249 LORING AVE - BUILDING INSPECTION �4
M The ('Ultlnlonµealth of Massachusetts
1 - ► y I;U.11'dUf 13talIJlllg RQgnlallolts and Standards t MI NI('1I'.\I.I'Il
MaSSaChtlSettS State Building Code. 780('MR, 7"' edition I S1:
p. He i n J J�u11w,i
Building Permit Application To Construct. Repair. Renovate Or Denlulish a i
One- ru- Tn o-Famih• Du efGng
r
` This Section For Official Use Only
Building Permit N mhrr: Datte applied: --
i � f
Signature:
B nE Couunnsiol I Inspector of Bill ldwgs Date/
SECTION I: SITE INFORMATION
1.1 Property \ddress: 10t/� 1.2 Assessors 31ap & Parcel Numbers
olL�7 I
I.la Is this an accepted street? %es Map Number Paul \weber
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning DistrictProposed Use Lot Area(sy.to Frontage III)
1FPublic
5 Building Setbacks(f )
Front Yard Side Yards Rear Yard
ryuired Prodded ReyuueJ. ProvidedWater Supply: (M.G.L c.10, §51) 1.7 Flood Zone Information: 1.8 eage Disposal Sys[ern:
Zone: Outside Flood Zone? ,municipal ❑ On site disposal system❑ Private❑ Check il'yes❑
SECTION 2: PROPERTY OWNERSHIP'
2 I Owner'of Record: '
CL.a�nE"r7�'" y-a;Z(. lr✓2at.t.t1'�i � �-yS Lssti.r%�s A ✓g.
Name t Print), Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairms) ❑ Alteration(s) ❑ Addition ❑
- Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other O Specify:
Brief Description of Proposed Work': c/�?n"f 2ad)` �Q h, /LLriJ'J,1 12" l/J''n` AVIOW4LT
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and %IalerialO -
I. Building 5 �.df�-" 1. Building Permit Fee: `6 Indicate how tee is JetermmeJ: t
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item G) x multiplier x
3, Plumbing $ 2. Other Fees: S {�
4. Mechanical (HV;\C) 1i List:
r
S. Mechanical (Fire $ rotal All Fees: S — ---
Su ression)
�—
Check No. Check Amount: .(.'ash .\nutum:
j b ToWI Project Cosh S f�-'��T ❑ Paid in Full ❑ Outstanding Balance 1)ur:•
d SECTION 5: CONSTRUCTION SERVICES
y 5.1 Licensed Construction Supervisor(CSL)
,-1-AveA-A-A License Nmnh.r I vplrauau 0.ue
I Nano of('SL: fluWer_ �•-- h �,r�
�/ ni��114�� �y r(H O)9•V List CSl_'I}Ix nee heluw)
\J res. fv. • Descri roan
L l .IXIU C'u 1:1.1
R ResincteJ 18:2 FmnJs Dsv rllnte _
Y SI nlallll • NI Masonrs Oniv
a RC RrRcslJrnual Kutdin• Cava-mg
i reephone \\:S slJcnn:d N}uJuw and SnLnv _
SF Rcsldeniwl Suhd Furl Btimmee \ppk mce lua.dlawm
D Ravdeniml Denntlm nl
5.2 Registered Ilome Improvement Contructor(IHC)
a Registration Number r--
FIIC C'unlpany Valve or HIC Re'istru l Naay.- b
✓1A/Lt�o a.✓G(,a[�Gr� Ga-I IM Git .y g
Address
`f/ /l s.�?✓�✓L✓�� '.t3 ✓1 f^ ' /��� Y L _)-1l41' Expiration Date
. Signal urr Telephone
i
Y
SECTION 6: WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to proi.ide
i this affidavit will result in the denial of the Issuance of the building permit. Q
i
Signed Affidavit Attached'! Yes .......... ❑ No........... ❑ '
g SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
' 1, as Owner of the subject property hereby t
authorize to tact on my behalf, in all matters
relative to work authorized by this building permit application. .
1
fSignature of Owner - Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I
r 1. - ,as Owner or Authorized Agent hereby declaro
t that the statements and information on the foregoing application are true and •accurate, to the best of my knowledge and
behalf. - ✓/
a Print Name��
Signature of wort ur.out urizcd.Agent Dat�
(Signed under the pains and penalties of perjury)
NOTES:
1
1. An Owner who obtains a building permit to do his/her own work.or an owner who hires an unregistered contrlcwr
(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. 1.12.4. Other important information on the HIC Program and
�. Construction Supervisor Licensing(CSL)can be found in 780 C NIR Regulations I IO.R6 and 110.115. respectively.
_' When substantial work is planned, provide the information below:-
s I Total flours area ISq. Ft.l (including garage, finished basement/attics.decks or IN)rch)
j Gross living area tSq. Ft.) Habitable room count
Number of fireplaces Number of bedrot Ims
Number of hathruums Number of halt/bath.,
l'ype of heating system Number of Jerks! porches
'rype of cooling system Enclosed Open
3. "Total Project Square Footage• may be substituted for-rotal Project Cost" I 1
J
i
CITY OF SALEM
PUBLIC PROPRERTY
•� DEPARTMENT
\l .•., N IS`X'.,;1tI\,:':J�)aiET � i.,;. f1. \tA,i.\t '.,' �.. , :.•1'-
�Fi:`)7l1.7Y5-')i95 1 \:(: 77&7i.17A 46
Construction Debris Disposal Affidavit
(required fur all demolition LLid renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Dcbris, and the provisions of VIGL c 40, S 54;
Building Permit At _ _ 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 V1GL c
t 11. S 150A.
The debris will be transported by: i
1.
— -^ ��am¢ othaultr)
l'Le cbr s will be disposed of in
• - CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.ALi� n 12_ ;n<It-.i • S.vI :st, ALs�s.it nl Sri :, -1'/
1,1 : o-8_1-i59S`)?
Workers' Compensation Insurance Aftidasit: Builders/Cuntract4)rs/LlectriciansiPlutnbers
11, 1 ilixant Information Please Print LeeibI
`milc Inasm-i Itr_anlcuwn.Indn:dual r.
City,swe Zip: Phone #:
Are you an employer:' Check the appropriate box: "Cype of project(required):
I ❑ I aut a employer with 4. ❑ 1 ant a general contractor and 1 6. ❑ New construction
cmployces (full andfor part-time).' have hired the sub-contractors
7. Q Remodeling
'_.❑ I ;un a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees '1"hese sub-contractors have 8. Q Demolition
working for me in any capacity. workers' comp. insurance. q. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of per MGL I L[J Plumbing repairs or additions
exemption P
myself. [No workers' comp. c. 152, §1(4), and we have no 12.E] Roof repairs
insurance required.] employees. [No workers' 13.Q Other
comp. insurance required.]
•;\uy apphtant That checks box 01 mint also till out the section below showing their workers'compensation policy information.
' I Io,neownen who submit this affldav it indicating they are doing all work and Ihen hire outside contractors must submit a new affidavit indicating such.
Contractor,racturv'that check this box nuut attached an additional sheer showing the name of the sub-contractors and their workers'comp, policy information.
[am an employer that is providing workers'compensation insurance for trry employees. Below is the policy and job site
inl6rnration.
Insurance Company Name:
Policy a or Self=ins. Lic. AL: Expiration Date:
.lob Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Ftilure to secure coverage as required under Section 25A of ISIGL c. 152 can lead to the imposition of criminal penalties of a
tine up m S l,S00.00 and/or one-year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S'_50,00 a day against die violator. Be advised that a copy of this statement may be forwarded to the Office of
Im cstivations of the DIA fur insurance coacrage vcrific;uion.
/ /or hereby cernJi- under the pains and penalties of perjury that the infi)rrrtatiotr provided above is true and correct
�i^_n,uura:
Phone
f)%/icial use on/v. Do not trite in this area, to he completed by city or town official
Ciry or lbw": ___— ----- -- Pennitil.icense
Issuing; AuthoritY (circle one):
I. Huard of Health 2. Building Department 3. Cih'/town Clerk 4. Electrical In
5. Plumbing Inspector
6. Other -. —
Contact Person:-----_ __-- ——__. -- Phone 0:_— -
10
Information and Instructions
\LtsSachusetts (h•neral Late. chapter 15' requires Al cnplo%ers to pro%ide %corkers compensation for their employees.
I'ur,u.uu it) this lt:uute, .m einjukoree is defined ors "._c%cr% person in the set%ice of another under ally contract of hire,
c\prc,s or implied, oral or %%rittcn." .
.\n emp6rter is defined as ":m indi%idual. parrnernhip. a;soeiaiion, corporation or other Ie_al entity. or any mo or more
„f the tor.•_oing engaged in ajoint enterprise. and including the legal rcpresent:lit eS of a deceased employer. or the
I ccci%er or trustee of an individual, p:uutershlp, association or other Ic_al entity, employ ill, employees. Ilow'e%er the
o r.%tier of a dwelling house having nut more than duce apartments and %rho asides therein. or the occupant of the
d%%clling house of another who emplovs persons to do maintenance, construction or repair work on Such dwelling house
,a ,m the -,roun.ls or building appurtenuu thereto Shall not hCsAlSe of Such employ mcnt be deemed to be an employer."
VOL chapter I 2, 2506) 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 bus not produced acceptable evidence of compliance with the insurance coverage required."
.\dditionally, \IGL chapter 152, 25C(7);rates 'Neither the commonwealth nor any of its political Subdivisions shall
enter into any contract for the performance of public %cork until acceptable e%idence 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 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 he 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 tfte event the Office of Investigations has to contact you regarding the applicant.
Please be Sure to till in the permit/license number which will be used as a reference number. In addition, an applicant
drat 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 locutions 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 thata 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
fi.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
I-hc Office of Investigations would like to thank you in advance for your cooperation Lind should you have any questions,
please do not hesitate to give us a call.
I he D) partntent'.s address, telephone and tax 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
Fax # 617-727-7749
www.mass.gov/dia .