12 LEMON ST - BUILDING INSPECTION _ The Conunomcealth of Massachusetts — —
t Board of Huddiniz Regtdations and Slandaids tt Ill
tr '� MassdCltusrtts State Building Code. 780 (•h1R. 7°i edition Mt N'll II' I fl l
r Building Permit Applic To (lutsu act. Rrpair. Renos air Or Demolish Krrn., /! onr ro r
O •- ATno-FrunilrDuelir/g l. -tnr,s
Thi 'eclion For Official Use Only —1
Bui Wine Permit N nhcr: Date Applied:
Sienature:
Budding Cununtsao •r/ x•aur of Ruddmgs Dane
SECTION 1: SITE INFORMA FION
X1.1 Pro erh Address: _ 1.2 \ssessors flap & Parcel Numbers
�- %l Number Panel Nn111hC1
I.la Is this an accepted soeet'.r ses nu a P
I.3 Zoning information: - 1.4 Property Dimensions: ..
Zoning District Proposed Use Lot Area(sy It)- _ - Floatage Ali, -- --
1.5 Building Setbacks (It)
Front Yard Side Yards Rear Yard
Required Provided Requited Provided Requoed PnniJrJ
I
r
Water Supply: tM G.Lc. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
_Zone:c ❑ Private❑ Check if yes❑Outside Flood Zone_' Municipal ❑ On sim disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 OE:; of ecord:
,Name tPrintr J9 Cf ` I t,/• Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Bwldin Owner-Occupied X.11 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'':
' _ --- -- - -- -_ —_�1�IL�GL__ L.✓!{'r _---ire/.vl� I
SECTION d: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor:md Materials) Official Use Only
I. Bmldine Y I. Building Permit Fee: $ Indicate how lee is Jcter nu nrJ:
❑Standard Cily/Town Applica fun Fee
2. Electrical Y ❑Total Project Cost' (item 6) x multiplier ..x
3. Plumbing S �. Other Fees: S
1. Mechanical IHV:\C) S Lis[:
5. Mechanical (Fire ---------
Su resalorfl st Total :\II Fees: 5
Check No. ('heck Amount: ._ Cash \nnntnt��
Xb Total Project Cost wp :rid to Full ❑ Outstanding 13al:une Due
, 46t L
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Stin
P eisor (CSI,)
l_I.rna N'un)her 1!spu.won Da(c i
Name of( 51. 1lolder Lint CSI_T pe I,ec hcloW l
\JJIC>• 1. I I1reHIlCled 1111)(it %'.000 Cu I'L I
R Re,;nctcd I"', F,InuI\ DWclhilo _
KC Rc.IJ:Itual Kuul ulc
h�liph�ne \\S Kc,ld,illul \l mJno end llJu_1r
iF lle,ldCl)Ildl SI)hJ 1-•.1c1 11LIHI ' v ..rl�_111'"1ldow,
D Kc,Idel u.d 1)cm1)llw
..? Registered [ionic Improvement Contractor (IIIC)
IIIC C'onglany .N'anm or IIIC Registrant Name Reg)elratiun Numhci
_ E.tpl raulm I Im
Slgnutwr
SECTION 6: WORSCERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. S 25C(6)) 1
Workers Compensation Insurance affidavit must be completed and suhmitted with this applira(ion. Failure ao pro,Ide
this affidavit will result in the denial of(he issuance of the building permit.
Signed Affidavit Attached'? Yes ......_ . 11 No -.__....- ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L _ __— as Owner of the .subject property hereby
authorize _.___-._ to act om my hef.llf, III all Inauels
Ic:atr:e to •.vork authorized by this building permit application.
I
Slkllalll rl'U(UWarr Date --_—
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
i
1 , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best uF my knowledge and
behalf.
Pont .Name
Signature of Owner or Authorized Agent Dale
(Signed under die 2ains and penalties of rriu ) _
NOTES:
I. An Owner who obtains a building permit to do his/her own \cork. or an owner who hires an umnegu(cied Contractor
(nut registered in the Hume Improvement Contractor (HIC) Pr(,gram). will not have access to the Intimation
program or guaranty fund under M.G.L. c. 14_A. Other important information on the HIC Program and
Construcnon Supervisor Licensing (CSL) can be found In 780 C NIR Regulations I M.R6 and 1 I0R5. respectively.
When ,ubswmtal work is planned, pi )Hide (he information below:
rotal tloors area (Sq. Ft.) (including garage, finished basemem/au ,:s. decks or porch)
i Gio.s.c livmg area 1Sq. Ft.) Habitable room count —
---
Numberat tneplaces Numberof hedrooms -------------__-.
Number of hathronms Number of hilt/halls
rspe of hea[1112 system —_-.--- Nu m her otdecks/ porchc>
Tvpe of coolttlg s\stem fnahocd __ Open
i Total Project Square Footage" nlav he substituted for Nord PnryeO Cost" ---.
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
rs
\porkers' Compensation Insul-• rice Aftidacit: 3 ilders/ContractorsiElect use Print L ebibl
\ouhkant Inlormatiun p— P� �yQ
`.1111� i liu,inc., k h_.nnt/.i W lit InJil i,luol Cl:
C'it 5tutc.Zil Phone : q� /
\re vfiu ' employer:' Check the appropriate bus:
Tvpe of project(required):
. I :tin a employer with 4. ❑ 1 fill a general contractor and I 6 ❑ New construction
1
culpluyees (full and'ur part-time).' hate ton t lire a sub-contractors shaft. 7. ❑ Remodeling
listed on the snitched sheet.
2.❑ J an, a sole proprietor or partner- I hose sub-contractors have S. ❑ Demolition
ship and have no employees workers' comp. insurance. y, ❑ Building addition
working for me in at capacity. 5. ❑ We are a corporation and its
[No workers' comp. insurance ME] Electrical repairs or additions
required) officers have exercised their
right of exemption per tvl6L I L❑ Plumbing repairs or additions
} ❑ I y a homeowner doing all work c 5152• $1(4),and we have no 12.0 Roof repairs
myself. . employees. (No workers'
insurancee required.) t workers' comp 13.❑ Other
comp. insurance required.)
\uy oppI,cant that chocks box NI must also Inn out the section below showing their workers'compensation policy information.
' I lomeuwners who suhmit this afriduvil indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
'(•owraoors that check this hox must aftzched an additional sheet showing the name of the sub-contractors and their wurkers'comp.policy information.
/alit an employer that is providing workers'compelffri tion insurance for trty eniployeec. Below is the policy and job site
information.
� Ot�1(� r� /FA
Insurance Company Name: �--a
Policy 4 or Self-ins. Lie. p: Expiration Date:
Job Site Address: City State/Zip: i
.\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 b1GL c. 152 can lead t) the imposition of criminal penalties of a
tine up to S I.Soo.00 a nd'or tine-year imprisonment. as sell as civil penalties in the form of a STOP WORK ORDER and a fine
„I kill to S2511.nn a Jay against the t lolator. He ad\I>cd that a copy of this statement Inlay be forwarded to the Office of
lift c+n_anions of file DIA I-or insur:uue cut erhge tenfwanon.
/du hereby certily under lie pains acid penulaer uj perjury that the atjorination prat tilt dd above is true and correct.
Dale: D —�
i nyn_n fir
Iq m.c
--ollirird ate unlr. no not write in this area, to he w itpleted by city or town ojjiciaL
Pcnniul.icense N - _ ..- ---
City or row it:
Issuing Auihorih (circle fine):
1. Board of Health 2. Building Deparinnent 3. city/fulsn Clerk 4. Electrical Inspector 9. Plumbing Inspector
6. Other ---------
Contact Person: .._-_-. _ —__-- _ Phone N:--- _----.
Information and Instructions
\la„ac!ul,cus (icnrral I att, ch:gttcr I rryuuc, .111 cmplutu, it,pro,IJe oorkcrs' conglcns.lwm for their employees.
I'ul,uant to thls ,lature. .,it emplane 1, ,Irtir.cJ .Is ' ct ery parson in tine ,en Ica ol'.ulothrr under .ulv eon[ract of hire.
c yn c,, „r un l,I led, oral or t%Inn ell
."
\:: .•e[plo err Is Jclined is '.Ili mart:.lual. p.un:cr,hq), .I,sucla uon, torpor:ulun or other Iceal ennn, or .uty hto or more
,,I [he li,te_oinp en_aged in a butt cwerpri>e. and u1cluJ1119 the le,-,al represent.tote,of a dcccaxd employer. or the
:cecrtcr or nu.,tce Of Ili InJlt,Jual, patincr,hlp. .ls,oclauon or other Icgal cyuny, employ Inv cntployccs. I lotsetcr tale
,,tt ncr of a Jttalling house hating nut more that Ihrce,lparinlultts and t\ho rcNidcs Ihen•nl, or the occupant of the
,IN c lllllg h,nl,c of .mother w ho cmplut, pervons [u dmilan, Priamcc.con tructlon or repair stork ors ,uch duelling house -
�.1011 The _rounds or budding.q)puirctiant thetcto ,hall nol he:ausc of,uch enlpiotntcnt be decided to he an employer."
\I(.1 chapter I s 1. j2iC( ,) also ,[ate, [hat -eery stare or local IicensinK'agenc� .hallttsithhuld the issuance or
renewal of a license or permit to operate a business or to construct buildings in the conunonsscalth for any
Applicant svho bas dot,produced jicejitable es idence of compliance %sigh the insurance,coserage, equired.
.\ddl l ionally• .NIGL chapter 152, j IiCi`, .;[.ties "\'tidier the comdioniv'calth norlany)f its purl ill 4:a6Suhdivistons ,hall
cnror into any contract for the performance of public ttork until acceptable et idence of cu111pllallce with (he insurance
requirements of this chapter have been presented to the contracting authority." o
Applicants
Please till out the workers' compensation affidavit completely by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) namc(.$), address(es)and phone number(s) along with their certilicaro(s)of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are nut 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
I11tIU5trial 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 be sure that the affidavit is.contplete and printed legibly. The Department has_pZ( vided a space at the bottom
Of the affidavit fx)r YOU 10 (III 1)UI In II1C'eteitt t'hC Office of Intestngations has to contact y6aregarding 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 infi)nmation f if necessary) and under"lob Site Address"the applicant should write "all locations in (city or
tote n)." 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 fix future permits or licenses. A new affidavit must be filled out each
year. Where a hurtle owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e. a Jog license or permit to burn leaves ctc.) said person is .NOT required to complete this affidavit.
Ilse ()I lice of Intestigations would like n, thank you in advance fix your cooperation and should you hate any questions,
plca,c do not he,rtate to give its a call.
the Dcpalrtncnt's address. Ielephunc and fax number:
"-' The Commonwealth of Massachusetts,•- ..., + •, v"
Department of Industrial Accidents
Omit:e of Investigations'
600 Washington Street
Boston, MA 02111
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
tct„c,l .o-I,i Fax k 617-727-7749
www.mass.gov/dia