87 LEACH ST - BUILDING INSPECTION r
F� The Commonwealth of Massachusetts
v Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'" edition
Building Dept
Building Permit APPlication Co struct Repair, Renovate Or Demolish a
O - or Two-family Dwelling AWOL
ThjqkSccti4n For Official Use Only
Building Permit Numb r: Date Applied: i -r76�` p�
Signature: f 2l O�' � U
Building C m ssioner Inspect r&f Bd ings Date
§yRfION 1: SITE INFORMATION
1.1,�Piroperty Address: 1.2 Assessors Map& Parcel Numbers
7�gPr�n ��-
L I a Is this an accepted street?yes—,L no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: _
Zoning District Proposed Use Lot Area(sq ft) 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Prin[)�—�� Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 61 Owner-Occupied ❑ Repairs(s) Alteration(s) O Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': I .�:p In p)4 N Pj U a, r s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost"(Item 6)x multiplier x \^
3. Plumbing $ Other Fees: $L
4. Mechanical (HVAC) $ List:
J
5. Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 gqLicensed Construction Supervisor(CSL) CS (n 4 -3 7 I V l )"O
'"qcc �- k W 4 I 1 t cel yy, License Number Expuauon Date f
Name of CSL- Holder 1 r LJ / `l List CSL Type(see below)
Add s t T Description
,t ,��,,,,t U Unrestricted u to 35,000 Cu. Ft.)
' ""� -6� R Restricted 1&2 Family Dwelling
Signature 7 M Masonry Only
CI 7 7_ cl �J— 3�j 7 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 pR.}egister d P me Improvement C ntrac o'��rl(HI ) / r
IX Ll In CPIs � � Sv rl � y
HIC Company Name d HIC Registrant Name S S I 1 n Registration Number
Addr ! T3� Zal.o
Gi7� (�pyq, 3Pj'3(� 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
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 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I ,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 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 110.116 and I 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
AF PUBLIC PROPRERTY
DEPART'/IENT
'.I
12 A.\iI II\t..,!\$I:U:I'T 0 1.\I I'\1,
Construction Debris Disposal Affidavit
(required li)r 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 of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
(name ofhaulcr)
The debris will be disposed of in
I
(name of facility)
(address of lacilitw) 1
signature of permit applicant
date
CITY OF SALEM
i, j; PUBLIC PROPRERTY
t J DEPARTMENT
J,nti of 1'1'Unlit..n 1
l2�W,\it tl\a;1,)N S I a LLI' * SM I`M,M,%lS%t.I 11 it'I I s u 197-
7LI: '178-,'1y95'15 9 f.ss 97g-741'-984(,
Workers' Compensation Insurance AfftdayiC Builders/Contractors/Electricians/Plumbers
A ) )Iicant Information Please Print Letihly
�I01nt: l0uunesyr�r;tsnuatinn/IndrvuluuU: f��'ldtJ�.
Address:
City,State,Zip: Phone
Are).to an employer:' Check the appropriate box: 'Type of project(required):
I.❑ I :un a cmplu)cr with 4. ❑ 1 ant amoral contractor and 1 6. ❑ New construction
enlployces(full intL'ur part-time).' have hired the sub-contractors 7: ❑ Remodeling
2.❑ 1 ;un a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have ti. ❑ Demolirion
working liir me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
[No workers' cum insurance 5. ❑ We are a corporation and its
I P officers have exercised their 10.0 Electrical repairs or additions
I required.] I I. Plumbin r repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per NIGL ❑ b "P'
myxlf. (No workers' comp. C.
152, ¢1(4), and we have no 12.❑ Rouf repairs
insurance required.] t employees. LNo workers 13.❑ Other
comp. insurance required.]
-4ay.ytpLuanl thur dicks box Pit must:dw fill out Ir,aaw showing their wurkwr cumpunsmion pulicy inlirrrrwtion.
' I lomeowrwn rs'hu submit this affidavit indicmng they Are doing all work and then hire uutside eurracrurs Pius[suhmil a new al'r:davil indiuhng such.
-f'omrntun dmr check this box mtuf arioched an additional..hvvj showing the name of IfLL sub:onrractun and their workors'comp.policy mfornP riun.
l urn an employer that iv providitrg workers'c olopensation ins"rance for toy employees. Belon,is(Ire policy and job Vile
in/oralutiun.
Imurancc Company Naine: —.__. -. -._..-..
11olicv a or Sclf-ins. Lie. ?: . _._ Expiration Date:
Job Site Address; ___. CttyrSlatelzip:
Altach it copy of the workers'cumpensation policy declaration page (showing the policy number and expiration date).
hailure Lo secure coverage as required under Scwon 25A of>IGL c. 152 can lead to the imposition of criminal penalties of a
tiny op to S1.5110.00 and/or une-year hnpi isomncnt, as ,roll as civil penalties in the furor of a STOP WORK ORDER and a fine
of up to S'-50.00 a Jay against Ille violator. Ile advised that a copy of this sf atement may be forwarded to the Oi ice of
Inv afl,a inns ul Lhc DI,\ for in,urancc co,cragc \eiiticanun.
l Ju hereby certify larder ibe pains unit penullic.v ojperjury that the uifurination provided above is true uud correct.
Date —
(ji/Jicial o>e only. Do not n•rite in this area, to be cwapleted by city or town official.
City or 1'own: --- -- Permit/License 911_. ..
Issuing Aulhurity (circle noe):
I. Iloard of Ilcallh 2. Building Mpartincnt .1. Cit).?ono Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Co angel fcr>uu; ._ __ Phone it:
Information and Instructions
.\ma�sachusetts General Laws chapter I?2 requires all employers to provide workers' compensation for theireniployces.
Pursuant to this statute,an empfuree is defined as"'._every person in the service of another under any contract of hire,
cvpmss or implied. oral it written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the l:neeoing engaged in a joint enterprise, and including the legal representatives of a deceased enipluyer, or the
feces%er or trustee ul an individual, pwlriership, 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,construction 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."
.tIGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewul 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, NlGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
cnicr into any contract f-or the performance of public work until acceptable evidence ot'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 certificates)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 dale the affidavit. The affidavit should
be resumed 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 ;md 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.
I'laase be Sure to fill in(he pennittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple penniUlicmisc 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. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I liJ i)1IKe of Investigations would Inge to diank )ou in advance for your cooperation and should you have any questions,
please du nut hesitate to give us a call.
the Deparhnem's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMCC of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
B�rd of soi�d 6 R�rg�°d0i:ud Standards
Construcdon Supervisor Uaenss
Licerlsq: CS 64371
Expirsdow. 4/7 612 01 0 T1 23259
Raytridion: 1G
d
s _ ,
MARK E WILLIAMS
5 LENA MAES WAY
SALISSURY,MA 01950 Commiasi
oner
�/ee -lOomoieouuticalC� a��CaaJac�iiravt(a
Boar)of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 153016
Expiration: 10/23/2010 Tr# 275502
Type: DBA
QUALITY CONSTRUCTION
MARK WILLIAMS _
5 LENA MAE'S WAY ��"�
SALISBURY, MA 01952 Administrator
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