25R LYNDE ST - BUILDING INSPECTION IT
li
a Fhe Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Code, 730 C'MR, 7 thedition Revised iwnwr.r
/, 2008
Building Permit Application To Construct, Repair, novate or Demolish a
One-( ro-Furrlily Dwel!'tK
his Section For OFF I Use Onl
Building Permit Num r: D Applied:
2 / 3/v/-1 ----
Signature: Date
Building mmissioner/1 spe-tor o' lu' i
SE T ' 1:SITE INFORMATION
t., Pro a L AddFes : U 1.2 Assessors Map& Parcel Numbers
. Ma Number Parcel Number
1.la Is this an accepted street'?yes_ P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use [.at Area(sq 11) Frontage(R)
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 Zonal Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if XesO
SECTION 2: PROPERTY OWNERSHIP' [�7
2.1 Owner fR or / 1Z (tie S d-rint)
�e (r1� AddresstorSevice: X r1
Signature 'relep one
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building' Owner-Occupied ❑ Repairs(s) 13 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ 'Specify:
Brief Description of Pro ed Work'* �' l Q
/ A1 �4G( lr9htS.
C.
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building S ® ® a I. Building Permit Fee:S Indicate now fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 0 p 2. Other Fees: S
q. Mechanical (iIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
r/c-
I
l-'
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
�S Ioa� ) 1 I f�Z • y
�Z.ZLC\l) License Nwnher Expiration Date
Name_o13'SI.Alolder
IIP nr-"k= ' ®y n't 1-�ilA I.i tC'SL I')pe(scc Wow) l�
:\JJ •ss � Vh rs Description
' -yi st l!nrericied a to 35.O00 Cu. Ft.)
�" R Restricted IX:2 F'amil Uwellin
�S/e'F,matarc M 1 Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Buming Appliance Installation
1) 1 Residential Demolition
5.2L�R��tered Home Improvement Contractor(HIC)
!3_ -� 11
` - %1 mp,ny Name ur t IIC Rcgistmnt Name Vq� Registration Number
Expiration Date
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..........4 No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNE/R'S/AG/ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ( � ✓l(t ✓{� IYCC- IZ4 / Gt.J as Owner of the subject property hereby
authorize_ r 44- ,)'O _ to act on my behalf, in all matters
relativ o k authorized Nhis building permit application.
Si aturcaFOwner Date
SECTION 7b:OW t OR AUTHORIZED AGENT DECLARATION
1• ,as Owner or 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.
�h-u.r ,
Print Name/ f- f b
2'
Signature t((f Owner t Muthorized Agent Date
Si red un�he ai sand •mottoes of rjur�
NOTES:
I. 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(111C)Program)•will tigi 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 I I O.R6 and 110.115. mspcctively.
?. When substantial work is planned,provide the information below:
Total floors area(Sy. Ft.) (including garage, finished basement/attics.decks or porch)
Gross living area(Sq. Ftj Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"
CITY OF Sill ENE, AXSSACHUSEZ`I'S
BUILDING DEPARTNLF—NT
120 WASHLIIGTON STREET. 3"FLOOR
TE1_ (978) 745-9595
FAx(978) 740-9846
K1.,t8FAt FY DitiSCOLL THONUS ST.PtEutB
MAYOR DIRECTOR OF Pt SLIC PROPERTY/BL:IIDLNG CONLUISSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
r Iicant Informrtion Please Print Legibly
E T k1 "Va rl,4d
Nance(Busitx5&organiratiomindividual):^ S r1�F
Address: q 3 P %/n
City/Statcibp: b&P1 noe- S Phone #:
Are you an employer?Check the appropriate boa: 'Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees full and/or part-time)." have hired the sub-comractors
( P 7. El Remodeling
2.M 1 ship
a sole have
no proprietor o partner-
listed on the attached sheet.t
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
(No workers'comp. insurance 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
right of exemption r MGL I I.❑ Plumbing repairs or additions
3.❑ I am a homcuwncr doing all work c 6152,§1(4),and we have no 12.❑ Roof repairs
myself.(No workers'cump. employees. [No workers'
insurance required.) 13.❑ Other
cump. insurance required.]
-Any uPPltcum nut dtnks bo:rl must also rill uut the anlim below showing their workeai mmpens uban Policy M1161 matiun.
'I i,,meuwnen who submit this aHldavit indicating they am doing all work and thm him outside cantmctors most submit a new alEdavit indicating such
Cuntrxtun that chuck this box meet attached an"khtiured sheet shuwing Iho name of the sutscomrxiorr and their workcol comp.policy infotmatian.
I um an employer that is providing workers'compensation insurance for my employees. Below Is r/re pollcy and job site
information.
Insurance Company Name:
Policy 4 or Self-its. Lis 4: Expiration Date:
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 ot'MGL c. 152 can lead to the imposition of criminal penalties of a
line 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
invesligutiols ul'the DIA for insurance coverage verification.
I do hereby c card under the p Ins and peauldes of perjury tfrat the information provided above is true and correct.
XS' t
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Phoric
ojprtral use only. Do not write in this urea,to be completed by city at town offlelat.
i
City or'I'awn: _ Permit/I.lcense _.—
Issuing,%ulhority(circle one):
I. Board of Health 2. Building Department 3.Cityffuwn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: . __. ... Phone 4:
(
Information and Instructions
Massachusetts Uencral Laws chapter I J2 requires all employers to provide workers' compensation for their employees.
Porsu:um to this statute, an ernpfgree is defined as"...every person ;n the service of another under any contract of hire,
vpress or implied,oral or written."
\n employer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more
�t the t„rewing engaged In a Joint enterprise,and including the legal representatives of a deceased employer,or the
tecerver or trustee of .us individual,patmership,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."
NIGL chapter 152. §25C(6) also states that "every state or local licensing agency shall withhold the Issuance or
renewul of it 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."
Additiunully, NIGL chapter 152. §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ul'public work until acceptable evidence of cunrpliunce 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 ilia boxes that apply to your situation and,if
necessary,supply sub-contractor(s) namc(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 usher 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 die 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 pennit/licerse 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
t i.e. a dug license or permit to burn leaves ctc.)said person is NOT required to complete this affidavit.
I It,; r)f f tic of Invesfigatlomi would like to drank you in advance fur your cooperation and should you hace:uy questions,
please do not hesitate to give us a call.
The Dcparuncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Once of Investigations
600 Washington Street
Boston, MA 02111
Tel. N 617-7274900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mass.gov/dia
1
s;
CITY OF S.u.&M. A-1SSACHUSErrs
• BUILDING DEPIRTIMNT
13o w.ksHLNGTON STREfiT, 3 °FLOOR
hL (978) 745-959S
FAX(978) 740-9846
KISBERLEY DRISCOLL
I
MAYOR �tO.�Lis ST.P[F.RRS
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG 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 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:
0 _t
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
slate
lcbnvi(d.k
Uassachusetts- Npartmenrof Public Safetj'
A Board of Building Regulations and Standards
.,Construction Supervisor License .
License: CS 100217 — —
Restricted to: 00 AMAL' .
RALPH PEZZUIO
PO BOX 404
WEST LYNN, MA 01905
Expiration: 1V29l201f
c, ('nnunisriourr - Tr#: 100217