23 LAUREL ST - BUILDING INSPECTION (3) Ifhe Conunomve:dth of Massachusetts CITY
r Board of Uuilding Regulations and Standards OF S,1LEM
IL1 "Massachusetts State Building Code, 780 C•MR, 7"edition Revised Janudrl•
iII�J �s ✓
Building Permit Application 'fo Construct, Repair, Renovate Or Demolish a
U -or Two-Family�Dteellinx
is Section F Official Use Onl
Building Permit Number:
Date Applied: dC-
2-np, 2� 1
Signature:
Building Cum i loner/Ins -tor Buildings Date
CTION 1:SITE INFORMATION
1.1 Property Addrggssa:� ' 1.2 Assessors Map& Parcel Numbers
Z �ibv�
Ma Number Parcel Number
I.I a Is this an accepted street'?yes_ no_ F
1.3 ZoqJng Information: h 1.4 Property Dimensions:
NIAWater
rict Proposed Use Lot Area Oil f ) Frontage(fl)
ng Setbacks(R) J
Front Yard Side Yards Rear Yard
d Provided Required Provided Required Provided
upply:(M.G.L c.40,§54) o Flood Zone Information: Mu icipalSewn DV fai System:
Zone: _ Outside Flood Z e't Municipal Zile disposal system ❑
Public Private❑ Check if es
SECTION 2: PROPERTY OWNERSHIP' q
2.1 OwW1ofReS5ord: _ d rfu �gna,tVy UZ3
h /�-- Sro:.wtky
Nome(Pri t) Add ss for Service:
3c 14
Signature, Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check a that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ NumberofUnits 7i Other ❑ Specify:
Briel'Description of Proposed Work': 1—NS till ✓z-i7(itC? .TM ))"JdkVv t//N5 St t� �`� �0 �
elf-4 A/tk, d d c K
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
i I. Building Permit Fee: S Indicate how fee is determined:
I. Building S Zv^ 6"`'M ❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List: J �l
5. Mechanical (Fire S Total All Fees: S—
Suppression2
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
0\0(l v
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) S ., S� ! .3,. Z iL, — Z v 13
kr License Numhnr T Expiration Date
Name ut(.'Sli Ilolder Q I.ixICSL f)pe(see below)
Address r�pe I Description
��htf,Ws //64. ci Il 1 1!nresiricted(up to)5.000 Cu.Ft.
Signa re C C R Restricted l&2 Family Dwelling
R(' Residential RootingC'overin
felephort WS Residential Window and Sidin
SF I Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant N+une Registration Number
Address
Expiration Date
Signature 'fcicphune
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 f the building permit.
Signed Affidavit Attached? Yes.......... Nu........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
11 , 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: OWNEW OR AUTHORIZED AGENT DECLARATION
I, J e'a�p 4 J}- S�(J A^wt k( ,as Owner or Authorized Agent hereby declare
that the statements and information on the forQQQgoing application are true and accurate,to the best of my knowledge and
behalf. / . v � -•1/7_ {
Print Name I,/
Signature of OWner or Authorized Agent Date
(Signed under the pains and penalties of r'u
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 no have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 7R0 CMR Regulations I 10.116 and I IO.RS, respectively. I.
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.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half7baths
Typc of healing system Number of decks/porches
hpr of cooling system Enclosed Open
3. "Total Project Square Footage'•may he substiluted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
J all;n:f l':1Mhl:r q 1.
SI Nr�g ILC WASH0161 VS S'I'a ELT ► $MINI,MA9SACIII iEI-IN O07:)
1'1%1; )78.7i3-9395 Is I:vX, 978-NC-+846
Yorkers' Compensation Insurance Affidavit: liuilders/Contractors/Electricians/Plumbers
koolicant Information Please Print Leeiblv
_ / c
Viume t0astncssi0raanlralinNlndlviduall: +� G >Ae4 /4— S'k cIA,
�Chve S MA-- 0f97'3PhoneJ: sWr — GI 3 If `F
Arc you an employer:'Check the appropriate box: 'Typo of project(required):
LEI 1 am a employer with 4. ❑ 1 am a ,cncral contractor and 1 6 ❑ New construction
nployces(full and/or part-tune).• have hired the sub-contracture
I ant a sole proprietor or partner.
listed on the attached sheet. 7• Remodeling
2
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. 0 Building addition
No workers' com insurance 5. We area corporation and its
I P• ME] Electrical repairs or additions
required.) � oRicers have exercised their
3.0 I uni a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.[No workers'comp, c. 152, 91(4),and we have no 12.[3 Roof repairs
insurance required.) t cmployccx. IKo workers' 13.0 Other
comp. insurance required.]
•Wiry uppheanl that chucks box ill must also fill son the wcrian twluw showing fheir wutkai cumpensmion policy intiirmativa
' t lameuwnwm who submil Ibis affidavit indicating they:ne doing all wurk a,W then him uurside cwumeron must.uhmit a new,al'rdavil indicating such.
-C'omxwuu thus chuck this box mtal anwhcd an addiliunal.sheet,hawing the nmlle of the sub-conlractom and their svurkom'cane.policy information.
lairs air employer that lr providitkq workers'roinpensatioit ittsurtittee fur uty employees. Below is the policy and Job.rile
hil/arrnutidn.
Insurance Company Name: __...: _
Policy Expiration Date:
Job Site Address: City;StateiZip:
Aeach is copy of Ilia workers' cumpensation policy declaration page (showing the policy number and expiration date).
failure to secure coverage as required under Section 25A of 1lGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1.500.00 and/or sou-year imprisomnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of tip to 5250.00 it Jay against the violator. Rc advised that a copy oftim siiacincril may be furwardcd to the Office uf
I m'aangaunns of the DIA for insurance covcragL'\erltil.lhd+ll.
/do hereby certify e e pains anndt petralti•v of pe jury that the infurmwlon provided above
ris true run!correct ,
Sig,:,,litre:
C� y / t Data r'law G i�� 'Zv'1(
rhea: •;i:
Official rise or1 y. Ito itot write in this area, to be cunipleted by city or lorvn official
City or 1'own: ._ Permit/License 0—
Issuing.whority(circle iliac): i
1. Buurd of Ilealtb 2. Building Mpartincut 3. Cifi'fowu Clerk 4. Electrical luspcctor 5. Plumbing Inspector I,
6. Other ---.
Contact I'cnuo; _ .. Phone N:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an empleired is defined as"...every person in the service of another under any contract of hire,
es,press or implied, oral or written."
An employer is defined as"an individual, partnership,association, corporation or tither legal entity, or any two or more
,it the loret;oing engaged in a joint enterprise• and including the legal representatives of a deceased employer,or the
receiver or trustee of Art individual,partnership,associatioa 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."
%IGL chapter 152, s+25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewul of a license or permit to operate a business or to construct buildings in the commonwealth for arty
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additiunally, :bIGL chapter 152. j25C(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 conipliance 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 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 dote 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 time event the Office of Investigations has to contact yuu regarding the applicant.
Please be sure to fill in the pennit>liceiue 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 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 ctc.)said person is NOT required to complete this affidavit.
I he 01-lice tat Investigations would like to thank you in advance fur your cooperation and should you have,tny questions,
please do not hesitate to give us a call.
The Deparmnenl's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofi3ce of Iovestlgadons
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
ifeviscJ ;-26-05 Fax k 617-727-7749
www.mass.gov/dia
' CITY OF S.U-&Nt, NL,ss.A cH1USETrS
• J3uILD12NG DEPARTMffiiT
130 WASHINGTON STREET,3'D FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRMOLL
T
MAYOR t�tou�s ST.FtI?RRfi
DIRECTOR OF PUBLIC PROPERTY/Bt:nncIG co%L%IISSIONEA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
1n accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit # 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
111,S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
G4 I Mn. .
(address of facility)
9 signature of permit applicant
/h4-tic4 l9- �J(�
Bate
Jtbn>al(Jk