33 LIBERTY HILL AVE - BUILDING INSPECTION (3) -7 C.
The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR S
Revised Mar
Marar 2011
00 Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
t Ttus Section For Official-Use Only
Building PerO Number: Date Applied:
Bidding mc_ia1(Priat Name) Sigaahae
'SECTION I'SITE INFORMATION '
1.1 perty d, 1.2 Assessors Map&Parcel m` [ --..._ / 1 Numbers ,q.
I.
Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: ty.
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
From 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❑
SECTION2: PROPERTY OWNERSHIP'
2.1 O er'of
ame(Prin, V City,State,ZIP
�3/f L� i >zIJI AVL ' - 9� g�o�
No.and Streeter Telep one Email Address
SECTION 3:DESCRIPTION.OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : d 'At, kr'rC�jZ-yJ
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 $ 13 Standard City/Town Application,Fee
Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ .
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Cheek Amount: Cash Amount:
6.Total Project Cost: $ ❑paid in Full ❑Outstanding Balance Due:
T, C� �- � -
tvi
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) },0 SS 7
G/tiw T�V✓�,)lj Li `censsee1Number Expiration Date
Name of CSL Holder
76 C 'Eis�� List CSL Type(see below)
No.and Street , Type Des List
U I Unrestricted(Buildings no to 35,000 cu.ft.
R I Restricted 1&2 Family Dwelling
City/1�te,ZIP M I Masonry
RC Roofing Covering
WS I window and Siding
Ay_���l))) j� �p p SF Solid Fuel Burning Appliances
O r/ S rRZ J j-jn✓pi /bl�l)�n� I Insulation
-'"r Tele hone Email D Demolition
Y5.2 Registered Home]Improvement Contractor(HIC)
��Q t �'�+ HIC Registration Number Expiration Date
4,1 HI , any Regis t Name r'+
3Q �QA t P %1 /t�o1 in 1 ..
No.and Street .#�^ Y; -f t G 7� �� mail addrea
ne orr 1r oP7O Z /(() ArzrG�
City/Towfi,State ZIP Telephone
SECTION 6:WORKERS°COMPENSATION INSURANCE AFFIDAVIT(ALG.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
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
15--
Print—Ownerfs or rized Agent's Name(Electronic Signature) Date
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 can be found at
�titinv.mass.gov/oca Information on the Construction Supervisor License can be found at w .mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor 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'
The Commonwealth of Massachusetts
Department oflndustrialAccfdents
l Congress Street,Suite 100
Boston,AM 02114-2017
www massgov/dia
UVWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information �/ ,�J Please Print Le bl
Name(Business/Organizationandividual): (7 TEN t lXIV VK
Address: -30 C L�--rc�c S ! ,
City/State/Zip:OjJAae S-CO C Phone#: A/l z
Are you an employer?Check the appropriate box: Type of project(required):
1&Iam a employer with employees(full and/or part-time).* 7. New construction
2.Q I am a sole proprietor or partnership and have no employees working forme in g, ernodelin
any capacity.[No workers'"comp.insurance required.] g
3. I am a homeowner do' all work ] 9. Demolition
mg myself.[No workers'comp.insurance required. t
4. lama homeowner and will be ld contracaux to conduct all work on m 10 Q Building addition
tTmB Y Pmperry. I will
ensure that all contractors either have workers'compensation insurance m are sole 1 L�Electrical repairs or additions
proprietors with no employees. 12. Phanbing repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sleet.
These sub-contractors have employees and have workers'comp,insurance.= 13.Q Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.Q Other
152,§I(4),and we have no employees.(No workers'comp.insurance required.]
'Any applicant that checks box#1 must also fill our the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the tame of the sub<onhamors and state whether or not those entities have
employees. If the sub�connactors have employees,they must provide their workers'comp.policy number.
,ram an ernployer,lhat is providing workers'compensation insurancefor my employees. Below is the policy and job site
informadan. / l
Insurance Company �Name: cc,
7 (.�CG 6�
Policy#or Self-ins.Liicc..#:/ l /j'Expiration Date:
�
Job Site Address: l d ll'/�. �� r C � /17 (/ (,L /State/Zip: ,��fC✓I��J
Attach a copy of the workers'compensation policy declare on page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ceerrhyyy und/erepains andpenalties ofperiury that the information provided above is truce and correct
Su /rKt�/�y Signature, VJI A^ Date-
Phone M 7 ,C-
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 I=Plumbing
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An 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,MGL chapter 152,§25C(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 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 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 confirmationof 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill 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 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02 1 14-20 1 7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
QYYOFSALEM MASSAMLSETIS
BInMCDEPAMENT
120 WA=VMSMWT,3mFiooR
UL(971)745.9595.
Rii�lRRRiltyDlug�j j,
PAX 8 740.9846
MAYOR 7UO"SrY=w
DincTcat crPLxUcPFj3WUY/BMD=COHWWCM
Construction Debris Disposa/AfdVIV t
(required for all demolition and,renovation work)
in accordance with the sixth edition of the State Building Code, 780 CAM, Section 111.5 Debris,
and the provisions of MGL c40,S 54; Building Permit R is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150.4.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
GyN �
(addresi of facility)
Sign ure of applicant
/Z L
Date
The deck repair of the 23C Marion Rd, Salem unit- dxrozenberg@gmail.com- Gmail Page 1 of 1
a' r 4 i tB
vcoMPos1 American Properties Team, Inc.
i
TO: 23C Marion Road
All Nlaif FROM: Jennifer Pappas,Property Manager
Address BE - Deck Replacement
DATE: May 11.2016
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'j Please be advised that the Board ofTra lees f'or Pickman Park has approved the replacement of
1 the deck at the above referenced unit. This approval is contingent upon it matching the existingON
ry
deck(composite materials can be used)and following the Engineering Alliance Deck
Specifications. The Board will ,or allow any design ahorulions.
t
We also require that permits be pulled in advance(regardless of what your contractor may tell 0
YOU),and then a copy of the final approved permit once completed trust be sent to APT for the
unit file as well.
You will need to bring a copy of this letter w the Salcm Building Department in order to receive
your permit.
Should you have any questions or require additional information.please feel free to call the APT y
Cc Service Team at(781)932-9229.
cc: Unit File
M WEST CUMMINGS PARK SUITE 8050 W08URN MA-01801-r81-932A229-FAX 781-9354289
I
https://mail.google.com/mail/u/O/?tab=wm 5/11/2016