10 MALL ST - BUILDING INSPECTION Q SECTION 5: CONSTRUCTION SERVICES a p
5.11 Licensed Construction Supervisor (CSL) �p ZZ3y 4 _ZrJ O
/rd O*Er License Number Expiration Date f
Nam t�if CSLI- Huller n ' List CSL Type (see below) U
r 1✓t�//1Gr g�3' uc
Type Description
address
S� k4, MO O) !n O R Unrestricted(u to 35.000 Cu. Ft.)
J Restricted I&2 Famil Dwelling
n'Sig rc M Masonry Only
RC Residential Rooting Coverin
Telephon WS Residential Window and Siding
A O _ �1 SF Residential Solid Fuel 13urnim! A>>li:mre InSiall:iiun
01 •, 0 81 s� [—I o'G7 I D Residential Demolition
' 5.2 Registered Home Improvement Contractor(HIC)
Ii1C Company Name or HIC Registrant Name Registration Number
Address
000 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 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, , as Owner of the subject property hereby
authorize to act on my behalf. in Lill matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print Name
Signature of Owner or Authorized.Agent Date
(Signed under the 2ains and penalties of perjury)
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 and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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" may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts E D
1 FOl2
Board of Building Regulations and Standards
aVj' l Massachusetts State Building Code, 780 CMR, 71'edition MUNfUSE I I Y _
Building Perm' Application To Construct, Repair. Renovate Or Demolish a H�'i'iSc'��J,uutut)
Otte- or Tiro-Funtily Dn:elling
Building Permit N r
This Section For Official Use Only
Date Applied:
Signature: 2'
Bw ding Cannot sioi I Spector of Buildings Dale
SECTION 1: SITE INFORMATION
1.1 51 Property OAddr ess 1.2 Assessors Map & Parcel Numbers
1.la Is this an accepted street'? yes-k< no Map Numher Parcel Numher
1.3 Zoning Information: r 1.4 Property Dimensions:
liC�j'► c�Pni?r,rs t'
Zoning District Proposed Use - Lot Area(sq ft) Frontage (to
1.5 Building Setbacks(ft)
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? `/
Publicpa Private ❑ Check if yes?-", Municipal AVOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner Ioioil Record:
00
�7 S�
Name (Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 54qV0 , 0� 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee j
2. Electrical $ �0 670
❑Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2_5'12q e-0 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
'TotalSuppression) All Fees: $
Check No. Check Amount Cash Amount
b. Total Project Cost: Sr0� 000. t0s ❑ paid in Full ❑ Outstanding Balance Due:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employein the provide
workers another undo any' compensati011 o their CMPIOYC of him
to this seatus.an emphv a is defused as'...every Pe
eapress or implied.dcw or writte&"
a/fOailOoa.OOrPaaflott ere other legal enttly,a eery two or mom
Aa enpfayar is ddlead as"as itsmvithasl'Per�tO' to er•or the
Of
the foregoing enttefied in s 1Oi01 carerptisc and including the legal representatives of a deceased emp y
Y,.uwjbh,.. uweierioo a other legal eatity,employing employees' However the
recaver or ItYalOt Of JO YldlYldltal.y���•t. and WIIO teaid"tAe eim,4<the Occupant of the
owner of a dWelhng house having not more than three apartmewa
dweBittg house of another who employs persons to do mainwasocs,cmatructioe Or repair work on such dwelling house
or on the groun
ds or building appurtenant dictate sh&B no because of an&employment be devoted to be an cmployer."
htGL chapter 132,¢2SQ6)also stores that•'@very ate"or load 8eottdng&assay shag withheld the tueatece or
b Operate a business or to construct buildings In the cotsmoswe&kh far say
renewal of i o has
a or Pro uced wept"avidew of compgais"with the Insures"coverage requlyd."
apditiona sob sus cat peed nor
Aoklitiomhly MGL chapter 152•i12�� 'Neither the conuttoawealthvidea"�complwmco wi ��nwraacvl
enter into any contract for the ptxf Public work until acceptable
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation aflkevit completely.by checking the boxes that apply to your situation and, if
necessary.supply sub-enenaracror(s)name(4 addre*cs)and phone number(s)along with their certificates)of
insur&n" Limited Liability ,(LLC)a Limited Liability Partnerships(LLP)with no employees other than the
members or partners. insurance. If at LLC or LLP does have
am ad required m carry worker'compensation
employees,a policy is required Be advised that this affidavit may be submitted to the Deparirmeat of Industrial
Accidents for confirmation of insurance coverage. Ababa Burs to sign and date the affidavit. 'nte affidavit should
be returned to the city Or town that the application for the permit or license is being requested, not the Department of
in.lustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a worker'
at the number listed below. Self-insured companies should enter their
compensation policy.please sell the Department
.elf-insurance license number on the lire.
City or Town Offldish
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 OtYee of Investigations has to contact you regarding the applicant
t'Ieasc be sure to till in the pormit/licertse number which will be used as a reference number. In addition,an applicant
that must subunit 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
townl•"A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the
applicant as proof that a valid affidavit is on fate for future permits or licenses. A new affidavit must be tilled our each
year. Where a home owner or citizen is obtaining a license or permit two related to any business or commercial venture
t i.e.a dog license or permit to bun leaves ate.)Said parson is NOT required to complete this affidavit.
I'ha t)t iix o 'kivesti.. , m] would bile to thank you in advance for your cooperation and should you have any questions.
;ease du not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Depaftment of Indlimial Accidents
Odke st Inivestlptleas
600 washinSIM Sftd
Boston,MA 02111
Tel. N 617-7274900 ext 406 or 1-977-MASSAFE
Fax N 617-727-7749
2cvi.ed -,-26d15 www.ni&w.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,tutu nttr ustscuu
W vac• 12C t/a4n.W.-KW!P gar a f:Altlt,W\BACra ?.1'tX019n
• TILL,978.745."" a F.vx:9M7e0.9tie6
Worlters' Compensatfoa Insurance Affidavit: Builders/Contras'tors/Electricians/Plumbers
%nnlleant information /1{ /7 Please Print Legibly
VamelHuaitrssKk)iattiratioralrmltvuhmll: C�?Porfe_ U /y ✓L0f ar? r/
Address: `� k✓1*,rG tt Cr-AkT Q ILL
City/statoizip: Sf✓/e,n,t, h2//3 laboae P _6) 'Y 8/S-
Are you an employer'Cbeok the appropriate box
I.Q 1 am a employer with 4. Q 1 am a Sentnal contractor end 1 . of oat wfidrad).
emplusub-contractorsa(full and/or pa -tinte).• have hired the sub-contractors
6' ❑*'evew conattuetitm
2•51I am a sok PrnPricta or partner- listed oo the attached sheet t 7. ❑ Remodeling
ship and have no employs" Than wk•eonoraemrs have I & Q Demolition
working for me in any capacity. workers, tamp. insurance. 9 Q Building addition
[No worked'carp. insurance S. ❑ We am a corporation and its !0.❑Electrical napalm or additions
n:quired.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MOL I I.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Ruof repaid
insurance requited.) t :mployces.LNG workers' 13.❑Other
comp. insurance required.)
•,van.Pphc&M Ibis elw[aa ban el aft ahe an aut the secitae bataw ' jag user wataa•aanpnWA;aa Panay iariw im
' I I.r Wneoa who octant this amdwu indiming it"an dairy all work and that the ateddo co mmom aw, Submit a taw antJawil inJialina aw•t.
;CI rmws the cost this bat maw aruelted as add'uiamel Shot.towns toe nap of ale sad their warren'aww.Iteticy ini mnrb.
I um an employer that 6 providing worked'romperrradon Luaranee for my employers Below is the pulley and Job silt
irrfora ot"
laurance Company Nome: _. ._
Policy a or Sclr-inL Lic. 0: _ .. Expiration Date:
loo Site Address: City/statuzrp:
Attack a copy of the workers'compensation policy declaration pagit(showing the policy number and expiratlun date).
Failure w accum coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa
ring up to 51,500.00 and/or one-year impriann'"cnl,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a Jay lPinst Ile violator. lie advised that a copy of this slap ment may be furwardcJ to the O1)ice of
Iue:angauutta ul'd:c DIA ror insuraree covcra;u raificatiun.
i do hereby,rereify r the pill end pen milks of perjury that the informal/on provided above it rime amd correct
<i•n:uur" - Date• Z'
D/J/e ir/are um/)e /b woI wrier in thk area,to b.compleled by city or Iowa o/fla•/ld
City or 'rown: Permif/Lleense e
Ibau(ng Autburity (circle otte): — —
I. Buurd of Ilealth 2. Building I)epartmcnt I. Cilylfoma Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
C"Illacl Person: Phone q:
CrrY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
..��.at all tia9l
NW&IS lie w.%AcQ7.-ONSmff•3Al•1[L1L71V11t:M 11s::1
Tn.~44m; •Res 19w4 wea
r-
Constructios Debris Dbp mf Affidavit
(reyuiNd IN all deer ados and remato low worst)
(n mcon(attes w ith am sisdt edidam of the Sets Building Code.7W 06M soctim I I l.S
Debris,utd dw provisions of MGL c iQ S 54
euitdiq Ffta is ismsd with the coodixim that the debris reatldus Ras
this wak shall be disposed*(in a property licensed wsum disposal &cility as dented by WX e
lI1. SINA.
rho debris will bs u-muported by:
1�.of hou1M
rho/&bris will bar disposed of in :
1V Or�t ci rT1 ✓1
Itanle ul'fa:duY)
..sit