21 MANNING ST - BUILDING INSPECTION (2) ,y
The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7t'edition OF SALEM
\1 Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
(.� This Section For Official Use Only
v� Building Permit Number: Date Applied: Cj
Signature:
Building Commissioner/1 pector of Buildings Date
SECTION 1:SITE INFORMATION
`1 j Zr ddress�pe �,_j, 1.2 Assessors Map&Parcel Numbers
�� l V^- J
Lla Is this an accepted street? no Map Number :Parcel Number
1.3 Zoning Information- 1.47 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards :Rear Yard
Required Provided Required Provided Required Provided
1.6 Water apply: (M.G.L a 40 §54) 1.7 Flood Zone Information: 1.8 Sewage/D�'sposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipa('O On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:\\� � 1 A r /
Name(Print) Address for Service:
Sir Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check al hat apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) V Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units J Other ❑ Specify:
Brief Description of Proposed orkz: a
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Fown.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 Amount:
6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
12A Or�n�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Cons uction upervi or(CSL)
License Number E pimti Date
Name of C H List CSL Type(see below)
Address ^•�� T Description
S' U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone r� `� WS Residential Window and Sidin
l� � ^qrs 4 SF Residential Solid Fuel Burning Appliance Installation
6 D Residential Demolition
5.2 R SHotne rpro, eot Con raetor(HIC)
HIC Company Name o HIC Regism nt Name " R strati0 Number
Address
N—i ltJ1 E,pi ion Date
Signatur Telephone 3
13
SECT N 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 P erm't.
Signed Affidavit Attached? Yes ..........❑ No...........cr
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by his building permit application.
Silfat4m of Owner Date
SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION
1, D hd—J V��b Lt.6r-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. U
Pri ame
Tigri6iripte of Owner or Authorized Agent Date
(SiAA under the pains and penalties of perjury)
NOTES:
I. 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 110.R6 and 110.R5,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"
Y
Gf/� �pomvmoeuuea�l�i a�✓l�amac�fueelO License or registration valid for individul use only
Office of Consumer,\(fairs& usiness Regulation before the expiration date. if found return to:
lug
� HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
Registration:' 14 Park Plaza-Suite 5170
Expiration: 9/22/2011 2011 Tr# 288884 Boston,MA 02116
Type: Individual 1
JOSEPH S ORETO.
JOSEPH ORETO--
7 NEPONSET ST:
REVERE;MA 02151 Undersecretary f I valid with ut signature
� ;�Iuss3Chuxctts - De artincnt ofPublic S
ateq
Board of Building R•••� ulations
S� _ and Standards !
WSJ
Construction Supervisor License
Lice
nse: CS 79930
Restricted to:.00
JOSEPH S ORETO
34 SHAWMUT ST
REVERE, NIA 02151 rz e
Expiration: 1/16/2011
(' nm,i..vion.•r Tr#: 9159
d
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1 t M 12^.W dB11.VC.I UN S'fa EL•T • SAt E.M,M.\S5A(:I It %L I I v 0197-�
1'c1.:978-743.9393 • lass 978.71C-Is46
Yorkers' Compensation Insurance Affidavit: Builders/Contracturs/Electricians/Plumbers
It t ylicant Information Please Print Le ihl
N 11111C Illaiou;%s Or;;anilalinNlnJlvlduall:
Address:
Cily;Stami%ip! Phone 0:
:\re you an employer? Check the appropriate box: Type of project(required):
L❑ I and a cal lu cr with 4. 0 I ain a general contractor and I h.
P Y ❑ N• construction
el yces(full and/ur part-time). have hired thesub-contractors
2.0 1 ant a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no cinployces These sub-contractors have 8. ❑ Demolition
working fior me in any capacity. workers' comp. insurance. 9, 0 Building addition
I No workers'comp. insurance 5. 0 We area corporation and its
required.) of icerx have exercised their 10.❑ Electrical repairs or additions
3.0 1 ;lilt a homeowner doing all work right of exemption per INGL I LCI Plumbing repairs or additions
myself. tNo workers'cunip. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.) r unployccs. LNo workers' 13.0 Other
comp. insurance required.)
e(ny ailphcam thus chucks box 01 mull also till our the section W.uw showing Iheir wvstkui cumponu,siws policy inliunmtiun_
' I lomalwnun who submil this affidavit indicating Ihcy are doing all wurk and Then hire outside conuxton must suhmil a new ulydavil indicting.och.
-C'entrscwn that chuck Chia box meal asachod an addilionul..heel showing the niona of the subcontractors and their wurl a s'comp.lndicy infonstaaun.
I ant un employer that it pruviditrg workers'cuanpeusadaii insurance jar any eutployecs. Below is the policy and Job.vile
iafanoation.
Insurance Company Name: _.. ... .....
Policy Is or Self-ins. Lic. tl: _. . .. _. .._ Expiralion Date:
Job Site Address: _ City/State/Zip:
Attach it copy of Isle workers' compensation policy declaration pale (showing the policy number and expiration date).
Failure to secure coverdge as required under Section 25A of}IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.5110.00 and/or one-year intprisunlncnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it Jay against Ilse violator. lie advised that a copy of this slutcmunt may be forwarded to the Oflice uC
Invcsngaunns ufthe DIA for iosurarcc covcragc verification.
lilt,hereby certify ua,
r •r he pains otd penNFer"ry
rotation provide/a owe is t mlrl correct.
tiie:rmle Dat : 1-4D I'Iv n:•;i;
Official use only. Du nol write in this area,to be completed by city or fo,n official.
Citv or fawn: Permit/License V
- I
Issuing Auilturily(circle one):
I. Board of lleadth Z. Building Npartrnnrt .i. Cilyi Ibwn Clerk 4. Electrical Inspector 5. Plumbing luspcctor
6. Other
Cmliacl 1'I:rvuo: ._ Phone l:
Information and Instructions
\lUs.lchuselts Gencrai Laws chapter IJ2 requires all employers to provide workers' compensation for their employees.
Pursuant to tilis statute, an emplucee is defined as"...every person in the service of another under any contract of hire,
caprcss or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
d the fbreeoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of am individual, partnership,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 groundv or building appurtenant thereto shall not because of such employment be deemed to be an employer."
%IGL 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 has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, bIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of conmpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill 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 at fdavit should
be retuned to the city or town that the application for the permit or license is being requested, not the Department of
I ndustrlul 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 ut 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 sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennidlicelse 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 he tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
1 i.e. a dog license or permit to bum leaves cteJ said person is NOT required to complete this affidavit.
I be t)Ilice of Investigations would like to drink you all advance fur your cooperation and should you have ally questions,
please do nut hesitate to give us a call
The Dc:V aruncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OIBce of Investigations
600 Washington Street
Boston, MA 02111
'ref. i1617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
R.viscd 5-26-05
www.mass.gov/tile
4
CITY OF SALEM
PUBLIC PROPRERTY
'?_''' •� DEPARTMENT
F
8 i1111:!RI P.1'''BhrJ�11.
120 WXSI II\L';'i1,V)I'RLI'T * $AI FS1, %1ASiM.1 II it I it JI'>
TEI:978J45-9i95 • Fm 978.740-9846
Construction Debris Disposal Affidavit
(retauired 6or 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
di
this work shall be sposed 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)
(14�
The debris will be disposed of in
(name of facility)
(address of facility)
. ignature of artuit applicant
9 :�_) // C_�
date
Jclu i:atT uue