42 LARCHMONT RD - BUILDING INSPECTION 21 The Commonwealth of Massachusetts
o Board of Building Regulations and Standards fl)R
i. Massachusetts State Building Code. 781) CMR, 7ib edition •It'Nl Al l tih I I 1
Building Permit Application To Construct. Repair, Reno%Lite Or Demolish a Rope,!Atnum i
One- or Tsru-Fumilc DN elling '003
This Scction fticial Use Only
Building Permit Num Dat Applied: p .O
\ Signature:
� 8l) 0o
Budding Commissioner/ Inspector of Bw m Date
SECTION 1: SITE INFORMATION
1.1 Pro rty %ddress:/ / 1.2 Assessors Map & Parcel Numbers
L la Is this an accepted street?yes_ no ' Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
V Zoning District Proposed Use Lot Area(sq fo Frontage(it)
v 1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Reyui led Provide) Require) Provided ReyuireJ PnrviJed
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
\ Public ❑ Private❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal ❑ On site Disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 OOrer'ofRecord: / � I�jgyK ✓p A: �� A 1•
Name r U Address for Service:
6FG
He ic
S ore Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) O 1 Alteration(s) ❑ Additnrn ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Br.ef Description of Pr000sed Work': S r4le lriM.lA9 Pam-9+V9 P"A/ T 2oomr
- *%TeHeX/ RdPL . Ti Ki7CA(wt l :t ,
a wc.t Y n07 4-A64-- A~1 A.YV a,®. litrcZs "D
w d Tote
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and dMaterials)
1. Budding $ LQ Oop 1. Building Permit Fee: E Indicate how fee is determined:
/ yK ❑Standard City/Town Application Fee
2. Electrical $
3 mob ❑Total Project Cost'(Item 6) x multiplier .x
3. Plumbing $ V voro 4AN+c 2. Other Fees: E
4. Mechanical (HVAC) 3 List:
5. Mechanical (Fire Total All Fees: E
Su ression)
Check No. Check Amount: Cash :Amount:
6. Total Project Cost: 5 <' Gd� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
d f/-�1+85 �Lf/�FZL.4
License Number Espoauon Date
Nana of CSL Holder List CSL Type(see hclow)-- �J
,s 3 �T L= <AlIV4A** BL9a'L � 1, Descritiun
%Jdress L Unrestricted to to !S.000 Cu. Ft.i
R Restricted Idt'_ Frond Dsselhn
ignature N Al anon Onl
j5' SAS RC Residential R,Io1i 11 Cosenn
r lephone WS Revdenoal Wmd—, and SiJm
SF Resvdenual Solid Fuel 1lnrnnl\ 1111:a1L lu.i.illauun
D Re>idenaal Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 1 25C(6))
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 .......... Iff No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
17�>>� � as Owner of the subject property hereby
autFibrize to act on my behalf. in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and l
behalf. �(i/1� 17�'eV,io�� ✓� / .
Print'J _ — '�A.ati / 2,
7 ,?/�G�
Sig or f Owner or Authorized Agent DatDat�.�—El--
(Signed under the sins and nalties o r"u )
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an7110.R5.
istered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC m and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 an respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementlattics. decks or porch))
Gross living area (Sq. Ff.) Habitable room count i
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/ba(hs
"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' ,
CITY OF SALEM
PUBLIC PROPRERTY
aG DEPARTMENT
\L\r,It< 12 INcla.r.f # �sllst, �Lxs.t� !natl :: ;I'1::
l'rI: 978-7t;-h9s ♦ F.Ns: 9' 9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
', t licant Information Please Print Legibly
' �i;lllle tnu:mcssl lrg:uuctuun lndls idu:d): y^r"'�J �''x"��
Address:
City:State!Zip: ,GY�fl/�/ � i'hunett:
.tire you an employer? Check the appropriate box: Type of project (required):
1.❑ 1 ant a employer with 4. ❑ 1 ;un a general contractor and 1 6. ❑ New construction
cm lu yees(full and/or art-time).' have (tired the sub-contractors
I�� P y P listed on the/attached sheet. t 7. Remodeling
?.IjI� t aln a sole proprietor or partner-
ship and have no employees These sub-contractors have 3. ❑ Demolition
working for me in any capacity. workers' comp. insurance. y. ❑ Building addition
No workers' cum insurance 5. ❑ We are a corporation and its
r� P officers have exercised their 10.0 Electrical repairs or additions
required.[
3.❑ I am a homeowner doing all work S exemption/ion right of per MGL I L❑ Plumbing repairs or additions
myself. [No workers' comp. C. 152, }1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
•Any applicant That checks box Nt must also till out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/an an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy #or Self-ins. Lic. 0: Expiration Date:
Job Site Address: City/State/Zip:
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 of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00;mdlor one-year imprisonment, as well as civil penalties in the /iron of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigmions of the DIA for insurance coverage verification.
/do hereby certify under the pains and penalties ofperjury that the injimnation provided above is true and correct
tii n tour -y--t�—
011hial use oily. -Do not write in this area, ro be completed by city or town ajjhiaL
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 k:__,
Information and Instructions
\lassacluiscus General Lanus chapter 152 requires all employers to provide workers' compensation for their employees.
rursuam to this statute. :i in ewpLq•ee is defined as "...even person in the ,en ice of another under any contract of hire.
c�press or implied, oral or written."
.\n .mtphijer is dctined as "an indi�idu:Il, partnership, association, corporation or other legal entity, or any two or more
of the tixegoing engaged in a joint enterprise, and including the legal representaM es of a dercascd 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 nut more than three apartments and who resides (herein, or the occupant of the
(walling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtemmt,dhercto shall not because of sucp cmplu}went be deemed to be an employer."
\I(',L chapter 152, §2506) also states that"every state or local licensing agency, shall iyUhhold.the issuance or
renewal of a license or permit to Operate a business or to construct buildings in'the commdnivealth for any
applicant who has not produced acceptable evidence of compliance with the in:a surance-coverage required."
.\dditiunally, MCiL chapter 152, j25C(7) states"Neither the comnwmvcahh 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 till 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permidlicense number which will be used as a reference number. In addition, an applicant t
that must submit multiple permitilicense 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
(own)." 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give LIs a call.
fhe Departtneu's address, telephone and fax number:
i The Commonwealth of Massachusetts l,t.
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Re%iscd 5-20-05 - Fax # 617-727-7749
www.mass.gov/dia
Paige
Wrentham
MassPlailnerS mailing list
MassPianners@cs.umb.edu
http: !/mailman . cs .umb.edu/mailman/listinfo/massplanners
Tile -�omrao,nura/// y�'
Board of Building Regulations nd Standards
Construction Supervisor License
° License: CS 46126
Birthdate: 6/16/1950
Expiration: 6/162009 7r# 1747 t
Restriction: 1 G
JAMES SCHIAZZA l
5 INGALLS ST
i
LYNN, MA 01902 -�—�-
Commissioner
2
2
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Kl\l;;! SI I I Rh1j)l I.
120 WASI[IN(,ION$I XLE T + SAI It �I I i0P)I/z
I III: 1)178-743-9i95 4 FAX:979-743-9846
Construction Debris Disposal Affidavit
(requited I'm all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it - is issued with the condition that the debris resultingfrom
this work shall he7,.s—j)oscdof in a properly licensed waste disposal facility as defined by MGL c
I I I, S 150A.
The debris will be transported by:
AS —10e7ave
(name of hauler)
The debris will bedisposed of in
("'M of facility)
(address oflucilitv)
signatuic of permit applicant
(late