1 MANSELL PKWY - BUILDING INSPECTION (3) 2 rhe Commonwealth C ommonwealth of M•rssachusetis
Board of Building Regulations and Standards CITY
t!( j Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
Revised Jomruary
Building Permit Application To Construct. Repair, Renovate Or Demolish a /. 21NAY
One-or rwo-Fo !v Dwelling
This Section or Official Use Only
Building Permit Nu r: Date Applied:
Signature: ' \ 6�,�/ /��
Bui g Commissi d lb"tor f Buildings Date 'r
SECTION 1:SITE INFORMATION
1.1 Property. Address 1.2 Assessors Map& Parcel Numbers
I Ma. Zll f'��t K qf,-.,
I.la Is this an accepted strecO yes ,---no� Mop Number Passel Number
IJ Zonlog loformatloo: g,.� ` 1.4 Property Dimensions:
7
Zoning District Proposed Use La Area(sq 11) Frontage(it)
1.5 Building Setbacks(fl)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Requited 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?
Public Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
"Construction
rd:
.SSD Address for Service:f?ff S'/WsCTION 3: DESCRIPT N OF PROPOSED WORK'(check all that apply)
Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Wotk
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OOlclal Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. ElectricalS Cl Standard City/Town Application Fee
U"v O Total Project Cost'(Item 6)x multiplier x
3. Plumbing S a7 2. Other Fees: S_
4. Mechanical (HVAC) S List:
5. Mechanical (Fire ..�Suppression) S Total All Fees: S
6. Total Project Cost: 5 C6 Check No. _Check Amount: Cash Amount:
r car 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) iD
19 T3 ��
�•��lS C P�AY/Al umber ENpiraliun Dale
Name of C•SI.• Ilulder Type(see below)��Address IInmiricteJ u 10 35.000 Cu.Ft.Restricted Id2 Famil UwellinSiM• (htl. /7 g j��/�3�� Residential Roulin C'overinResidential WindowaResidential Solid Fuel Buntin A liance Installation
it
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Company Name or IIIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.C.L.m 152. 1 2SC(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 ..........O No...........Cl
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
11 4�_,eq",O-,S /' ,C�d✓1/1'/!J __, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this b�g permit application. J
Signature of owner Date �^t
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si under the *ins and penalties of 'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will Zg have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 10.146 and 1 10.RS, 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/parches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may be substituted for-Total Project Cost"
CITY OF SALEM
�, ` PUBLIC PROPRERTY
4- DEPARTMENT
'.,IMM KI FY DaISCOLL.
�IaYttn T2C WASHINGIONSTRELT • SALEM,MASSACIlt:iP.I 1501970
11.1.;978-745-9595 is Pax:978.)40.7846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
)nliwnt Information /1 Please Print Legibly
Name (nu<incssiOrganizitinNlndivi(tual): ewlIN/ if-
Address:
Address: --fl `f7--
CityiStarei/.ip:OV!G!�[�,—�� Phone i.'-:
Are you an employer'Check the appropriate box: 'Type of project(required).
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. E] New construction
{�employees(full and/or part-time).' have hired the sub-contractors 7. ❑ Remodeling
2'[ 1 ant a sole proprietor or partner-
listed un the attached sheet. :
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'cum 5. ❑ We are a corporation and its
� P insurance officers have exercised their 10.E3 Electrical repairs or additions
required.] +repairs or additions
3.❑ 1 ;nn a homeowner doing all work right of exemption per MGL I I.❑ Plumbing P'
myself. LNo workers' comp. c. 152, $1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. LNo workers' 13.0 Other
comp. insurance required.)
-any:ytplicad dial checks box ill mull also rill caw the seclion wow showing their wurkeri cumpensation policy infurrtuLium
t I lomcuwmaa who submit this alYdavir indicating Ihcy are doing all work and then him outside cunaaetors must autnnit a new affidavit indicating such.
-C'ontraUun that check this box Mout aaachcd an additional Acel sho-inll[tic name of the sub-contractorsand their workers'eump.policy information.
1 aur un employer that is providing workers'compensation insarance fur sty empdayees. Below is doe policy and job site
information.
Insurance Company Name: —_...__.-. . . ._
Policy j$or Sclf-ins. Lic. .. ..____.___ Expiration Date:
Job Site Address: City,Stateizip:
Attach it copy of lite workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A uf.MGL c. 152 can lead to the imposition of criminal penalties of a
Fine up to 51.500.00 and/or one-year imprisoencnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this smtemunt may be forwarded to the Office of
Inv'esligaiitms of the DIA for insurance coverage cu'itication.
Ida hereby certifv ander the pains anodd pennaaltieess ufperjury drat the information provided
above is trite an/d`correct
-�'�� Date• (7 l,� — �V
Phone-j `
Official use only. Do nor write in this area, to be completed by city or town official.
CilvorTown: _-- _ Permit/License
Issuing Aulhorily (circle one):
f. Board of health 2. Building Department 3. Citvffowo Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.0lher
Cunlacll'enou: _._... - - - --._-_ Phone H:
Information and Instructions
;Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employes is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of:m individual,partnership, association or other legal entity,employing employees. However the
owner of a dwellinghouse 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."
MGL 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, MGL 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 ofcompliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill 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 nuntber(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 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
111;:ase be sure to till in the permit/license number which will be used asia 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
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 tilled 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.
l'he 0111ec of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfBee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Rcviscd 5-26-05 Fax# 617-727-7749
www.mass.gov/iiia
., s CITY OF SALEM
f PUBLIC PROPRERTY
- •4� I'
DEPAR"I'MENT
. rll ': n. • ICI
I ',', \I �M II\:..��\ll tl:l r ♦ 1.\I I \I,
1'\Y: 9,4 J4}.'15h,
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 CMR section I1 1.5
Dcbris, and the provisions of%1GL c 40. S 54;
Building Permit if is issued with the condition that the debris resulting trona
this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
--rte• —
(name of hauler)
Ilse debris will be disposed of in
t
(name of lacuity) /
(i cress of laclli )
✓r
'mitature of pen a .Ipp (cant
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