98-100 LINDEN ST - BUILDING INSPECTION r The Conunonwealth of Massachusetts
F +.. Board of Building Regulations and Standards Fc)12
,�, Ml'NK III.\Lill
Massachusetts State Building Code. 780 C'MR. 7 edition
I'.til:
Building Permit Application To Construct, Repair. Reno%ate Or Demolish a RrrisrJ./inn iu e
One- or- Ttru-Fumih, Drrclling �
'Phis Section For Official Use Only
Building Permit Number: Date Applic _
sienature: V2 F, log
Building Conuui sioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
LI Properl, Itddr ss: � 1.2 Assessors Map & Parcel Numbers
� - —1.[a Is this an accepted street' yes no_ Nlap Number PaIM Number
1.3 Zoning Information: 1.4 Property Di en arms-
nin Zog District Proposed Use Lot Area(sq It) Frontage (it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Piuridrd
1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'' Munici al ❑ On site disposal s stem ❑
Public❑ Private ❑ Check if yes❑ p I y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) Address Ior Service:
Signature ITelephune
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 111 Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Descri on of Proposed Work':--�-��-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash :\mount: _
6. 'fatal Project Cost: ❑ Paid in Full ❑ Outstanding Balance Due:
f Y C el/PxhCcl
51 ""' h _q - 0(970
SECTION 5: CONSTRUCTION SERVICES
5.1 ice tsed C nstruclion Supervisor (CSL) �S ji��L / �lVe l!� Lwensc NumberEv r
Namc of 'SQL- I I tld•r
L tp .Gw List CSL Type (scc hclokc)
"1' c Descri riion
Wdrrss
L Cnrestncted(Lip to 35.M0 Cu. hl.)
R Restricted I:c'_ Fanuk Dwelling
Sign uuny;� _. M Masonry Only
RC Residential Routine Corenne
"rrlephone \1'S Residential Window and Siding —�
SF Rrsidennal Sohd Purl If tinting :\ >>h;m.r Insl.il l.umn
D R eidenlial Demolition
5.2 Registered ynte 1 rSe e t Contractor (HIC) _-
HIC Company Nara ur HIC Rcgptmnt Na to Registration Number
Addres• r --- ---....--
Expiration Date
Signature /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 prucide
this affidavit will result in the denial of(he Issuance of the building permit. J
Signed Affidavit Attached? Yes .......... ❑ No . ❑ I
SECTION 7a: OWNER AUTHORIZATION TO 3E COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPL.Ic.S F'OR 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.
Signature or Owner ---- -_-_ _ Date
SECTION 7b: OWNEW OR :AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby Jeclare
that the statements and information on the foregoing. application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Dote
(Signed under the pains and penalties of perjury)
NOTES:
L An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered con(rtctor
(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 and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 1 I0.R5, respectively.
' When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics. decks or porch)
I Gross living area(Sq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hull/baths
Type of healing system Number or decks/ p�.rches
Type of cooling system Enclosed _. Open _-_—.__--
3. "Total Project Square Footage- may be Substituted fir '•Toull Project Cost"
CITY OF SALEM
f
S& S�"
7 nlki�-
PUBLIC PROPRERTY
DEPARTMENT
12C, A 12 1:1 TO SAI I Nt. %I\1i Xt 11 11 1 ,'w
778-'4 59R95 * 1:\X: 978 74"9846
Construction Debris Disposal Affidavit
(I-CLIL[ited fior all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Btli Idin debris resulting from
.g Permit # - is issued with the condition that the d lting c 0
this work shall bedisposed—of ill it properly licensed waste disposal lacility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
Inane of hauler)
'I he debris will be disposed of in
(name of facility)
(address of facility) --
signature of permit lit.11)1)1 is alit
date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\Norkers' Compensation Insurance :\(fidaiit: Builders/ContractorsiElect Please ns/Plumrs
Prin ?-ebbs
\ r llirant Information
�.11 111 i Hu.wc., t h_anv,w.m Indio i.Lt.tlC rt' t/e ��
� � n
ddrebs
City State Zip: L % Phone #:
Type of project(required):
fire you an employer? Check the appropriate box:
I ❑ I :un a ei loyer w ith 4. ❑ I all? a general contractor and 1 6 ❑ New construction
have hired the Sub-contractors 7. ❑ Remodeling
CHI yens full anml'ur part-time).' listed on the attached sheet. t.
solo a sole proprietor or partner- I"hCSe Slob-contractors have S Demolition
,hip and have no employees workers' comp. insurance. y" Building addition
iNo worker' sum
oeork ing for me in any capacity. 5, ❑ We are a corporation and its
p. insurance IQ.Q Electrical repairs or additions
officers have exercised their
required.] I I. Plumbin repairs or additions
3.❑ I am a homeowner doing all work right of exemption per Nl(jL ❑ g P
C. 152, §1(4), and we have no I'_.Q Roof repairs
myself workers' cutup. employees. (No workers'
insurance required.] 13.❑ Other
Bump. insurance required.)
•,\ny applicant that checks box nl most also till out the section below showing their workers'compensation policy information.
t I lumeowmrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ched an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
:('ummcn+rs that.heck this box most atta
tun ate employer that is providingkern'co pen.sution insurance for troy emp/oyees. Below is the policy and job site
injorma(ion.
Insurance Company Name&- � ✓ ��
Expiration Date:
Policy # or Srlt=ins. Lic. a:
Job Site Address: City,State/Zip:
.\ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure m ,ccure coverage as required under Section 25A of,IGL c. 152 can lead hl the imposition of criminal penalties of a
line up to SI,ioomo and'ur one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
nl up to 125O.l)Q a day against time m iolatur. Be ad%i,ed that a copy of this slatenlent may be fires arded to the Office of
Orr:s1 uali+m, of e I for insurance co(crage \cnlicanun.
!do hereb • :er /'' ref• pains ood penaltiev of perjury that the injorrnurion provided ahoy is tr r and c orrre'G
<I yn,our
I'P.,,r.e
—UJJiriof loci Dole. no not it in this area. ro he cnnrplered by city ar town oJ/iciat
( its or flown:
Issuing; \uthorily (circle one):
I. lioar(t of licalth 2. Building Department t. Ciq,-fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ---- -
Contact Person:
Information and Instructions
r , -
\Lls,.tcl u,rtts Gcncral I m ch:gner I ; rnµurrs All englloters Io prot ide ttorkers' congicns.uton for their enlplotees. ,
Vill,u.utl to this ,talule. .lit ently1mee to dctin.cd .Is " ct er.N person in the +cft Ice of.mo her under an_v contract of lure.
:ya cs, ,'r unpI Icd. oral or brit tell..'
\;: rmfdu ter is dctined is ",ut '"If" kit'-d, pr..tncrshiP .t s
. sucl.Ition. corporation or oilier Ic_al entity. or .Illy tnso or more
,.I the folc_om� engaged in a joint cntcipn,e. .wd including the Ie_al rcprc•sentatit cs of a dece,,cd cnipltu er. or the
;eceltcr nr It Ll,feC of an utditidual, Pautncr>liip. .tssoclation or other Ieval entny, enlplojme engllotces. IIoue%er (Ile
WA tier of a dwellutg house ha\ fle no( snore than three .lp;Irtmcnts and oho reside, therein. or file occupant of the
dot ci!uig hoax ,I another who emplo s Penann (o do Ind llltenance. construction or repair fork on such duelling house
Im lei the _rounds or budding, .ippuiten'til thereto ,hall not bei.Ill,e of such entplos nient be deemed to be .in employer.'.
\1(iL chapter 1'2, s2s(((,) also ,tafes that 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 csidence of compliance with the insurance coverage required."
Additions l Iy, NIGL chapter 152. j2 s0-) states 'Neither the conuuunwea I(h nor any-of its political suhdivisiuns ,hall
cuter into ally contraA for Ille perfiirniance of public work unit acceptable et Idcttie of conipli a lice with the insura tlee
requuenlents of this chapter hate 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-contractorts) nanle(s), addresses) 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
incnlbers 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
,elf-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of the affidavit fix you to fill out in the event file 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
tau n)." A copy of the affidavit that has been officially ,tamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on tile 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.
Ilie ()Bice of Investigations would like to thank you in adtancc for your cooperation and should you hate any questions,
plca+e do not he+nate to give us a :all.
t he Ocraitnlcnt , address, telephone and fa.x mmihee
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
ce,ised -'o u5 Fax # 617-727-7749
www.mass.gov/dia