low..m,anutn ul :hc DIA :or ussioarcc covcr.ige serilic.ltioll.
/ to hervhy c ertijr,older toe poinv and pennoics ujperjury that the infortnation provided above is true and correct.
Date
Vll� rc
O/jiriul a ce aptly. Do not write in thix area, to be completed by city ur down official.
('itv or fown: _.... __ Permitdl.iccnse At_
Iauing.t uahuriiy (circle one):
I. IF,ard of Ilwalch ?. Iuilding Uepartiueot 3. City."fora Clerk 4. L•'lectrical Inspector j, Plunibing Inspector
6. Other _ -
Phone It:
'1 Conuet 1'cnun: .. -- i
N. �
Information and Instructions
\IaJ6.tchusetts General Laws chapter 152 t'eguires all emplo)ers to provide workers compensation for their colployces.
Pur,u Alt to tuts statute, all emphuiee is defined as"_.every person in the service of another under any contract of hire,
evpress or unplied, oral or written."
An employer ii defined as "an individual, partnership, associatiou, corporation or tither legal entity, or any two or more
"t the foregoing engaged in a joint enterprise. and including the legal representatives of a deceased empluycr,or the
receimer or trustee of .ul individual, palnmebhip,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."
NIGL chapter 152. Q25C(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, 325C(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 ot'cunipliance with 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-contractor(s)name(s), address(es)and phone nunnber(s)along with their cerfificate(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 dale the affidavit. The affidavit should
be reuinmvd to the city or town that the application for the permit or license is being requested, not the Department of
lndustrlal 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 own Officials
PICasc 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 in the penniLdicense number which will be used is a reference number. In addition, an applicant
that must submit multiple Pennit: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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I h/t)t ice of hlveltigations%%uuld line to thank )'ou in advance for your cooperation and should you have:my questions,
_please du not hesitate to give us a call.
The Department's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfAce of investlgations
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia