70 LAWRENCE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards OF CITY
ITY
k ' SALEM
Massachusetts State� Building Code, 780 CMR, 7" edition Revised Junn<Iry
Building Permit Application To Construct, Repair, Renovate Or Demolish a l• _1008
One-or Two-Fomily Dwelling
is S etion For Official Use Only
Building Permit Numbe : L
/ Date Applied:
3, Signature: �!°�"° 1
Building CommissioneF/Inspecto ( Date
I/ SE T N : SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&r Parcel Numbers
o c f
L l a is this an accepted street'?yes t/ o Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private[I Zone:
if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ca /-IaS GoMQ- C v La 1vV LZ hC `r
Narn j(Print) Address for Service:
61
Signature Telephone --"
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) I,
New Construction ❑ Existing Building❑ Owner-Occupied %d I Repairs(s) V I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units 2... Other ❑ Specify:
Brief De n d o lion o P oserk':
SECTION 4: ESTIMATED CONSTRUCTION COSTS -
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ Y o- 6G 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S 1. S'i`U ❑Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S (p U v 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
o. Check Amount: Cash Amount:
6.Total Pr oj ost: $ I rJ t I v U ❑Paid in ❑Outstanding Balance Due:
��j• OJ �
SECTION 5: CONSTRUCTION SERVICES
5..^1 Licensed Construction Supervisor(CSL) � J C // , Z 1 ,-
l up i0 r G a'M e- S license Number Expiration Date
Name of CSL- Bolder U'
70 La p. li@rt c List CSL Type(see below)
AddressF' a Description
U Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
q�F 3)r 3 rrdl RC Residential Rootin•Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5. Registered Home Impprovement Contractor(HIC)
HIC Company Nmne or HIC Registrant N7 e i Registration Number
5 -7 c -J,+I-a f s r 2-,i 3 �) � I Z
Address NL ' '
�..n (.7 � t�7Y_� S—; JrG/ Expiration Date
Signature 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 Issuance 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, C of H P S G c, Yg a. as Owner of the subject property hereby
authorize GGI 0103 (.—c, )+, of 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
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
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.115, respectively.
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.) 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"
!e CITY OF S:u.EM, AXSSACHLSETTS
BLI I)MG DEPARTMEINT
' 120 WASHINGTON STREET, 3"FLOOR
TM (978) 745-959S
FA-x(978) 740.9846
K1JfBERt FEY DRISCOLL THOMAS ST.PtERM
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING COSLNII5SIONER
Workers' Compensation Insurance Affidavit: Duilders/Contractors/Electricians/Plumbers
4 t Iicant Information Please Print LeQibiy
. rlf r
Va111C l0usin.yyO(stnirmiorvindividual)' C6i u GOP% 0
Address: (/ L U 1v e ►i C 2 S f S of 'C al
City/StatedZip: A I f h,U G1 0 40 Phone N: 61 7 P'
Are you an employer?Check the appropriate box: Type of project(required):
-1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(fail and/or art-time).• b-c
have hired the suonuactom
P 2.09 1 a sole proprietor listed on the attached sheet t 7. ❑ Remodeling
.
ship p and have no employees r- These sub-contractors have S. El Demolition
working for me in any capacity. workers'comp. insurance. q. ❑ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
required.) officers have exercised their
right of exemption r MGL 1 I.❑ Plumbing repairs or additions
3.❑ 1 ys a. (No workers'
doing all work c b152, §1(4),and we have no 12.❑ Roof repairs
myself. (No workers'comp.
insurance required.)t employees. (No workers' 13.0 Other
surance required
comp. in .)
-Any upplic:ua ow ducat box e1 must alru fill out the c,lion below showing their ww1mri compenwion policy innurmation.
I I Intneuwnurs who submit this affidavit indicating they am doing all work and than hire outride conimctars most submit a xw atndavtt indicating such
=Cantmvtuo that check Ibis box most attached an additional sheet showing the rtamr of the subcontractors and their workers'romp.put icy information.
l am on employer that is providing workers'rompensaton brsuranes for my employeex Below is Nie policy and Job site
information.
Insurance Company
Policy N or Sclf-its. Lic. N: Expiration Date:
Job Site Address: City/State/Zip:
,%ttach 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' GL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the OI'Iice of
Investigations ol'the DIA for insurance coverage verification.
/do hereby certify ands the pains and peeo"hies of perjury that the/aforaratlon provided above is true and correct
s „ , . &,111 Grp 9? Da( : 12 q I fa
pho C,Y 6'1 -2Y 33r- 3Gol
O icird use only. Do not write in tbls area,to be completed by city or town gJUA
City or Town: . .._—
Issuing,\utllorily(circle one):
1. Board of Ilcalih 2, fuilding Department 3.Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.01her
Contact Person: _ _ . ._. _.. Phone th
1
Information and Instructions
\Iasi achuscns Gcneral Laws chapter 152 requires al l employers to provide workers' compensation for their employees.
11ursuint to this statute, an emploree is defined as "...every person in the service of another under any contract of hire,
%pre»or implied, oral or written."
An employer is dctined as"an individual, partnership,association, corporation or tither legal entity, or any two or more
-t the 60rculing engaged ;n a Joint enterprise, and including the legal representatives of a deceased employer, or the
fecciver or trubica of at Individual, pwmership,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 maimenunce,cunstruction 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. §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, 'tIGL chapter 152, 4. 25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
` enter into any contract for the performance ufpublic work until acceptable evidence of cumpliance 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 ilia boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es)and phone nuuber(s)along with their cerfiftcate(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 confimafion of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he 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 haw 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 ut 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
Ihat mubt submit multiple pennitllicense applications in any given year,need only submit one❑ffidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"ell lucatiuns 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.
I lic I)Mice of lovebftgatmns would like 1%) thank you In advance fur your cooperation and shuuld you hu%e:my questions,
please du nut hesitate to give us a call.
The Ucparunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
olflce of Investigations
600 Washington Street
Boston, MA 02111
Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE
R..ued 9-'_ii-US
Fax H 617-727-7749
www.mas3.gov/dia
I
r"
CITY OF S�U.E.tii, .NLvLxSSACHUSETTS
• BUUMLNG DEPARMENT
120 WASHNGTON STREsT, 3' FLOOR
T L (978) 745-9595
FAX(978) 740-9846
KIN(BFRr t=Y DRISCOLL
MAYOR 'Il'tO.titAs ST.PiERRB
DIRECTOR OF PUBLIC PROPERTY/BUUMIING COUNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL a 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 defincd by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(na epf facility)
(address of facility)
signature of permit applicant
date
- Jcbnaalfde;