85-87 LEACH ST - BUILDING INSPECTION The Commonwealth of Massachusetts I
i Board of Building Regulations and Standards l t)R
,i, �Il Nll.'IPAIJI-) I
Massachusetts State Building Code. 780 CMR, 7 edition I SI:
Building Permit Application To Construct. Repair. Reno%ate Or Demolish a Rc i t%/ AmIN11a
One- or Tuv-Ftimi1v Duelling 1. 'nna'
This Section For Official Use Only
Building Perm Number Date Applied:
Signature: "'1'�.•� "llf'Lr'-� •J (/
Building Comma:ionrd Inspector of Buildings Date
SECTION 1: SITE INFORMATION
\ Ll P�yperty Address* + 1.2 Assessors Map & Parcel Numbers
I I.la Is this an accepted street? yes_ _ no_ Ma_p tvumbcr P:uccl �,\'uutbrr
'.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) 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 I Private❑ Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner l of Record:
_ Datl �✓1�r�P f
Name (Print) Address for Service:
I Signature Telephone 7 ---
�--- SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied, ❑. 1 Repairs(s) 531Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify:_ -_ --I
Brief Dzscrip on of Pr:;pct- V,,,.
cc ��,<.,k /. Y I.�----GrrLu
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost (Item 6) x multiplier s
i
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List'
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash :\mount: _
0. Total Project Cost: $ a"Q 1 0 0 0 0 Paid in Full 0 Outstanding Balance Due:_ __
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSII.) �oG �'7G �"7 ] 4{//,QJO
License Numher ISspir:uiuu Dale
Name of CSL- Holder
List CSL Type ace hrlew) _
"I'ype Dcsrri ttion
\ddreas
L L'nresuiacJ lu to 351000 C'u. Pr r
'R Restricted I,2 Fandly D%�eihne
Signature ,�l Nlasunry Only
RC Residential Reu ling Cuscrmg
'telephone \VS RrsiJenu at \Vmdw% and Snlme
SF Re]Idelltlal Sehd Fuel 13unune \ t thane: hnl.il i.uinn
D Residential De!nulmon
5.2 Registered home Improvement Contractor(HIC) 15 .3 O I
HIC Company Name or HIC Registrant Nalny. Registration Number
&LIA r) p
Address Le.� i+a[iun Date
Signature i ele_hone
SECTION 6: WO KERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application Failure n+ pr t:vide
this affidavit will result in the denial ol.the Issuance of the hul;Jing oerr.;i;.
Signed Affidavit Attached? Yes .......... ❑ No .........- LI
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED 'WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PE MIT
o •
I, as Owner of the subject property hereby
authorize .__—___.____. to act -in my behalf, ig all mutters
relative to work authorized by this building permit application.
i
Si nature of Owner DJ1e
SECTION 7b: OW'NEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent herei,y declare
that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
behalf. j
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the 2ains 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 cuntrac or
(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. I42A. Other important information on the HIC Program and . i
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.R5. respectively.
2. When substantial work is planned, provide the information below:
Total Hours area (Sq. Ft.) (including garage, finished base ment/att ics, decks or purchi
Gross living area iSq. 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"
Board r Building Regulatio 8,
Standards
Construction Supervisor License
,i. . _.. License: CS 64371
Expiration: 4/16/2010 Tr# 23259
Restriction: 1G
MARK E WILLIAMS
5 LENA MAES WAY
SALISBURY,MA 01950 - 7'Commissioner
���4 L(IIt/II to I/I/WIAIII / . I[I(_:Jill�/(JG[W
Board of Building Regulations and Standards
• 1 .HOME IMPROVEMENT CONTRACTOR
Registration: 153016 -
--: Expiration: 1 0/2 312 0 0 8 Tr# 253062
Type: DBA
QUALITY CONSTRUCTION
MARK WILLIAMS 1.
5 LENA MAE'S WAY ��,..e0 a,,...`
SALISBURY, MA 01952 Administrator
• • A
1
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
. \Lod I': \\ �.I�:�.�,:� � i:!.� II • iV: �l. \I t .l� !. .: � . =1 ' '
[it •t'Y.'V�.l;h 11\: ty.'+_ 'tYii,
lilurkers' (-'on)pensation insurance AflidaNit: l3uilders/Contractors/Electricians/Plumbers
Please Print Legibly
i ) )Itcant Information
\,Illlc 'mi'loc.. tIr_.tnveu.�n IuJt,:du.tl l:
�lafvk wl � � �ti.IC �J4 � lT' / CatiS
Wdless: 5 Le ale G`'l ae S
City St Ile Zip:
�e,� Vj(�ul� �/`�� O (I5 - Phorle41 ef'-7 383CS
tire you an employer? Check the appropriate box:
Type of project(required):
I ❑ tin a cmplo}er w ith 4. ❑ I ain a general contractor and I [, ❑ New construction
employees(Full and'ur part-tinge).' have hired the sub-contractors 7. [( Remodeling
_ listed on the attached sheet.
]. I .tin a Nole proprietor or partner- Ihese sub-contractors have S. [aDemolition
,hip and have no employee; workers' comp insurance. y_ ❑ Building addition
working for me in anv capacity.
[No workers' comp. insurance 5. ❑ We arc a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their
required.( 1 1. Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL ❑ g F'
% myself. (No workers' comp. C. 152, $1(4), and we have no 12.0 Roof repairs
insurance required.] s employees. [No workers' 13.❑ Other
comp, insurance required.]
•:Nay applicant that checks bun NI must also till out the section below showing their workers'cumpenaatiun policy information.
' I lomeuwncrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affdavit indicating such.
$',nttrvc tors that.heck this box m ac]lost an hed an additional sheet+hawing the name of the sub-contractors and their workers'comp.policy information.
f tun an eatployer that is providing workers'compettsadirn insurance for my employees. Below is die policy and fob site
information.
lll,inranCe Company Name:--
Expiration Date:
Policy 4 or Self-ins. Lie. a:
City'state/Zip:
Job Site Address:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure ctnerage as required under section 25A of MGL c. 152 can lead to file imposition of criminal penalties of a
line up to S 1.501).00 and'or one-year itnprisomnent- as well as civil penalties in the tilnn of a STOP WORK ORDER and a fine
„I op to S_251) It)a day :l_eam.,t ole %iolator. Be ad%iscd that a copy of this statement may he forwarded to the Office of
Im c.n_anionN of the DI:\ for insurance coscrage scnlicanon.
/do hereby t ertilr under the pains ttnd penalties of perjury that the infirrntution part i,led above is true and roti
tnlr
il,•
--ollirial rise atilt'. Do not write in this area, to be completed by city or towto uffiriuL
( tit or Iles it:
Issuing %uthority (circle one):
I. Board of Health 2. Building Deportment 3. ('ity/fawn Clerk 4. Faectricul Inspector 5. Plumbing Inspector
6. Other
Contact Tenon: _—__-. _—_--. ------------ -
__-- Phone #:_-- -----
Information and Instructions
\Li..e:h,u.rus l kncr.d I .rws chapter I �' rcguues .ill cinplMer, To pro%ide workers' compcnsanon for their enlplmees.
I'm'u,ult to this ,tatule. .ur rntploi'ee :, dclmf d .is ". c�ers per,on "' file ,cl%tcc of.mother under.its contract of hue.
:yv cs or inpl tcd. oral or w ntiell
empluirer i., defined as ".m Milt;.l u.11. pal incr,ht p. a,soct.0 ton. corporanon or other Ice.rl enwv. or .0 IN two or more
,,I the tw:_omg cngagrJ in a join cutcrpri,e. .utd mcludulg the le al rcprescntatnc, ofa dccc.r,cd cniploNer• or the
;cecncr or IILI,IeC of.tit u1Jn jdual, p;rfncr,Iup. .I,,ocialion or other Icgal cntit . cinplos In❑ colplo,ees. l[owe,er the
,,•.%ner of a Jwelhng house has ing nut :core than three apartnn•ns and �%ho restdcs therein, or file oecupant of the
,I��i lllllg Iwu,e of another who emplo" persons to du nl.nn4'nance. construction or repair %%ork tin ,uch dwelling house
.a .nl file _rounds or building .ippuitctI.tm filereto ,hill not hed.rn.,C of.uch enlplos mcnt be deeured to he m employer. .
\1(.1. :haptcr I5'• j_'SC(h) also .late., that 'cscry 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 commonwcalth for any
applicant who has not produced acceptable evidence of complia nee with the insurance cu%er age required."
A dduiona l ly• \Ril- chapter 152, §S25('(-) ,talcs 'Nei l her the connlunwea l I nor any of its political subthvis ions shall
enter into any contract for the pert ,[nlance of public work until acceptable es idence of compliance wish the insurance
ragmrenlcnts of this chapter [late been presented to the contracting authority."
Applicants
['lease till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) nante(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 date the affidavit. The affidavit should
Ile 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
Ili 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
that must submit multiple permit/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 ,tamped 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 tilled out each
y car. 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 erc.),:lid person is NOT required to complete this affidavit.
I lie (mice of hisestigations would like to (hank you in advance for your cooperation and should you lase any questions,
plca,e do not he*rt.rte m give us a call.
I he Depai anent'. address. telcphune and fax nuurber:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021 1 1
Tel. f1617-727-4900 ext 406 or 1-877-MASSAFE
Key j,cd ;-'n-u; Fax N 617-727-7749
www.mass.gov/dia
CITY OF SALEM
J-nyx--:;wl PUBLIC PROPRERTY
DEPARTMENT
.Il I�t it 12, A VS1 II],,:i INS I It T
978 74.�1)846
Construction Debris Disposal Affidavit
(rc(ILlil Cd for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions ofMGL c 40, S 54; from
Building Permit 4 -- is issued with the condition that the debris resulting 0
this work shall he disposed of ill a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(nanic of hauler)
I he debris will be disposed of in
MLL
OIJMe of racilit;5
P-
;address of facility)
Nienature of permit applicant
date