1 LINCOLN RD - BUILDING INSPECTION (3) ������ .�� .
� The Commonwealth of Massachusetts
*� Board of Building Regulations and Standazds CITY OF
�F� Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Applicarion To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number. Date Applied: ,
�� �
Building O�cial(Print Nazne) Signature Date
I SECTION 1:SITE INFORMATION
11 Property Address: 1.2 Assessors Map&Parcel Numbers
/ L-.l�u�oc,�S�'Rokn
1.1 a is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Intormation: 1.4 Pmperty Dimensions:�
Zoning Distric[ Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yazd
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.4Q§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal sys[em ❑
Check if yes0
SECTION 2: PROPERTY OWNERSHIP'
2.,1/Owner of Record: C ,��1
KR1S'f"L-� d-�dF� J3/��1Ct1ZC I J�LdM , 1"lA �
Name(Print) City,State,ZIP
I L/NCOLAI S`t'. 974� 5'7B I'1�(
. No and Stree[ Telephone Email Address �
SECTION 3:DESCRIPTION OF PROPOSED WORK�(check all that apply)
New ConsWction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ SpeciTy: �
, BriefDescriptionofProposedWorl�':
�^�lOOEZ I � F�LIX32 �14T7-1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Of5cial Use Only
Labor and Materials
1.Building $ �� 1. Building Permit Fee: $ Indicate how fee is de[ermined:
2.Electrical $ �� �Standard City/I'own Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ L ,S�°j 2. Other Fees: $�j^ // �`�
4.Mechanical (HVAC) $ List: l,qf� ��n7V /Jv �C/�
5.Mechanical (Fire $ Total All Fees:$
Su ression
Cfieck No. Check Amount: Cash Amount:
6.Total Project Cost: $ S C� ❑Paid in Full ❑Outstanding Balance Due:
�N� c�h2�� %� �i/�`
�-8�'� s�v-r � I ��
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1-1 2.r—>q / J -
I License Number E ra on Date
Name of CSL Holder
List CSL Type(see below) (J
Type Description
No.and Street
/`/� .�/�,k� U Unrestricted(Buildings u to 35,000 cu.ft.
(S ,'��'c R Restricted 1&2 Family Dwelling
City/Town,State,ZIP �n M Masonry
1"lI� OIQ7U RC Roofing Covering
/ WS Window and Siding
SF Solid Fuel Burning Appliances
J� J4L/ S LL��a LUUt 1--.KT Al I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC) ZO-13 7L
G
[) � LI-sr2 ! HIC Registration Number xpirat on Date
HIC Company Name or HIC Registrant Name
f::-141tLL 99 e a— Comcai7.
No.and Street Email address
Ci /Town,State,ZIP 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..........BL No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR JBIU�I,LDING PERMIT
I,as Owner of the subject property,hereby authorize ETA d}eL LT/'cLL
to act on mybehalf,i II matters relative to work authorized by this building permit application. /
Owner's NaAc(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.
�c arc R�6K- AA ' 1
Print Owner's or Authorized Agent's Name(Electronic Signature) [e
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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dus
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"maybe substituted for"Total Project Cost"
I
CITY OF S.1LE�I, N'I��SS��CHL'SETTS
BI:II.DING DEPARTMENT
130 WASHINGTON STREET, 3�FLOOR
TE1- (978) 745-9595
FAX(978) 740-9846
KI\IBERL.EY DRISCOLL
LMAYOR T�-a6w ST.P>ERRE
DIRECTOR OF PUBLIC PROPERTY/BUMDING CONMUSSIONER
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, and the provisions of MGL 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.
The debris will be transported by:
—Oc> StVt< Ttx�G
(name of hauler)
The debris will be disposed of in :
1110 Sine Cyz'TW6
(name of facility)
S b)"'I l9SC6T-r F20
(address of facility)
signature of permit applicant
date
dcbrisuffda:
The Comtltonwealth of Massachusetts
kvDepartment q(7ndustrial Accidents
Office of Investigations
600 Washington Street
I Boston,MA 02111
y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Let*ibly
Name (Business/Organization/Individual): }—/ -G' L
Address: 16 A1ft-
City/State/Zip: S Ltc►vi M 0870 Phone#: 5-7& /9 (�
Arc you an employer?Check the appropriate box: Type of project(required):
LM I am a employer with_.2__ 4. ❑ I am a general contractor and I 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have
8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. n
[No workers'comp.insurance comp. insurance.= ❑Building addition
required.] 5. ❑ We are a corporation and its l0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their i 1.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL
insurance required.]t c. 152,§I(4),and we have no 12.n Roof repairs
employees.[No workers' 13.❑Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
'Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-coalmctors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 6UAJZO 2/5, (7o /,
Policy#or Self-ins.Lie.#: 4—>4 Expiration Date: l 14
Job Site Address: 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$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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains nd penalties ofperjury that the information provided above is true and correct.
Signature: Date: r
Phone#: S78 146)
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#:
r
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 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 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 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 us a call.
The Department's address,telephone and fax 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
Revised 4-24-07 Fax# 617-727-7749
www.mass.gov/dia