23 LEACH ST - BUILDING INSPECTION iy�-aolp
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Workers, Compensadoa insurance Af7idaviC Builders/Contracton/ElectridandPlumbers
aonlicaat Information /I Please Print Legibly
Name tnaunesttlksaniratiaMttrlrvuhmfi: b 15 h Ok C&4 5 7�'V M riyL__L j6
Addreas: b d /UZW 6al9 VVk_- 5L
City/Stamizip: ( )4', )A(6(' Yd0,. O l Yt0 ► done a: '70 , Z 5_iO3 ki6(
Are yen to empteyert Cheek the appropriate boa: 'type of project(required):
1.CR ' •+m a ctnpbyar wide—? 4. 0 1 am a general contractor and I b
employees(Adl and/or p:ut sc).• have hired the sub-contractors ❑New cos attuetion
2.❑ 1 am a sok proprietor or partner- listed on the attached sheet 1 7. [i IGoodeling
ship and have no employom The"shbcontraetea have S. C3 Demolition
working for the in any capacity. workers'comp insurance, q Building addition
(No workers'comp insurance S. ❑ We am a corporation and its 10.0 Electrical repairs or additions
nquirctij officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or adtitions
myself. (No workers'comp. c. 152.(il(4),sad we have no 12.0 Rt)ofrcpaim
insurance required.j r employees.LNo Workers' 13.❑Other
comp. im-;um a required.]
'Alp;aMliwm nr cltttc'Its ban-nl man ales till as ate wi,m ttcturr dmwiaa their awraen,aanpMWlm pulicy iarurvoutim
' tl,mwwnen*he submit this atrldnvu indiwma dry are daina eU wtk sad etes bha amsids e0rarnarra mar.utanil a 1111111'atttdseit indiadina iW%lb.
;C t rovam the amok this box mun attaeltad m Wi itimal Jaws.bowing the trams of the ah.mn4acsoA and their wurk",map•Policy offirmadpa,
I oar un employer that/s provfd/ng workers'cornpenYadon livarance for my employees Below Is the puNay rand job size
hafarmar" /�,.,,, _ n
Insurance Company Vame: ro r' teA`��r G �a4h a4ONO_✓&A U t&P
Policy a or Self-ins. Lie. M: /W C 'u2—cf/�-.W Expiration Date: -3 � I q J(��/�
Jub Site Address: "zoCityrState/Ztp:�L� l/�1 /y l a, o���
Artach a copy of the workers'compensation policy declaration poke(showing the policy number and expiration date).
Failure to swum coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of s
Ang up to S 1.500.00 and/or one-year imprisrrmncnt,as well as civil pcnaltica in the form of a STOP WORK ORDER and s fine
elup to 5250.00 a day against ilia violator. lie advised[hut a Cully of this statement may be lurwarded to the Office of
Inr,.ugmnttts ul'tlic n1A for insurance covcraju vcriftcatiun.
/do hereby rerr/fy under the�pr ' uud penudier ofper/ary rhw the infarwallon provided ubowris true(Arend correct.
O flc/ad tore unlit. Be Misr write Is this area,to Air completed by c/ly or town of li•Ild
City or 'ro%irw Pcrmit/Llecnse M
having Authurity (circle ono): —
1. 114'ard of Iicalth 2. Building Department ). Ciglrowa Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _ Phone p:
Information and Instructions
.%la;s rchusets General Laws chapter 152 requires
mtsd s all employeesraw inprovideue�iher under any coaaset of hire,
Pursuant to this statute.an taa/f�yde is defined as*...every pe
,:%Wss or implied,oral or writtes."
anseiaueIL OwPoratios er other kV"entity.or any two a more
eyw is deNaed a itdividvd.Pam` the k representatives of a deceased employer.a the
Of the foregoing engaged is a joist ennetPrwa,and itschutin{ ttd However the
uweiatioa Or other legal entity.employing employees
receives tits trustee of m individual.of ma rshn esi. and who rends therein.or the occupant of the
three
owner d►f a dwdhng hove hsvitig tssa mace rhos aparsntestt
of another who employs Persons W do mainwnmce,cusstructios or repair wont on such dwelling house
house be as
JteeUrnj such be deemed to emP1OY
a thereto shall net ttedeatsst a< empleyttiest
or on the grounds or building PPu*tenant
stales that"wary stets or Weal He
agency shad witbheN the Wilson Or
.%tGL chapter 152, 42S(6)�s b tM ce=mesweaW for say
retread of a geese or permle to operate s bursae or to eoustried bd�pslosurasee coveragewas required."foay
st Islas loss act Predseed seceptable avideme of cOOPHRsos with the
�s §25 7 stases"Neither the conutmnwealth nor any of its Political subdivisions sbsU
AJdr into sac MGL chapter 1 S_. form )
for the performance of public work until acceptable evidence of compliance with the insurance
enter into anyOf
contract rued to the contracting authority."
requirements of thirst chapter have been p
Appaesses
Please fill out the workers' compensation affidavit Completely.by checking the boxes that apply to your situation and, if
necessary.supply cob tor(s)name(s),names)aid Phone nutmber(s)along with their certiticate(s)of
Companies LC)or Limited Liability Partnerships(LLP)with no employesa other than the
insurance. Limited LiabilityO1Opsn workers'compensation insurance. If an LLC or LLP does have
members or partners,am act tequirod toc carry
employees.a policy is required. Be advised that diu affidavit may be sign
ansubmitted to the Depsremtt. h affid vit
Accidents for confinrtadOn of insurance coverage Abo M sttrear lice�od�date requested.
e u tr d.not the De tptutmetw of d
be returned to the city or town that the application for the penait { eq
Industrial Auidenu. Should you have any questions regarding the law or if you are required to obtain s workers'
Cali the Department at the number listed below. Self-insured companies should enter their
compensation policy.Plena
self-insurance license number on the line.
City or Tows Ofikiab
Please be sure that the affidavit is complete and printed legibly. The Department has provided a speed at the bottom.
of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant.
I,Icase be we to till in the permivliccnse number which will be used as a reference number. In addition,an applicant
that must submit multiple permivlicense applications in any given year,need'o'rily submit one affidavit indicating current
policy information lif 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 rile for future permits or licenses. A now affidavit mum be tilled 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 Jog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
i'hc Ot iicc of Investigations wuuld like to thank you in aJvance for your cooperation and should you have any questions,
icaae Ju not hesitate to give us a call
The Dcparment's address, telephone and fax numbs.
The Commonwealth of Massachusetts
Department of Industrial Accidents
0 of[awsdptles"
600 WafdlinQooa Street
Boston,MA 02111
Tel. 0 617-7274900 ext 406 of 1-977-MASSAFE
Fax 0 617-727-7749
2cviaeJ 5-?6-US www.una.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
al.�.. 13C 7.%ZCW.aWi.Uff a UL; 1c 1111t:N �r1f:.i
Construcdofa Debris Dbp"Af Affidavit
(reyuiml IN all demoWiost and rmovad"wart)
is mordams wA dw sixth edidom of dw Slats Building Cods 7110 C16 It sactioa 111.E
Debris,and dw provisioro of NtGL a 406! 54
Building ramm A _ is issued with dw coodidoo dwt the darts resulting Dos
this wort shalt be disposed of in a property licensed wssm disposal facility as dented by MICR.a
tl1. SU"
The debris will be transported by:
-- teams of horlad
fhe Jcbris wilt be disposed of in :
t u.mr of fx�Aty)
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r.. N':�!lam }' ✓� jQ'K((/P9LUL � J•. �����i/� ' � Y,.
Board of Building Regulatfonsand Standards i_ ,. I,
HOME IM EMENTCONTRACTOR `
• r , Registration 130720
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7ISHOPCONST
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j80 NEW SALEM ST°
'.WAKEFIELD;MA01880 .
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` 01, of Building Regulatfom and St ndards t+^ . .�.". h
EC to ructt n puperVisor License k
trill, 11253
' l'ODD A BURNE �-_ •+'-� 1 i.iR ` ,A,r.
137 BERWICK -
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1FOR
The Commonwealth of Massachusetts
i Board of Building Regulations and Standards
MLINICIIIP
':\LI'fY
d(,a Massachusetts State Building Code, 780 CMR, 7°i edition
USE
Building Permit Application To Construct. Repair, Renovate Or Demolish a Rei ne l✓olm(o:c
One- or Tiro-Famd.v Dwelling 1008
This Section For Official Use Only
Building Permit Nu er: Date Applied: )
Signature:
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
i
1.1 Property :\ddress: 1.2 Assessors Map & Parcel Numbers
��Ln.�I-c.h �J"✓a�-f�
L la Is this an accepted street'? yes ✓ no Map Number P:ucel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq f) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
i
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 Cr'bn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP' ,q
2.1 Owner'of Recp{d:n�� I U Z3 / �� •c /c lZ��n /YCC( 0Jq(-,7p
Name (Pr,tyy)�� Address for Service:
af'7 9- 17q-5- L-5& 4 8
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New ConstructiIfPropctsed
Exg Building Owner-Occupied Fa' Repairs(s) Alteration(s) ❑ Addition ❑
DemolitionAcory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Descriptio Work': 2-M0V-Q— - f 717 t`k1
i
f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
�S (Labor and Materials)
L Building $ 35Q p �1. Building Permit Fee: $ indicate how fee is determined:
0
6tandard City/Town Application Fee
�777 2. Electrical $ nU 0 ❑ Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ 5'U0 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:
Check No. Check Amount: Cash AmountZ�
6. Total Project Cost: $ �-5 v0 &�fa-id in Full ❑ Outstanding Balance Due:
14l.-i -ro "705 sue,
SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 6/� Ja/7 OF
0
�� .4 - .�aYAt, License NuUunber Expir'ati)on Date .
Nanpc oI CSL- Hu1d r � ✓ List CSL Type e tsee below) v
S /
_ T e Description
4ddre
�_ Unrestricted (Lip to 35.000 Col. Ft )
R Restricted 18c2 Farritly Dwelling
Signa�r M Masonry Only
Z r �3O RC Residential Roofing Covering
('\ Telephone \VS Residential Window and .Siding,
SF Residential Solid Fuel Mining Appliance Instalkaiun
v \ D Residential Demolition
5.2 Registered Home [m oveme [ Contr for(1IIC) 2
h, e Home ,��rl c i' � /3D a
HIC Company Name r HIC Regi trant Name Registration Number
AdJres- �Iho/D
_ �W,z_V F, k,30 J Ex`pfrationDate
Signatu/ 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
1, g/.en Dkdd'aA/07 -, as Owner of the subject property hereby
authorize 0&o--!9,e to act on my behalf, in all matters
relative to wo k thorized by this building permit application.
Signature o wner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, /V-o D 0 ugly , 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.
�p i� uoLV
Print Na
Si azure Owner o: orizcJ Agent Date_
(Signed nder 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 trot 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 IO.R6 and I IO.RS, respectively.
'. When substantial work is planned, provide the information below: -
Total floors area (Sq. Ft.) (including garage, finished basemendattics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms - Number of halt/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"