Loading...
5 LARCH AVE - BUILDING INSPECTION (2) E �$, ! oo RECEIVED �� The Commonwealth of Massachuset LK CITY OF Board of Building Regulations and Standards nS SALEM ± � Massachusetts State Building Code, 7801f[VIM 22 A 8- `Rdvised.�1ur2011 Q Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Divelling This Section For Official Use Only ' . Building Permit Number. Date lied: 4 -Duilding Otlicial(Pont Name) IINFORNIATION e Date SECTIOATION 1.1 Property Address: ors Map& Parcel Numben1.I a Is this an acce ted street?yes nor Parcel Number 1.3 Zoning Information: rty Dimensions: Zoning District - Proposed Use It) Frontage(11) - 1.5 Building Setbacks(R) . Front Yard Side Yards Rear Yard t0l`rivate - Provided Required Provided. Required Provided 1.6 pply:(M.G.L c.d0,§SJ) 1.7 Flood Zone Information, t.R Sewage Disposal System: Publ ❑. Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑ Check if es❑ SECTION2: PROPERTYOWNERSHiP4i 2.1 Ownert of cord: JJ�- ��� ✓In� i7/ y .Wme Print City,State,ZIP No.and Street Telephone mail Ad, SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that opla New Construction❑ Existing Building Owneo-Occupied Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ NuntberofUnin_ Other ❑ Specily: Brief Description of Proposed\York=: t SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I Building $ / Cyr I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cosi+(item 6)x multiplier x 3. Plumbing 5 2�Qther Fees: $ a.blechmtical (HV;\C) $ List: 5. Mechanical (Fire S Suression) total All Fees:S Check No. Check Amount: Cash remount: 6.'rotal Project Gnt: 'S ��� ❑Paid in Full ❑Outstanding Balance Due: a IAWOSECTiONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) _ �G � 'D't 7, .+ License um er Espi lion ate- n �/ N:une of CSL flo der „ d /l List CSL'rype(see below) Type' - - : . Description . No. and Street U Unrestricted(Buildings up to 35 000 cu. ft. ,,�t4J/fi]h'J /i'//•/ /j�rl �� R ResVicted 1&2 Family Dwelling City?awn,State,ZIP M Masonry RC Roofin Coverin WS 1Vindow and Sidin _ - SF - Solid Fuel Burning Appliances —+;7�t�y� S ,Iq if f kq h ("yY1d, 1 Insulation Telephone mail address D Demolition 5.2 Registered Home Improvement Contractor HIC) H[C egistmtion Number Er nratio Date f I IC Cu, y ame ar HI a sr 7l a No.and Street - Email address Ci /town State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G-L F.ISL§ 2SC(6)y, Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Is✓:uance of the building permit. Signed Affidavit Attached? Yes ..........O No...........O SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED W HEN' OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Pant Owner Name(Electronic alure t� SECTION 7b:OWNER'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 accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 n have access to the arbitration — -- P -- - --d — 6 program or guaranty fund under M.G.L.C. I d2A.O[her tm o tint information onThe HICYro ram can a loon �t www.mass.eov'oca Information on the Construction Supervisor License can be found at vwvw.nmss._ov:'dns 2. When substantial work is planned,provide the information below: 'total fluor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room coma Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths rype of heating system Number of decks/porches Type ofcoolingsystem Enclosed Open 3. "Total Project Square Footage"may be substituted I-ar"Total Project Cost" OTYOF SALEA AMACHL)SEM Btn ane;DErARneNr 120WAS CIMSMET,32DROOR 7hL(978)745.9595. I�ERiBYDRISQ7LL PAX(978)74D.9846 MAYOR 7 s STJIMM DMECrOR CFFLMU6PXCM 7Y/BUXDIWSCR Construction Debris Disposa/Afdavit (required for all demolition and,.renovation work) In accordance with the sixth edition of the State Building Code, 780 CAM, Section 111.5 Debris, and the provisions of MGL c40, S 54; Building Permit B 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 156A. The debris will be transported by: (name of had er) The debris will be disposed of in: (name of facility) (address of facility) ign ure of ap cant Date The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite I00 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNEWING AUTHORITY. Applicant Information Please Print Le 'bl Name: (Business/Organization/Individual): Address: ➢ ` City/State/Zip: aS 7 Phone#: Are you an employer'Check the ap ropriate box: �� FDddi roject(required): 1.©7 am a employer with employees(full and/or part-time).• w construction 2.❑I am a sole proprietor or partnership and have no employees working forme in modeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work molition ❑ ng myself[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on m property. - lding additionYP PertY. Iwillensure that all contractors either have workers'compensation insurance or are sole ctrical repairs Or additionsproprietors with no employees. mbing repairs or additions5.❑I am a general contractor and I have hired the subcotmacors listed on the attached sheet. These subcontractors have employees and have workers'comp.instmemet f repairs6.❑We are a corporation and its officers have exercised their right of exemption per MGL a er 152,§1(4),and we have no employees.[No workers'comp.to required.] 'Any applicant that checks 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 then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contmcors and state whether or not those entities have employees. If the sub-contractors have employees,they most provide their workers'comp.policy number. I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: //ll` Job Site Address: ys! �� j/� City/e polZip:� �L/ 70 Attach a copy of the workers'compensation policy declaration page(showing the policy number and ea [ration 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 pepayes ofperj ry that the information provided above is true and correct. Si afore. // Date: Phone FF0JffJtcia1use only. Do not write in this area,to be completed by city or town ofcial own: Permit/License# uthority(circle one): of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person' Phone#' 1 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 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." 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 permitflicense 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 dog license or permit to burn 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. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia