73 LAWRENCE ST - BUILDING INSPECTION 9 The Commonwealth of Massachusetts
(�y4 Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'"edition gamma
V \ ` Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit qum Date Applied: v (�
Signature: Z � � • () �
Buildi g mmissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Propert �+Addre
[�f�ss: nce Sd' 1.2 Assessors Map& Parcel Numbers
� 3
I.1a Is this an accepted street?yes_,, no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
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❑ Check if yes[] Municipal fH On site disposal system ❑
2n1 ,. SECTION 2: PROPERTY OWNERSHIP'
Owner'of Recofd:
Name(Print) T Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) 01 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_L I Other ❑ Specify:
Brief Description of Pro sed WorkZ: u* W I � C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ ,—7 jv oo 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical g C w ❑Standard City/Town Application Fee
a Or—, ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 6 S Sd Ca 0 Paid in Full 13 Outstanding Balance Due:
v
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7/
4,�,/Jy-/0S License Number Expiration Date
Name of CSL-HglJer i / List CSL Type(sec below) U
S t��nAl �L'46dr/� Type Description
AJ ess IF
U Unrestricted u to 35,000 Cu. Ft.)
�C1h R Restricted I&2 Family Dwelling
Signature M Masonry Only
3, RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 egistered Home Improvement Contractor(HIC) /3, //U
Y�3 /3 gf✓I-r5 Cc>n.ST/'tX-7`l/1`rj1_^/� Registration Number
HH 7 pGaNam 'Tl HIC egt_sStrantNam�fE'S�✓7 '��1�7
Address 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 .......... e No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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 71b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 i l f/,-"'e nJ C TCi S n J/\ ,as Owner or Authorized Agent hereby declare
that the statements and information oW the foregoing application are true and accurate,to the best of my knowledge and
behalf.
e
Print ra /7 31-U 8
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 10.116 and 1 IO.RS, 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"
CITY OF SALEM
Y
al PUBLIC PROPRERTY
DEPAR"I'MENT
Construction Debris Disposal Affidavit
(required lirr all demolition and renovation work)
In accordance \pith the sixth edition ofthe State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I It. S 150A.
The debris will be transported by:
(name of hauler)
Ilse debris will be disposed of in
(name of facility)--
(address of IaciliIV)
Ignature of permit applicant
�a 3� Q Y
la(.
:,I•i i....,:.
El
CITY OF SALEM
3- .. PUBLIC PROPRERTY
DEPARTMENT
::IUI::RLI!Y JRt1Q�L1. ',
12C.WAIHINGTOV STREET • SALEM,M.\y:\CI It Sli I'I S 0197^
'fta.:978-745-9395 • FAX.978-74C-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annl[cant information Please Print Leeiblv
N aMC (OusiocssiOrganizatinn/lndivi,lual):
Address: . r? --P"12✓/A-t
CityrStatei/.ip: /C��`�1��y / C/9 6/5�0 Phone i!:S 7k �t�r-- 3J'v
Are you an employer' Check the appropriate box: 'Type of project(required):
L❑ I am a employer will[ 4. ❑ I am a general contractor and 1 G. ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors
2 1 am a sole proprietor or partner- listed on the attached sheet. �• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
No workers'con insurance 5. ❑ We are a corporation and its
I P•
I required.) officers have exercise) their 10.❑ Electrical repairs or additions
3.❑ 1 am it homeowner doing all work right of exemption per MGL I LEI plumbing repairs or additions
myself. [No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. LNo workers' 13.❑ Other
comp. insurance required.]
-Ally:�pphca l that cheeks box ill must also fill out Ilse vfcfion below showing their w•otkas'eumpenution puliry intinmuriun.
'I lomcowm a who submit this affidavit indicaing Ihcy are doing all work and dicri him outside contractors must auhmii a new affdavit indicating such.
�Contewiun that check this box must adachcd an additional sheet showing the name of the Sub-contractors and their workers'comp.policy information.
1 tun un employer that is pro riding workers'c'ompen.cation insurance fur my employees. Below is the puliry and job rile
i ifurmation.
Insurance Company Name: _ _... .... . . ..
I'nlicv 4 or Sclf-ins. Lie. r,': ____... _._ . .._.____ Expiration Date:
Job Site Address: _. City/State/Zip:
Attach it copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
hailure to secure coverage as required under Section 25A of MGL 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 fine
Of up to S250.00 a day against the violamr. He advised that a copy of this siutcmcnt may be forwarded to the Office of
Im esiigatirms ul the DIA for insurance coverage eei ideation.
l do heroby terti y fouler the pnina'and penalties ufperjury that if n.infunatian provided above is trite and correct.
51e:l d II nc: Dalc: 42 - 3/--Ozy
Pl, • :i: c7a- 33S= 3�uc
Official rise only. Do not write in this area, to be computed by city or town official.
Citv or Town: _._-. _ ._ Permit/License X_____
Issuing Authority (circle am):
I. Board of health 2. Ihlilding Department 3.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _ . ____ Phone th
u � 9
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. ,
PUf5rrant to this statute,an employee is defined as"...every person in the service of another tinder 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, 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."
NIGL 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 perfomhance of public work until acceptable evidence or 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 continuation 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 he 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.
['lease be sure to till in the pennidlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennk/license 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Ol'ticc of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
ncc Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Rcviscd 5-26-05
www.mass.gov/tile