87 LEACH ST - BUILDING INSPECTION (2) ^> ('he ('ununonwealth ul tbtassarhuseus
t r Board of Building Regulations and S(:uidards Fult
"} NlassaclntsettS State Building Code. 780 CNIR. 7"i ediliott NN .NI( H, \1 I I 1
I SI.
Building PerntiI Application To Coiisu uct. Repair. ReIIot a I e Or I)rinoIi.h a R, I„",/
l Ont'- r,r Tu�r-lrurtilr Dtr<'llir!4 1. _�n,,y'
This Section For Official use Only --�
I
B UIldin-1 Permit N mher r--.-- Date Applied: --7
Bwldut (ui nis,ontrr/ In,pector oI n:.uldmLs
S5XTION I: SITE INFORMATION —
1.1 Prn rh Address: 1.2 \ssessots :Nlap S. Parnel Numbers — ---- - --
i.Ia
l
1.3t<:::a:rn —
`. ..- r s' ct Proposed Use Lot 1n.:;s4 to
F:a' a liii
1.5 Building Setbacks (ft) --- -- -- - — - -- - -- -
Front Yard Side Yards ------__ -__1
— —_ __H
_ Real Yurd
Reyooj Pon I.
Rcy:nrcd
PW%'Ided Reyutred PIo:oJrd
11 6 NVater Supply*I tM.G.L a. 10. ti.t7,' - - — -j 4 ) 1.7 F.aod "one Information. 1.8 Sewage B:Sposal S)Stem:
Puhlic ❑ Prieate ❑ ZUn�. --- Outside Flood Zone?
Check it yes❑ Nhrmcipal ❑ Oo .ite diaxsal Sy,tem ❑
_ SECTIONS: PROPERTY OWNERSHIP! ~
2.1 O nertof Record: -
- � Mf
N.0 ;c i Pnno -Addles, lirr Ser<ice: --
I
II Stgnauuc Telephone —____ —_.—____ I
I SECTION 3: DESCRIPT N OF PROPOaED WORK(che••k all that apply) i
New C t netk„ ; ❑ Esisong BuiFung Owner Occupied ❑ Repaurstsl ❑ AI'r rnutnlsl -:Jt,iu" C_._�
Jernell on ❑ I Accessory Bldy-. ❑ Number of Units I J her ❑ SPerily:
=l— -._-- --t
I Br let IJ�se ipti"m of Prupr.�srd Wurk'`:_�v�--
UJ.
�.._ Cam——6r}-�-�-1� - -1^es,..✓�----1 2-� '—L-L3� ':�1_.s�_ r_ .�r _�- - - - - ._q_ r
— SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: --;
Labor and Materials) Official Use Only
'$ I. Building Permit Fee: $ Indicate hues fcr t, JetennuteJ: '
�. Electrical S ❑ Standard City/Town Application Fee
❑Total Project Cost',item 6) x multiplier x
3. Plumbing Y ?, Other Fees: 5
1. Mechanical tHV:\CI S List: <�a
i. ;Mechanical (Fire /' -
t ressir:n) S
SuU �]�U Total All Fces: .5 -----------
_- r
—�0 Fotal Project Cost ) Check No, Check Amount u('. h Nn ount: E
: — ❑ Paid ut Full --- -- - f
' ❑ Outst:utdi ng 13al:utce Une:
t
SECTION 5: CONSTRUC'TION SERVICES
5 1 Licensed Construction Supervisor (CSL)
n Lunn e Number L.Nplr:lo, ll Da(C
/Nanw• i,f C r , 1 ' �aI Lot CSl. r,pe l•ei•hiluwl
/� "f /y "hN. e Dcsin mom
VJd L V
Cnresn' d I1 u 1 to li.lN)0(L I I
�/- RC>ulcle I:c' F:unIIN Uw elluta
Slgnutula , \1:uonn l)nl�� --
/._yg_ 3Qq/i RC "'de Ll l2uuhne( u,a
3 !7 \\S RC,,J.'uu al \\1 nJ,��� .�r.J liJin_ _
Fclepholw SF RC,lJant,.d Solid fuel Il,:u,in_ \pl�Lunr: In,l.il L,In a ��
U Rc,IJeuuul Uen„d lw.n --1
5.12 Registered Humle Irnp r vernenl 'untractor (HIC)
Reguoauun Nil cr cr
IC Copry Nallle
H m or MC Reg-iNvinl Nano
4-oI ( / J — p_J23; 1r ---
AJdr' . / q?gS �A—313[Ci Frpuaia,i Uat:
i — .relepm,ne T
signature
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit mint be completed and submined with this application. 1':ulure to pnls rdc
P building permit.
result in the denial of the Issuance of the
this affidavit will e
Signed Affidavit Attached'? Yes .......... ❑ No ., ❑ _ __
SECTION 7a: OWNER AUTHORIZATION TO BE COM1IPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
10 J , as Owner of the subject property hereby
i1. _-_._.— to act on my behalf, in all nlatten
authorize 4
-elative to authorized by this building permit application.
_ Date
Si nature lit Owner
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION i
as Owner or Authorized Agent hereby declare
L
e and accurate, n, the best of my knowledge an
that the statements and information on the foregoing application are tru
behalf. —
Print Name _—_--
Dme
Signature of Owner or Authorized Agent
F
Si ned under die inns and enalties of er u '1 NOTES:
permit to du his/her own work, or an owner who hires :ul unregnteleJ runts:nn�
uildin' a . . ,
An Owner who obtains a b 6 P hilralit n
(nut registered in the Hume Improvement Contractor(HIC) Program), wilt )ru! have access to Progi ll
oirriation
program or guaranty fund under)M.C'SLI ran,be fi)ther und inm750tC M1i the III(
R tRegulationan I IO.R6 and 1 IORSnd SPCCloely.
Construction Supervisor Licensing —�
I work Ia Ianngd, provide the information below: decks or ,,n�hl
When subo[anuu P (Including garage. tinuhed ba,cnlenUatucs. de I
floors area I S . Ft. t
" oral tl 9 room 1 count
r Habitable n 1 n
Ciro,s living area ISq. Ft.) of hedroums
Numbu --
Numberuf fireplaces Number of haltih,uh, ____—_------------
Number of hathruonls Number lit deck,/ p,cehcs __-- --_—
vpe of healing system . Ln:lused
FVpe of Coolltlg s.
7. "Total Project Square Footage" may be ,ubstnuted for ''fo[al Project Coet" - —
CITY OF SALEM
s�
PUBLIC PROPRERTY
DEPARTMENT
\1'urkers' Compensation Insurance Af idanit: Builders/ContractursiElect Pleice ns/PlPrint nibLeg rs
\ ) )Ii ant Informdtiun
\,11IIC �Ilr.,rir.. t 4,,an v.tm�n Indn nlu.tl i.
� r
�tlttr�„ bly
r
c ll� slate-zip: l/l p t/\
home #: _
tire you an employer:' Check the appropriate box: Type of project(required):
1 ❑ I :ern a anlployer with
J. ❑ 1 :ern a general contractor and I 6 ❑ Ncw cunstrucuun
eulpluyees(full and'ur part-time).' have hired the sub-contractors 7. ❑ Remodeling
listed on the attached sheet.
'.❑ I .ern a sole proprietor or partner I hose sub-contractors have Y. ❑ Demolition
;hip and have no employees
working for me in any capacity.
workers comp. insurance. y, ❑ Building addition
j. ❑ We are a corporation exercised
and its
[No workers' comp. insurance IQ.❑ Electrical repairs or additions
reyuircd.) UIhCCr5 have exercised their
ri ht of exemption per NIGL 11.0 Plumbing repairs or additions
i.❑ I am a homeowner doing all work c 5152, 1(4), an we d have no
myself. (No workers' comp. I'_.❑ Roof repairs
insurance required.) i employees. workers' ❑ Other
sump. insurance require).] 13.
•Any,µ,plicant that checks boa 01 mint also till our the section below.hawing their workers coinpenwtiun policy infutrnation.
' I lonieowners who submit this of idavit mdkaimg they are doing all work and then hire outside contractors must submit a new atfidav it indicating such.
�('nnracmrs that:heck this hux must attached an aJJnmwl sheet.hawing the name of the sub-contractors and their workers'comp.policy information.
/ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
inforinarion.
Insurance Company Name:
Policy # or Self-ins. Lic. M: Expiration Date:
lob Si(e 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%lGL c. 152 can lead to the imposition of criminal penalties of a
tine up to SI,ino.on and'or one-year Imprisonment, as well as cull penalties in the limn of a STOP WORK ORDER and a tine
nl up hi 1_25I)IIU,1 1,1v ,l�altb[ the %iolator. lie ad\i>cd that a copy M Ihls Slatellictir may be torwarded to the Office of
In,c*u_coons of the DIA for insul Ince cuscrage seritic lion.
/Ju hereby a erti/r under the pains and penalties uJ per/tor)'that the inforntwrort prul id d abut a is trite and a orretit
Date'
��rn,itura.
t)//iei,d air unlp, no nat i,rite in this area. ui he.oniplcted by airy or town officiaL
< in or loan: _._. ..—
Issuing \uthortly (circle one):
1. Board Ili Health 2. Building Deparnucnt t. ('ity, futsn Clerk J. Electrical Inspector S. I'lunibing Inspector
6. Other _ _ --- - - ---- -- - --
Phone
Contact person: ._—._--
Information and Instructions
\I.I—.$, u,Cu, l kncr'd 1 aw, ,haptcr I < Icquu c, all erlgtloser, to pro, ide workers' :ongtcn,auon htr ttctr cngtlmees.
P'ti.u.uu to tldu statute, .it entplo are t, Jci]n. d is Ct en person in Ihe_,ct,ice of.whither under .tits contrast IIf hire.
;\Ive or nnitl ed, oraI or whiten .
\c I mplu I er t, do I I II CJ .I9 ..,II :nJI%:du.I1. I'm urn It I p. a„o,anon, .orrp,Iranon or of her IcgaI cants. or .0 IN I%%It or nit Ire
,•1 the tote ,,mg cn_.i"d tit a nnnt cuter pn,e. .lid in,ludmg die Ir_.II rcpre,cntan,c, tit de,c.t,cd cmpht,er, or the
en er or ittl,Ice oI In it dui I. p.untcrnhip. a„ostation or other Icgal cutuy. employ uIg cntpIoscc., I lowever tie
,..,tier oI I dh%cl Lng house h.n ing no( more rh.rn thrce .Ip,Irtntents and wfto rc,Idc, tljcrc tit, or the os,upant tit the
dt,ei! iw hou,c III m tot her who engtlo„ peron, to do nL trimiance. con,trucnon or repair work on such dwelling house
r .,n the _rounds or hu Jdutg .Ippuncn.Int thereto shall not hecau,c of such cutplo,incur be dcctucd to he .In cnlployer.
\Il d ,hapncr 1 s2, ,'Slltt) also .tale, dial 'c%er %tale 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 whip has not produced acceptable cs idence of compliance with the insurance cuserage required."
\JJlhonally. .%I(il- chapter 152, s2511-t ,Ietes Nei the commomeca Ith nor any oftIs pul it lcal ,uhdis Lions ,hall
CItier Into any ,ontract for the per Ionnance of public work unml acceptable cs idence of compliance evnh the insurance
requirements of this chapter have been presented to the contrasting authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) namels). addresses)and phone number(s) along with their certificute(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 dues 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
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
,elf-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 -
otthe affidavit for you to fill out in the event the Office of Im'estigations has to contact you regarding the applicant.
Please be sure to till in the permit,license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemiiulicense applications in any given year, need only submit one affidavit indicating current
policy information Of necessary) and under"Job Site Address" the applicant should write "all locations in (city or
t
ow Ill.- 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 tile fix future permits or licenses. Anew atfidavit must be tilled out each
year. Where a home owner or citiicn is obtaining a license or pcnmit not related to any business or commercial venture
It c. a Jog license or permit to burn leases ere.),md person is NOT required to complete this atfddav it.
I It,: I of ice of fm e,ngations would like to thank you in advance for your cooperation and should you hale any questions,
plca,e Jo non hesitate tit glse u.s a ,all.
I he 1)Cparnnent', aJJres. relephone and tas ntunher:
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
www.mass.gov/dia
S S
CITY OF SALEM
f PUBLIC PROPRERTY
DEPART'NTENT
I \5.975-'4.`11ih
Construction Debris Disposal Affidavit
(re\luired for all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit It - is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal Iacility as defined by MGL c
t 11. S 150A.
The debris will be transported by:
I
lvlPI �r) 01r[PA�n164
t name of hauler)
I lie debris will be disposed of in
-- (uameo(faeility)
IT Y' INA
address of facility)
-- - signature of pmuit applicant
Mate .._ .-..
13 ` � '.
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