106 LEACH ST - BUILDING INSPECTION (2) yap-off
The Commonwealth of Massachusetts
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Board of Building Regulations and Standards I IP
Massachusetts State Building ode. 780 CMR, 71h editioni. MUNIc'IP \I,.I'll'-
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Building Permit Application To Construct. Repair, Renovate Or Demolish a Revised lanmu t
bOne-or Tiro-Family Duelling
This Section For Official Use Only
Building Permit No be : Date Applied:
Signature:Signature: - ` 00
Building Commission r'I Spector of Buildings Date
SECTION 1: SITE INFORMATION
L1 Property Address: 1.2 Assessors Mop & Parcel Numbers
)of I EAGN STR£iiT
I.la Is this an accepted street? yes_ no Map Number Parccl Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(11)
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, 5 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P y'
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record: �` 'O� -*a
ame( 0 Address for Service:
�7 �y�- sy Z
ignat a elephone
SECTIO : DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)NO Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units �' Other ❑ Specify: (/A I [ GDh11� O
Brief Description of Proposed Work : i b+ S
ar R laeernom of olle i s K @ecic-
ELIf Vsil. P
f.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building $ 3q o00 1. Building Permit Fee: $ 911 Indicate how fee is determined:
Standard City own Application Fee
2. Electrical $ 4 ODD ❑Total Project Costa (Item 6) x multiplier x
3. Plumbing $ a 1)00 2. Other Fees: $
4. Mechanical (HVAC) $ ) t Oct) List:
5. Mechanical (Fire $ Total All Fees: $
Su ression)
Check No. 16411 Check Amount hl/. Cash Amount
6. Total Project Cost: $ 4,000 ❑Paid m Full O Outstanding Balance Due:
4H
µ_me sll
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) D1794.25 8 8
C. ml fe-irk License Number Expiration Datc
Nameo;CSL- Huldcr D D�a MA D' Z I ListCSL„ Type(sec below) U
T Descri lion
Odd css
U Unrestricted iu wi5.00p Cu. Ft.t
R Restricted I&2 Family Dwellin
Si - ure M Masonry Only
6.35a'54W RC Residential Roofing Covering
Telephone WS Residential Window and Stdm
SF Residential Solid Fuel Burning A chance Installation
D Residential Demolition
5.2
f(1 QRRe6gTiTstle rHD EQ S m p
)Sa N
LCvement Contractor(HIC) n Number
HICCompany ameorHIC Nanr Registratio
VA
IDI4 �60
AJ es
9�g.3Sa 54�s Expiration Dates e
n lure Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.1 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........... O
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 mutters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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:
1. 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 IO.R6 and 110.115. 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"
r�$llr .�/ro M�Dd'Z-�?71 �u[cvF/zs
CITY OF SALEM
s
PUBLIC PROPRERTY
DEPARTMENT
61\ M KI I:l DKISCUI1.
�Lwr`k I_'C\v/nsiuNcr�?�5ncer:r Snu;st, AJsssAi,rn.-slsrrs01970
Fri,:978-745-9595 FAX: 978-74G9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
kpifilicant Information LL ap,r Please Print Legibly
Name tRosiness,Organizatiottilndividual): �'01�-�T• ��l""' S ��
Address: A
City/State/Zip: lJla2l Phone #:
Are you an employer? Check t e appropriate box: Type of project(required):
l am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors ❑ Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet.
7.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' cum insurance 5. ❑ We are a corporation and its
[ P� l0.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, $1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
•Any applicant that checks box N 1 must also fill out the section below showing their workers'compensation policy information.
t I fomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit anew affidavit indicating such.
�Cuntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/out tits employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. __11
Insurance Company Name:_AaTA- tf
Policy #or Self-ins. Lic. #: 16 W�-rt20d 3�- Expiration Date: 12�2'D I 8
Job Site Address: ID6 Lear.4y ST, -4a- Sa1f WTI KILk City/State/Zip:
Attach 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 MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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 violator. Be advised that a copy of this statement may be forwarded to the Office of
p Investigations of the DIA for insurance coverage verification.
!� /du hereby •rtijy u+ e Its ains�*uttdenalties of perjury 7thut7inforintation provided above is true and correct
Si�,natur Date: 3 2S 09
Phone #: K• 3Sa.
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone At:
Information and Instructions
f
:Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an errrplgree is defined as "...every person in the seta ice of another under any contract of hire,
express or implied, oral or written."
.\n 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, 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."
MGL 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, NIGL chapter 152, g25C(7)states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till 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 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
self-insurance license number on the appropriate line.
City or Town Officials -
Please be 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.
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 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 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 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 dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give usa call.
The-Deparnnent's address, telephone and tax 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
Itevisad 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
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I CITY OF SALEM
PUBLIC PROPRERTY
F- r DEPARTMENT
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0 $.\t;M. St.\5i.u:'.It ,i:l-:, ]:'t-:
rFj;978-745-7595 • 1'%X: 978J4Z-9d46
Construction Debris Disposal Affidavit
(required for all demolition &id renovation work)
In accordance with the sixth edition of the State Building Code, 730 CTN1R section t 11.5
Dcbris, and the provisions of N1GL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
I
The debris will be transported by:
E
- -_- (name of hauler)
I'he debris will be disposed of in
l nomr.,iiu�ulty)
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