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74 LEAVITT ST - BUILDING INSPECTION (4) Y9 - ao The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of " Massachusetts State Building Code, 780 CMR, 7 edition i Building Dept (� Building Permit Appl ton Construct, Repair, Renovate Or Demolish a *W $- 1a0a {vim\ One-or Ti•o-Fancily Dwelling dilooft �V Thi Sec ion For Official Use Only Building Permit Number: Date Applied: 1 Signature: 7/ Building Com ss oner/Inspect Buildings Date � AcIrION 1:SITE INFORMATION perty� as / L2 Assessors Map& Parcel Numbers _7,7 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(R) 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 yesO �e //SECTION 2: PROPERTY OWNERSHIP[ r a 'ofReye : l\Glf7,olZT C� Na nnq Address for Service: ., Signatu J Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 AI[ ion ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': !LL lJdT t3 2 n 23 .616te o o f t1 a �o rt4 02 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 $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ -j �(� ❑ Paid in Full ❑Outstanding Balance Due: 3 � � ��I. ZOO SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) CS 0 / D �blC yp-- ��Jam+ ��V— License Number Expi4tioKDate ' Name of CSL- Helder c.�flJ (-f List CSL Type(see below) Type Description U Unrestricted(up to 35,000 Cu. Ft.) R Restricted 1&2 Family Dwelling Signatur r M Mason Only )`S 2� "�3 L S L4 C` RC Residential Roofing Covering Telephone WS Residential Window and Siding _ SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition S Registered tleMe Impr vemept Contractor(HIC) /© 2 6 D HIC C nyUName or HIC Regist ntN� Registration Number 1/74, 713A�Cryo /-;-6C Eitipiration Date Si a r 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 CONTRACT% APPLIES FOR BUILDING PERMIT Yin 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 I I0.116 and I IO.R5, 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 PUBLIC PROPRERTY DEPARTMENT ,110 w'I\ iMPl .91 �1\,\wt IS: W,Nel1\d 1a�iI:1 LL Is 11\t, M.\s.+.\I nt it l 1,J 197-� I IA. 178.7$3.9343 • 1:\x 97&;'4,: Is46 'Workers' Cumpensation Insurance klfidu.it: Builders/Contractors/Electricians/Plumbers t iincant Infonnalion Please Print Le ihly Name 18ualkwl)/ryanlr.uina'I/Jodi\I.luull: �� Cam' Ciry.State.%ip Phone •': 1 5 Ci`i6 i 2- .\re)au an employer:' Check the appropriyte box: l')pe of project(required): 1.❑ 1 :tin a cmpluycr wilh 4. ❑ 1 anit a general contractor and 1 6, ❑ new construction unpluyccs(full and'ur part-ante).• have hired the sub-cureiracturs 7. ❑ Remodeling?�1 .tin a colt proprietor or partner- listed tin the n J sheet. ,hip:Ina have no elnployeex These sub-contractor have S. ❑ m Deolirioo working liar Inc in any capacity. workers' comp. insurance. 9, ❑ Building addition o workers'cols 5. ❑ We are a eni fic ration and its l f P insurance officers have exercised their 10.❑ Electrical repairs or additions required.)1 ifh 1 I. Ptumbin• repairs or additions 3,❑ 1 am a hnmcowner dieing all work right of exemption per hIGL ❑ b P' myself. LKo workers' cutup. C. 152, q 1(4).and we hove no 12.❑ Ruuf rcpuirs insurance requlred.J ? unpluyecs. LKo workers' 13.0 Other comp. insurance required.) •\iq .,;q,hcmlt that checks box pl muss:Jan fill two the vcOms Iwluw ahuwiny Ihotr workui eunlpunvtsiws Iwli y'w... nlitm. ' I lumalwimn who vlbmil[his aRlJavit indica,me;Ihuy Jm downy till,wrk ad Jsen hire twiside CtxIVx106 mu>I.uhmil a new flydavil...dialing.Iwh. -r.mtrKbM,Ihwr shuck this box mime Jt[xhcd an a waiunal.lice,,huwins few rank of the sub.canttaetoa and Ihelr wurkers'etwnp,polity miconadtin /trip? ail employer that is preivid/ng?vurkers'cumpenvorion ilisurarrer/br rely ernplgyres. Befoev is the pu/icy and Job.tile infuriation. - In,urance Company \Jame: _--- - - -- - --------- volicv is or Sclf-ins. Lie. n: _-.. .. _ _ __ Expiration Date: lob Site Address: _._. City;Stola2tp: .attach it copy of the workers'curnpensaliun policy declaration pale (showing the policy number and expirat)un date). Failure a,secure cuterage as required under Secliun 25A of NIGL c. 152 can lead to tile imposition oferiminal penalties of a tin:up to iL500.00 antYur use-year hnprisoomcnt, Js\sell as ;i%it penalties fit the Iloilo of a STOP WORK ORDER and a fine fop to S250.00 if Jay again>t lilt violaror. He advi.acd that a copy of this matcsnent may be iurwarded to the 011tce u1 Io\�,Ill(J Il�tll>ul :Ile DIA :or io,urarce a\v uJge \arilicatiun. If du hurt" t rt' v tin, •r Jar pit ev urtd pe u/bl'c of perjury that rile inforinetion provided YGU 'e rout?field correct. Daty__Z S /l e ( _ I'IU I • :/ U/Jiciu/uoe mdy. no not n'rire in thin area. to be caretpleted by city ur lown ,IjAial.. ( iiv ur 1'owre: _.... _-- Permit/License 4_ I„uing Aulhurily (circle one): I. Ilojed of Ilc.dlh 2. Ihulding Mp.irtulcut 1. Cit%A*uttn Clerk 4. Ucclrical luspector 5. Plumbing Inspector 6. Of her _ Contact I'cr>uir - .: Phone it: Information and Instructions >lassachusctis General Laws chapter I52 requires all emplo)ers to provide workers' compensation tier their employees. Pal ralallt to 1:1 is �14tule, all rmlu pree Is defined-is " .ea cry pcison in the service of another under any connacrof hire., c♦preNs or unpI led, tifal or lv1'11 ten." An employer Is defined U "an individual, partnership. association, corporation or tither legal entity, or any two or more .a the torcgomg engaged in a pent cntcrpnac, and including the legal representatives of a deceased employer, or the feeclver or trustee of at, Individual.pwincrshlp,aswcLatWn or other legal enmty,employing employees. However the owner of dwelling house having not more than three apartments and who resides therein, or the occupant of the Jwrlhng house of another who employs persons to do maintenunce, construction or repair work in such dwelling house or on the.,-rounds;or building appurtenant thereto shall not because of such employment be deemed to be an employer." A.IGL 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." A.lditwnally, `IGL chapter 152. 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of puhlic work until acceptable cvidenct:ufcumpliance with the insurance requirements of(his chapter have been presented to the contracting authority." Applicants Please rill 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 nuniber(s)along with their certificatc(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 dale the affidavit. The affidavit should he fetunted 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. ('fly or Town Official Please he stirc that the affidavit is complete and printed legibly. The Department has provided a space ut the bottom of the affidavit for you to fill out in the cvenl the Office of Investigations has to contact you regarding the applicant. Please be sure m till in the pcnnitlicense 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 intormation(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)." \ 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 i.e. a Jug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I h: a)I IleeUt IaAeNrlgatlun) %%cold line to diank you in advance fur your cooperation and should you have :my questions, please du not hesitate to give us a call. the Dcp.unncnt's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Ofte of Invesdgatlons 600 Washington Street Boston, MA 02111 Tel. All 617-727-4900 ext 406 or 1-877-MASSAFE Fax M 617-727-7749 www.mass.gov/din CITY OF SALEM PUBLIC PROPRERTY DEPART'vIENT 'd I'; \1.t,ni♦i•..��.>::,err � ti.0 i si. \L�.;�i ... ,: � . .I" _ v'x '4:-11.<4,. Construction Debris Disposal Affidavit (required lbr all demolition and renovation work) In accordance %%ith the sixth edition ofthe State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit # is issued with the condition that the debris resulting front this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I 11. S 150A. The debris will be transported by: (name of hauler) fhe debris will be disposed of in : (naine of facility) -7 f � S� taddress of Iacilav) +i uaturc of prr tit applicant late