23 LAUREL ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Buddin ulations and Standards CITY OF
Massachusetts ate B 'Iding Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Applicatio To Cons uct, Repair, Renovate Or Demolish a
O -or T}vo-F mily Dvellin
This Sectio For Offici se Only
Building Permit Number: 1 Da Applied: .J UW AL- 3 r
Building Official(Print Name) Signature Date
S O 1:SITE INFORMATION
1.1 Propert Ad�lress: IT 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zon�g on:
�{ y,�in Informati I J7 1.4 Property Dimensions:
- rrctch cX-
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wate Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage ' posal System:
Zone: Outside Flood Zone?
Public Private El — Municipal On site disposal system ❑
Check i f yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qauaert of eco d: e
��osy�t / - S]<ow,u sKl �i�tw-J, n'14- cieT -7>
Nine(Print) I City,State,ZIP
;qp F0- 1%1zooi cr?—}3q--f97-3
No.and Street Telephone Email Address
SECTION 3: DESCREPT1,9N OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) CVJ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units 7/ Other Cl Specity:
Brief Description Propg6ed Work'-: ] -e,w.a t a h cf
2— % d'C v0�w
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ `'�U/000 ❑Paid in Full ❑Outstanding Balance Due:
a � D
Y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
7 5� `3 -2to-zv�
License Number Expiration Date
Name of CSL HoMcr
/6} 15PA-r,/%� List CSLType(see below)
No.an treet � Type Description
GNy eG S Z U I Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/I'own, State,ZIP M Mason
ry
C� SDs 1�il- Z-191It RC Roofing Coveting
WS Window mid Siding
SF Solid Fuel Burning Appliances
6 7 1 D I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street
Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 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 Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION.7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
cont a' t this appl'cati�+ is tru accura to the best of my knowledge and understanding.
�� i b —3 w ( (
Print Own r s or A nhorized Agent's Mane(Electronic Signature) t Datli
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 can be found at
www.mass.�>ov!oca Information on the Construction Supervisor License can be found at www.mass IR <los
2. When substantial work is planned, provide the information below:
Total floor 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
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 Sad .&M, NLkSSACHUSETTS
BLMDLNG DEPARTMENT
120 W."HLNGTON STREE .To FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJt8EJtLEY DRLSCOLL
MAYOR Ttomu ST.Pmitaa
DIRECTOR OF PLBUC PROPERTY/BUUMLNG COS MMIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State BuildingCode 780 CMR section
n I11.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
�Vew 6� 9 �4 4 CJ �� s o 1, d r IAJ�,S �-
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
Sig azure of f
it applicant
4—//
3 2fr(
date
. CITY OF SALEM
it PUBLIC PROPRERTY
DEPARTMENT
iw:;a:l Y:rnhl,rll
12C Wn,ln.\Ia uv$rathT • inu•.vt,M.uv.u.ut a 1 n v177,^,
II:I: 'nL/tivi'13 p,x v7xJ•C'ISM
IlVorkers' Curnpensation Insurunce ►I(idavit: Hui tders/Cuntracturs/Electrlclans/Plumbers
1 !Hcrnt Infonnutio
Pleas Print Le 'hl
�IiI IT0 I lluaikyi Organ,rarinrvinJ,Y rdual l:
J oS.e k y'
�tldress: f U y✓��kc� S (/�
Lit .Srarc.7.i
Y p: �Igts, t AH
r Phone
Arv)ua an employer?Check the approprlose box:
Type of prnJect(rtqulrrd):I.❑ I ;it a employer with 4. ❑ I am a gcnenl contractor and 1
IPluyeca(iull und/ur part-time).• have hired the.vub•contractors G• ❑New ultstructiun
2. 1 run a Iola propricnx or partner• listed on the artached sheet 7. cillix ing
ship atW have no cmpluyl." These sub-contractors have g. Q Demolition
Linysclf.
rile me in any capacity. Work trio'comp, insurance.
Noerx'cutup, insurance S. Cl We are a colpenlion and its 9. ❑ Building addition
otrlcerx have c.eenixcd their IO.Q Electrical repairs or additions
cu,vncr doing all work right orertemption per h1CL I I.Q Plumbing rupairx or addition'o workers'cutup. c. 153. ¢1(4).and we hove17.❑ Rwl'mpairs
cyuircd.J t cmployeca. (No workers'
rnmp. insurancunquiad.J IJ.QUther
•gry•glpbcuu ihW ehaehsbW ell must:Jw)illuw,ho,scum,baIt, dwtwing IAuir.wwhwa Gun, kill ruliay udirtmulwq
'I lumwtwr,srs who„atmit this anldtvil indhuoina ihuy ate doing al wurk And,haul Aue uutlids Gotarnrrols mssl•uWnq a nsw alndsvit"Jiaaw"ll ww'h,
'•f,rinrlabur,AM ahash th:s boa muw auxhod r,n.uleiliuu,l,Ita�l,Anwing the nanM of tM nlersmraet rx and,Aeu wuhmx'Nnlp.pdtcy inn,rmanw
/fetn its employer Urur/r pear/r//nX rverkrr�'rurnpenrnNon lurumnca/br my rtnp/uprtr. Br/ulv/s the-pu//ay undl ii.,
Gr�unnulGnAIle
Insurance C'untpany Vmne:
Policy g ur Sclf•ine. Lie.rr:
_ . .. . Expiration Date:
Jub Site Address:
C1tyBtatetLlp:
Altach a copy of the workers',:umpensatlon Palley declaration pull#(showing the policy nurubur and espiratlun date).
Failure to vccuro coverage as required undcr 3cciiun 23A ul'SIGL c. 151 can lead to ills imposition of criminal Penalties of a
line up 1,1.1 1.500.00 ineVor une•year imprisuumcnr, a.v well ar civil pcnalltu in lhu iorin of a STOP WORK ORDER and a fine
Of toll to i250.00 a Jay .Iguinas die vialamr. IIt advi.acd that a copy of)his slulemunt may be rurwarded to the Ullice ut'
Inrcai��aur ma of: ie UTA for in,urarcc cj�vcragu ,ci iticanun.
/Ju hereby I erli/y feel, r rhrl rinc unJ1/ nrd e u� dry th the iu/bnnuNon pruyiJad above-is re un conerR
y ••
I'I,n: •�, i ,
IOfIltiuf rs..♦vuly. no r wrier in drlr urea, to Ae-rufrp/vle-d by city ur tmvn a//leiuL
If'irr ur 1'n,rn: _. Pcnniul.lcense e_ j
1„uing Authurily (circle file):
Ir. I dive rif IlcalUt !. Ihuldinr� Ikparnnenl 1. t:iti:To"ll Clerk J. Llectric•d hlvpcetur 5. plumbing hl,peetor i
G. tllhv♦ _
l'�nrY act I'e nun:
i
information and Instructions vlrvn, ee$.
Lon in the
service Jf another under any contract of hire.
�Lusachusctts General Laws chaper 1 i2 requlrcs all employers to provide workers' cJlnpensatlon tot P Y
I`ursu:ull to tills %latule,an Off, 'ee is detined as"...every pe
;%press or Implied, oral or written."
In etnpluyef Is dclincd as"an Individual, partnership,.Issoeulaoa,rorporall it or rather legal entity,or any two r t more
A the I�uegomg engaged m Alomt enterprise,and including the legal representatives de`mslo ets.ed lHcv evcrhthe
I,I the f Jf lfaalCe YI .al IlldlvldYOl. palmerihtp,association or other legal entity,employing ' P y
lion of repair work
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
.Iwelling house of another who a urtenamerions hereto shto a/llno1 because of such employment bM deemed rube an employer."
or on he grounds or building app
-,IGL chapter 152. 4'-SC(6) also states that"every$rate or local licensing aueoey shall withhold)he issuance or
en to has not pr ducad acceptable evidence Of erage
umptlaace with the Insurance cov
a irequlred�
PPlltant tsl , 75C 71 state"Neither he commonwealth not any of its political subdivisions shall
A dditionally, `IGL ehupter t S i_, -
enter into any contract for the pertomlance ul.pit blic work until acceptable widence ufcoupliarlce with the insurance
requirements of his chupler have been presented to the contracting authorit
Applicants s that Applyto our situation and,if
PIe:ISM Till out the workers' cumpellsation alyidavit completely,by checking the bog with theircartiflcutc(s)of
necessary.supply sub controctor(s)name(s).address(cs)and phone null] Misha along with no empIOYMs
insurance. Limited Liability Companies(LLQ o rLimited Liability
iab litioe ilvursnce�(Ilao)LLC or LLP does have
thyr he
Inembers or punnets• tiro not required to carry
e nlpinYee$.u policy is required. BM advised that this affidavit may be submited to the
Department of Industrial
nested,not he Mitlanment of
\ccidenu for confirmation of insurance coverage. Also be sun to alga and data eke uflldavl4 ThM atlittavit thou!
t Or liccose
he 1eltlmed IJ the city or town that the applic�;bras regardingor the lth low if youis are ng r quired to obtain u workers'
Industrial Aceidtnta. Should gnu have Any 4
colapensation policy, please call the Oepurtment at the number listed below. SMIf-insured companies should enter their
.elf-insurance license ntunhar on the appropriate tints.
city or Town Omeial.
Plenst he sure that the ainrail tlutalnr<he event he OIZICe O�InlVesl Investiy. The gations has tocontact You ecgarding the appld A space At the icant-
affidavit
Of the aft dJVIt for theme
1'Iewe be.<um to till in he permit/ticense nulbcr which will be used❑s s reference number. !n addition, is applicant
u or
ttl:lt must submit multiple pennitilicell IrrrMtla applications
Address!'he applicant ntt hauldear.need only submit ite null•lu eaiffidiuns in indicating current
Policy iufomationtitnecessary) Pp provided to the
town) file A copy of the Affidavit that has been officially sumpeJ or marked by ilia city or town mayso' out each
ouns
mij%of licenses. A
ya r1Ito
v`gherc a home utwnarlid u citizen isdavit ls onobtaininga license Or permit net related to any business avit tor comenitilled
rc al venture
a dug Ileense or permit to burn leaves cte.)slid person is NOT required ro complete his affidavit.
I he I)i l ice Ili Investigations wuuld like to hank you in advunee fur your cooperation and should you have:my yuesnous,
please du nut hesitato to give m a call:
the U,parunau's address, telephone aTh fax
C^mmonwealth of Massachusetts
Department of Iadtutrial Accidents
0MCII of InvesdQadans
600 Washington Street
Boston, MA 02111
"fe1. # 617-727-4900 ext 406 of 1-877-MASSAFE
Fax M 617-727-7749
www.masss.gov/die