47 LIBERTY HILL AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
V I Board ol'Building Regulations and Standards CITY
y ) Massachusetts State Building Code, 780 C•MR, 7'"edition OF SALFM
�/ Rerisrd Jwnnrrr
Building Permit Application To Construct. Repair, Renovate Or Demolish a
O or Two-Furni/P Dwel rng
is Section For OfficAl Use Only
Building Permit Number. I D Applied:
Signature: ell
Huilamit Commissioned In t o att ings Date
ON 1: SITE INFORMATION
1.1 rty 1.2 Assessors Map d1 Parcel Numbers
1.Is Is this an acce ted st ?yes noqV' Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Ama(sq 11) Frontage(11)
1.5 Building Setbacks(/1)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.Ja.§Sat) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION2: PROPERTYOWNERSNIPr
2.1 t 4t Regr
1167ywi
Nome(Print) Address for Servic� / ell
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify
Brief Description of Proposed Work':
SECTION 0: ESTIMATED CONSTRUCTION COSTS
Ilem Estimated Costs: OMCISI Use Onl
Labor and Materials y
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Slandard City/Town Application Fee
O Total Project Costs(Item 6)x multiplier x
3. Plumbing s 1. Other Fees: S
J. Mechanical (tIVAC) S List:
3. Mechanical (Fire S
Suppression) Total All Fees:S
heck No. _Check Amount: Cash Amount:
6. Total Project Cost: S ❑Paid in Full 0 Oulslanding Balance Due:
SECTION 3: CONSTRUCTION SERVICES
S.1 eased Construction Sup laor(CSL) O(�% O
I License Number Gxpimtion lyut
N al't7Cr'I +J List CSL II(xee below)
!/ � Ihscri iat
U Umeicted 1 u to Family
Dwelling Cu.Ft.
Restricted Id2 Famil
Signature Z- J�/1 M M (MI
(� RC Residential Routin Coverin
I'dephnne WS Residential Window and Sidin
SF Residential Solid Fuel Rumina Appliance Installation
D Residential Demolition //
5.2 R!g o m v Contractor(HIC) b S6S
I IIC C N yx Ii: ey7yt e R aismattion Number
l
l" �) ✓ L/J 0
Expiration Date
si ore
Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.9 25CII
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? Yea ..........a No...........O
SECTION 7n: 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.
Si ure of Owner Dote
SECTION 7b:O E 'OR AUTHORIZED AGENT DECLARATION
r
1 ✓ a)--) as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc We and accurate,to Ih best of my knowledge and
behalf.
Print Name O
Signature of(honer or Authorized Agent Date
Si under the sins and (ties of 'u
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 M have access to the arbitration
program or guaranty fund under M.G.L.c. I J2A.Other important information on the HtC Program and
Construction Supervisor Licensing(CSL)can be found in 7A0 CMR Regulations 110.R6 and 1 IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage, finished basemenUattics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of one
Number of bedrooms
Number of bathrooms Number of half7baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may be substitute) 1'or"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
w` DEPARTMENT
asuf:X:I Y:1x NCul1.
�iwt is 12:W,tSHOAi I ON S rxELT s inl E.N.MAt%ACl n u,t-I is 007^�
Ti.;V11-745-1595 • I°.yx.779•74C-7S46
`Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A ) ilicant Information Please Print Le ibly
Naine Iliucuksvl�r;;anirali /tywlu I):
)/f
' Atltlress:
r /T
City;Si:uc:/sip / f Phonei':
.)re you an employer P Check the appropriate box: 'Type of project(required):
4. ❑ 1 ran a .,encral contractor and t
141� 1 am a employer with a G. ❑ New construction
employees(full and/or part-tints).• have hired the sub-contractors
7. RemoJelin
� proprietor or )artner- listed on the attached sheet.
: ❑ C
_.❑ I :ua a soh. 1
ship and have no elnpluycts These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9• ❑ Building addition
I No workers'comp. insurance 5. ❑ We area corporation and its ME] Electrical repairs or additions
required.] officers have exercised their
3.❑ I ant it homeowner doing all work right of exemption per MGL I l.❑ P Imbing repairs or additions
myself. (No workers' cuntp, c. 152,§1(4),and we hlrve no 12. hoof repairs
insurance required.] r employees. (No workers' 13.❑Other
comp. insurance required,]
-.Any.y l,heam Him checks box of must alau till urn the secliurl Wow showing their w•urkui cumpenvuiomt pulicy inlbrmaliuH
'I lumauwnen who submil this.,Mdavir indica,iny they we doing all work arul then him uulside ewurmian,must submit a new alydavil indi"ing•uch.
fonmluu.n that chuk this box mtu,l muehexl an additional..h..rot showing the name of the sub-contraetors and their wurkeri sump.policy infurmatiun.
I am un eugyloyer that is pruvidi�w� npen.cntioit insurance fur tity employees. Belaiv is the pu/icy rated job site
infurrnutiom
Insurance Company Name:
Pnlicv!i or Self-ins. Lic. tl: Expirulion Date:
Job Site Address: /,✓ K/ .. City�Statd"Lip:
Attach It copy of the workers'culnpemation policy declaration page (showing the policy number and expiration date).
I-'ailurc to secure coverage as required under Seclion '_5A of 11GL c. 152 can lead to the imposition of criminal penalties of a
tine 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 i250.00 it Jay ;Igailtst the violator. lie advi,icd that a copy of this muteinunt may be forwarded to the Office of
Invesogawnls ul'the DIA for imuranee cuvcragl: variliealion.
I du hereby terrify under the pairs and penalties ufper urfurrnutlon provided above is true and correct.
Dat ze L
er v
Official use only. Do not write in this area,to be completed by city or town a/Jivial. I
i
City or Torn: ._ Pcnnit/Licence Al
Issuing Aulhurily(circle one): I
I. Board of Iicalth 2. Iuilding Department .1. Cityflbuu Clerk 4. Electrical Inspector i. Plumbing Inspector
6. Other _ —.
Cuntael Tenon: __ ._ Phone l:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation Kx their employees.
Pursuant to iris statute, an empluree is defined as"...every person in the service of another under any contract of hire,
evpress or implied, oral Or written."
An employer is defined as"an individual, partnership,association,corporation or tither legal entity, or any two or more
,d the 6xegoing engaged in ajoint 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."'
.%IGL chapter 152, v+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 comptlance with the insurance coverage required."
Additionally. INGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomwnce of public work until acceptable evidence of compliance with the insurancC7
requirements of this 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-contractors)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 dale 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 Deptutrnent at the number listed below. Self-insurcd companies should enter their
self-insurance license number on the appropriate line.
City or Town Offlclals
Please be sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom .
of the affidavit for you to till out in the event the Orrice of Investigations has to contact you regarding the applicant.
111.ase be sure to fill in the permitflicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitAicense 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 Ile Ol I Ice it Investigations would like to thank you in advance fur your cooperation and shuuld YOU have:ny questions,
please do nut hesitate to give us a call.
The Dcparonent's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Otflce of InvesUgatlons
600 Washington Street
Boston, MA 021 t 1
Tel. N 617-727-4900 ext 406 or 1-877-NIASSAFE
Fax N 617-727-7749
t,.ised 5-26-05
www.mass.gov/dia
- ' CITY OF SALEM
s. '?`.
, i PUBLIC PROPRERTY
DEPARTMENT
q„Kvi
\1 120 WAi1 IINt !ON SIBLLT • $AI F.M. NIA4iAt III it I-'1N JI'L
TLI:978-,74 9595 • P:%x:978.74C,9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris,_andthe provisions of.MGL c_40,S 54;__.._ _-
Building Permit It 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.
The debris will be transported by:
(name of hauler)
The debris will be disposed of i
(name of faciI t )
(address of facility)
jay
I
signature of permit applicant
date