4 LARCH AVE - BUILDING INSPECTION (2) I, The Commonwealth of Massachusetts
Board ul'Building Regulations and Standards CITY
Massachusetts State Building Cole, 780 CMR, 7' edition OF SALEM
Reviserl JYIn/rrrr
Building Permit Application To Construct. Repair, Renovate Or Demolish a /, 2MAY
One-or Two-Family Dwelling
is Section For OfTicid Use Only
Building Permit Num r: Date pplied:
Signature:
Hail ng ummisa - m or of Buildin Ime 'P �
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map dl Pared Numbers
r1 /Are- A✓e
I.to Is this an accepted street?yes no Map Number Panel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(n)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposals stem ❑
Check if es❑ y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofRecord:
M& + tirr �' tAnT 'L t't ✓g'e-
Name(Print) Address for Service:
,
Signmurt Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKr(check aB that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Unit_ Other ❑ Specify:
BriefDescription of Proposed Work-:
LC ro Sia rl /1/6—� all' c
�—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use On
Labor and Materials IY
I. Building is I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S ❑Standard Ciry/Fown Application Fee
❑Total Project Cost(Item 6)x multiplier x
5. Plumbing S 2. Other Fen: f -1 n b
4. Mechanical (HVAC) f List:_
5. Mechanical (Fire
Su ression S Tutol All Fees:f
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: I S III 'i S� — ❑Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
r�Llcenscdtruction Supervisor(CSL) (I.icense Number li.apimlion Mule
YYYI.istCSL fype lsee below►f Ikscri ion
Wdre U llnmIncled(up to 35.000 Cu.Fl.
R Restricted IA2 Family Uwellin
Signmure M M. Only
3 L- 1 Gv3 RC Residential Rooling Covering
I'dephone WS Residential Window and Sidin
SF Residential Sulld Fuel Rumin A liance Installation
D Residential Demolition
5.1 R latered Home Improvement Contractor(HIC) v S t& a-.1—
Q o y F' J er✓��` +'�` Registratim Number
I IIC Cumpan Name ur FIIC R istrarlt Name
LI
Add sm Espiruim Due
Siynuture 'felephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL / 2SC(6))
Workers Compensation Insurance afftdavil 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 ..........Z' No...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
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
rSECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
behalf—,
9t nj ^ ,as Owner or Authorized Agent hereby declare
d information on the foregoing application are true and accurate,to the best of my knowledge and l� I_�
( ner Authorized Agent Date
er the' 'ns and whin of 'u
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 gpj have access to the arbitration
program or guaranty fund under M.G.L.c. 1J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 IO.R6 and I IO.RS,mpectively.
2. When substantial work is planned,provide the information below:
Total Iloors 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 half7baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Ftmiage"may he substituted for"Total Prnject Cost"
CITY OF SALEM
' �� PUBLIC 1'RUPRERTY
DEPARTMENT
.IUI11 g!ry:)dtAs n.l.
\LU'lxt 12C WASMINQ IO\SIB ELT 4k Sit L E.M.MASS.ICI It il.I'1]01970
978-715-9595 • P.tx:978-NC:)si6
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
\ ) )licant Information Please Print Leeihly
V 81mC(Buciucss/OrBaniratinrpJindlvldual): en ,)c
Address: SC R nni l o ( - �
CHy/Slate;/.Ip: A-,4 f)Ij6o ('hone ,'': f 2P - 31' ZG6�
Are you an employer? Check the appropriate box: 'Type of project(required):
[�1 am a employer with
1 4. ❑ am a gene 6. ❑I general contractor and 1 New construction
I. _
employees(full and/or part-time).' have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 ;tin a sole proprietor or partner-
listed on the attached sheet. *-
Ship and have no employees These sub-contractors have t!. ❑ Demolition
working for me in any capacity, workers' comp- insurance. 9, ❑ Building addition
No workers'cum 5. El are it corporation and its
� P insurance officers have exercised their ME] Electrical repairs or additions
inquired'] 11. Plumbing� re airs or additions
3.❑ I :nn a homeowner doing all work right of exemption per MGL ❑ b P'
myself. (Ko workers' comp. c. 152,j 1(4),and we have no 12.[31ouf repairs
insurance required.] r employees. LKo workers' 13.❑ Other
comp. insurance required.)
',Any opphcut that checks box BI must also IIII nut the section below showing their work s compen,aion pulicy information
'I lomalwnen who ulbmit this affidavit indicting they are doing all work alul Ihcn his outside cuntr.wton must submit.a new alf:.lavit indiW mg such.
-r'ontncmrs oral check this box most ailwhud an addiliumd sterol showing the laic of the subContraelon and their workers'comp.policy infurtnaoon.
/onl all employer that is providing workers'compensation insurance for my employees. Below is the policy and)ob bile
information. t„t�
Insurance Company Name: -C e—
� . . ---
I'olicv is r Self-ins. Lie.i : �N C C Ll )1ill q6� Expiration Date:
Job SiteAddress: 4 C'ityislate/Zip: J9� / - eh9)�
Attach it copy of the workers' compensation policy declaration page (showing;the policy number an ecpirai n date).
Failure to secure coverage as required under Suction 25A of.NIGL c. 152 can lead to the imposition of criminal penalties of a
tins up to S 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 tip to S250.00 it day against the violator. He advised that a copy of this siatemunt may be I'urwarded to the Office of
Invcsugauons ul'thu DIA for insurance coverage vcrilicalion. .
/do hereby certify rimier the pains and penahics of perjury that the infbrmulion provided above is true and correct.
Si)aamrc: q 1 Dale. - O
O jiciul use mdy. no nor ivrite in this area, to be completed by city or town ojJiciaL
Gill or'fown: _. Permit/Licunse 0___----
Issuing %whority (circle one):
I. Hoard of Ilealth 2. Building Departnlcul 3. Cityi fown Clerk 4. Electrical Inspector 5. plumbing; Inspector
6. Other _- -
Contact Persuu: _. .-- Phone tt:
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empkovee 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 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."
`1GL chapter 152, ¢25C(6) also states that"every state or local licensing agency shalt 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 perfomwnce 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) namc(s),address(es)and phone nunrber(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 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 till 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 pennitilicense 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 chat 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.
l'he Ulf ice of Investigations would like (o thank you in advance fur 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 1-877-MASSAFE
iLcviscJ S-ZG-US
Fax #617-727-7749
www.mass.gov/dia
CITY OF SALL:M
fi r, PUBLIC PROPRERTY
�- ' DEPAR'I'VIENT
` �I I ,-Y.',;.•/jay . t \C: ';7g.'a:' .i L
Construction Debris Disposal At'tidavit
(rcyuired li,r all dcnfolition and renovation work)
In accordance n ith the sixth edition of the State Building Code, 780 CNlR section I 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resuhin� front
this work shall he disposed of in a properly licensed waste disposal I•acility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
(name tit Fiattled
The debris will be disposed of in
(mine ul facility)
l uddre„1.1 facility)
,ILllatnlc of Il11{)IIIJIII
data