44 LINDEN ST - BUILDING INSPECTION �D
The Commonwealth of Massachusetts
Board of Building Regulations and Standards OF CITY
ALEM
Massachusetts State Building Code, 780 C'MR, 7"edition Nasi.redJ,umun•
/// Building Permit Applicalion'ro Construct, Repair, Renovate Or Demolish a 1, =ODx
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date to
Signature: '
uii Ing Cummtssionerl Ins 11uiWings
SECTION I•SIT IATION
1.1 Property Addres t: 1.2 Assessors Map& Parcel Numbers
11�/ Llh �ti � i
L la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Toning District Proposed Use Lot Area(sq 11) Frontage(A)Tu
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system [3Public❑ Private❑ Check if yes13
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerrof n. cord:
Nome(
.Clines li
� r�7� Address for Service:
P 4
Signature ) Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Descr' t'on of Proposed Work':
boY r
Tr Ir uor
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMclal Use Only
Item (Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fie is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No._Check Amount: Cash Amaune_
6.Total Project Cost: S ,S-/00, 0 0 0 Paid in Full 0 Outstanding Balance Due:
5
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Cons��tr��uctionDDSupervisor(CSL) n�n Cis-. P O
P,�- /
- ,, /V/( (/l/Ja,N /• License Num/her? Expiration Date
Name of CSL-I luld r
1^f List CSL I')pe(see below)
Add -s _ " Description
D l!nreslricteJ(tip to 35,000 Cu.Ft.)
Signature
R Restricted l&2 Family Dwelling
q7b' tf '/- 023�' nt ,Reside alR
- ROnly
C' Residential Ruulin Covering
Telephone -WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D1 Residential Demolition
5 Ister d Ho Improvement Cont acto HIC)
ep4 /�lir ;�IoIV—�_C9ias01Pr� /030foS
1 IC Compan Name r f IIC Registrant Name Registration Number
ay A11-7
Es imtion Dale
Signature relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
1• r ,011 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 o wn Date
SECTION 77b:OWNEWOR AUTHORIZED AGENT DECLARATION
I, IF�/�]7 y-'e 1 'P r M I C,6 a/t-d ,4s,Q*4wPor 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. y
$ 0 P 1
Print Name
Signature a .3 D ��
Si g t�or Authorized Agent Dale
(Signed under the pains and penalties of r'u
NOTES:
1. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IIIC)Program), will rro 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 790 CMR Regulations I IO.R6 and I IO.RS, respectively.
?. When substantial work is planned,provide the information below:
Total tlooIs area ISq. Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hal0baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted fiir"Total Project Cost"
at CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
M:ry:MISC,11 I.
�I�Ynit 12^WASHIM;ION51aELI' • SAIL.M,MASI.M.III il.I150197�
11a.:y78-743-9595 • P.Sx. 979J4C-7846
Workers' Compensation Insurance Affidavit: 13uilders/Contracturs/Electricians/Plumber9
% ) flicant Information Please Print Le iblit
Maine (au,incisi()rgamraiiorvindlviduuq: r 6V&t5,_1M
:Address: ? 0� / f �/a St
City;stare;/sip: 6,01 M7- 0/01 Phone 2F',, y��r �a
:\re you an employer!Check the appropriate box: .'Type orproject(required):
1.Q I ant a cm lu cr with 4. Q 1 am a general contractor and 1 6.p y ❑ New construction
,.�/enlployccs(full and/ur part-tints)." have hired the sub-contractors
2. 1 ant a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
T'ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity, workers' comp.insurance. 9, Q Building addition
No workers'cutup. insurance 5. Q Wean:a corporation and its
required.]j
officers have exercised their 10.❑ Electrical repairs or additions
- -
3.Q I ant a homeowner doing all work right of exemption par NIOL I LE] Plumbing repairs or additions
myself. (No workers'sunup, c. 152.§1(4),and we have no 12.Q Ruuf repairs
insurance required.j r employees. [No workers' 13.Q Other
comp. insurance ruqulred.]
-any;�,pLanm tlwr checks bus ell muil also lilt an the section Ixluw showing(heir w•urkws cuntpcn Winn pulicy inlirtrturiun
'l lummiwran who udtmil this affidavit indiu,ing Ihcy are doing all work and then hire outside cwurxtos must auhmil a new alydavil indiading such.
•l'urttctcua5 Thal chuck ibis box pnticy informatiun.
l nor an elaployer fhot Lc providing workers'compensation incarance fur dry employees. Below is the pu/icy turd job.cite
injunrruriun.
Insuraucc Company Nalne: ... -
Policy 4 or Self-ins. Lie.d: _. .._ Expiration Date:
lob Sire Address: _ Cityrstatcizip:
Attach it copy of the workers'cmnpe cation policy declaration pulse(showing;the policy number and expiration date).
- failure w secure coverage as required under Section 25A of VIOL c. 152 can lead to the imposition of criminal penalties of a
tine up m S1,3I10.00 and/or one-year imprisonment,us well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 is day against the violator. lie advised that a copy of this statement may be lumarded to the Office of
laxrsngannns ufthu DIA for iosurarce coverage scrificadun.
l do hereby card r the pains and penahic• /'perjury that the infonnution provided above is true run/correct.
re' ( �j / -e"nG—y� Data
O[/ic•ial use only. Do not write in this area.to be cwuplered by city or lown official.
City or'I'own: PcnnittlAvrise d__
Issuing.liuthoriiy(circle title):
1. Board of Iicaldl 2. Iluilding Dcpartutcut .1.Cil.s I otsu Clerk 4. Electrical Inipector 5, Plumbing Inspector
6. Other _--
0,111al'I I'trwir _ .. Phone d: '.
A
Information and Instructions
.V assachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an empfurea is defined as"...every person in the service of another under any contract of hire,
evpress or implied,oral or written."
.\n employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
,A the loregoirig engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of.m individual,pmmership,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 W do maintenance:construction or repair work on such dwelling house
or in 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 his not produced•acceptable evidence of cuinpllance.with thc'Insuranee coverage required:'
Additionally, NIGL chapter 152, §25C(7)states"Neither the commonwealth nut 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 till 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 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 confimtstion of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be renlrned 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 slue to fill in the permitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicense 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 locutions in (city or
town)."A copy of the affidavit that has been officially stamped or marked by die 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.e.it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. .
I lie *JQC of IllveStigations would like to thank you in advance for your cooperation and Should you have any questions,
Please do nut hesitate to give us it call.
The Dcparonent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents �, �>C t
Office of Investigadona
600 Washington Street
Boston, MA 02111
Tel. k 617-7274900 ext 406 or 1-877-MASSAFE
Fax 11617-727-7749
;c;;ised ?rr-us www.mass.gov/dia
r
^b CITY OF &US.M. NL-kss.A cHUSET rs
9CILDLYG DEPARTMENT
120 W."HLNGTON STREET, Jw FLOOR
TEL (978) 745-9595
FAX(978) 740.9846
KI�03ERLEY DRISCOLL
.)MAYOR THo..%Lu ST.Pmm
Dit crm OF PLBLIC PROPERTY/BCIIDLYG COMMISSIONER
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 1 l 1.5
-- Debris,_and..tho-provisions-of MGL-c-40 5-54; - - —
Building Permit Al 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 in :
(name of facility)
/(V
(add aoffacility)
Signature ofpermit applicant
dale
I.bn�tf Jk