5 MARION RD - BUILDING INSPECTION The Commonwealth of Massachusetu
Board ul'Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR, 7'edition OF SALEM
ReviseJJmroevv
Building Permit Application To Construct, Repair, Renovate Or Demolish a
n One-or T%vqftcbrily Dwellin
This Lion F Official se Only
Building Permit N ber: Date A lied:
Signature: 4"14
Building Commissioner nspectorof uildi Date
SECTIO 1: VITE INFORMATION
1.1 Pro A dress: 1.2 Assessors Map dk Parcel Numbers
I.la Is this an accepted street?yes-ALno Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Ld Ares(sq 11) Frontage(11)
1.5 Building Setbacks(11)
From 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: 1.3 Sewage Disposal System:
Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if es0
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owaert of Record:
Name(Print) Address for Service:
Sob -29y-01737
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(chock all that apply)
New Construction O Existing Building O Owner-Occupied O Repsirs(s) Alterations) O Addition O
Demolition O Accessory Bldg.O 1 Number of Unit_ Other O Specify:
Brief Description of Proposed Work': 2CYr1DVC SOP I.JooO QLIC YXCI
W, S'i uC 01.n I rve.(J
Re$216ce Si_ S CrY D06C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost: IOfficial Use Only
Labor and Materials
I. Building S q 9'&-> I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S O Standard City/Town Application Fee
O Total Project Cost(Item 6)x multiplier x
J. Plumbing S 2. Other Fees: S
4. Mechanical (NVAC) $ List:
5. Mechanical (Fire
Suppression) S Total All Fees:f
6. Total Project Cost: S 6 1 Y8. Check No._Check Amount: Cash Amount:
(� ❑Paid in Full O Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES / J
5.1 Licensed Construction Supervisor irelcPhuft
]f � 7 00 �
DAN iel .SC(rJ/Q� icense NumM lispirutiun l rate
Name ul'l'St.- I lulder nst CSL Type fs. below)
6 �L�2/Yl�C 1 Jt9 fer Ikscri ion
U' I Iruouicted to)5.000 Co.Ft.
Restricted Id2 FamilyD%ellin
Signature M M Onl
q7P"8a5'�16RC Residential Roolin l'overin
1'elcpfa>ne S Residential Window and Sidin
SF Residential Solid Fuel Bumin A lia C lnstallatlun
D Residential Demolition
5.2 Reg�}tered Ho/pye Improvement onI c 1 7-7
1^I dme `�'I✓e"— �O 10 IRegistration Number
I IIC Company Name ur HIC Registrant Nome
(.� Dpn Sc✓t� 5�27 � IZ
Address .� Expiration Date
(� Sce,N (c � � JO v
-S;w,.y,,1e
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f 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 lssuancc_gf the building permit.
Signed Affidavit Attached? Yea .......... No...........O
SECTION 7a: OWNER AUTHORIZATION TO 8E COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si um of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
[bch*'1bpn ,'e1
Sct I e- ,as Owner or Authorized Agent hereby declare
t the statements and inform lion on the foregoing application are true and accurate,to the best of my knowledge and
\ 10
a uth Agent Dale
Eurbathroom's
under the ins and hies of 'u
NOTES:
Owner obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
t registered in the Home Improvement Contractor(HIC)Program), will ag have access to the arbitration
gram or guaranty fund under M.G.L.c. IJ2A.Other important information on the HIC Program and
nstruction Supervisor Licensing(CSL)can be found in 7R0 CMR Regulations 110.R6 and I MRS.respectively.
2. en substantial work is planned,provide the information below:
oors area(Sq. Ft.) (including garage, finished basement/anics,decks or porch)
iving area(Sq.Ft.) Habitable room count
r of fireplaces Number of bedrooms
of bathroom's Number of half/baths
heating system Number of decks/porches
cooling system Enclosed Open
tal Project Square Footage"maybe substituted tor"Total Project Cost"
CITY OF SALEM
PUBLIC 1'ROPRERTY
..� DEl AIZ"[' [ENT
III- '/•N •1;'/5'Ij � I \C: 'i'S.'J:' i Ja
Construction Debris Disposal ;affidavit
(required li)r all demolition and renovation work)
In accordance \%ill, the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal lacility as defined by MGL c
I t 1. S 150A.
The debris will be transported by:
� n Scvq (P�I `a-
1 name r t hauler)
I he debris will be disposed of in
�ainr ul laeihty)
laddrrss ul'Iacilityi
age lure ut : iit applicant
9 / 17 L
date �"T
CITY OF SALEM
; , f PUBLIC PROPRERTY
R - DEPARTMENT
=�ngo
.i V I!:NI 1'Y:11t Iq -1 rl.l.
Usn w I!.'WASHING IUN SI''KEL•T 1 SAIEN4,MsssACI It m Ia G197-Z
TiCi.:978-.745-9595 • F.sx:978.741'J840
`porkers' Compensation Insurance :iLffidavit: Builders/Contractors/EIectricians/Flu mbeIts
A ) rlicant Information Please Print Leeibly
V.CInC lBucio¢ssi Or,�,anituinNlndtviduu4:T1U C)n� C — o1U{IV V1
Address: 6 SceM I C
—
R� o77a
� y�.� ��
City,'`1I:ICCi Zip: 77) �'en/YC ( I-+=-- IshORC il:
a.rc you an employer' Check the appropriate box: 'Type of project(required):
4. Q inn a G. ❑I general coutractor and 1 new construction
I.❑ I am a employer with
en ees full andlur art-lime).' have hired the sub-contractors
Y ( P' 7, ❑ Remodeling
2 :un a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Middling addition
Ko workers' cum insurance 5. ❑ We are a corporation and its
� P• officers have exercised their 10.❑ Electrical repairs or additions
acquired.)
3.❑ I am it homeowner doing all work S P
right�ht of exemption per POOL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, ¢1(4),and we have no 12.❑ Roof repairs
insurance required.) t cmployees. (Ko workers' 1IM-Cllher <:�VI'1 A l OPGI C
comp. insurance required.I
•any;Ipphcaut that chucks box dl must alas till ow the union below slowing iheir workui cumpenaaaion policy inllunatiun.
'l Iomcuwnen who submit this affidavit indica,ing they are doing all work and lien him outside contractors must.uhmil a new al'CJavil indiutmg such.
:Conmwtor,that check this box must mrachcxl an aediriatinl sheet sfinwing nbc name of the subcontractors and their workers'camp.policy information.
l airs un eiisployer that is pruviding rvarkers'car»pensntion insurance fo•sty eitipluyees. Belory is the policy und)ob site
information.
Insurance Company Name:__-... - .....
Policy is or Self-ins. Lic.ft: ___.. . ----__ Expiration Date:
Job Site Address: — CiLy/State/Zip:
Attach it copy of the workers' compensation policy declaration page(showing;the policy number and expiration date).
Failure Lo secure coverage as required under Section 25A of:`IGL c. 152 can lead to the imposition of criminal penalties of a
tint up to SI.500.00 and/or sue-year imprisonrncnt, as well as civil penalties in the furor of a STOP WORK ORDER and a fine
Of up to 5250.00 it day against the violator. lie acivi.scd that a copy of this statement may be forwarded to the Office of
Incrsugauuns of lie DIA for iosurah:ee coverage orri Fication.
l do hereby terrify trader the poin.-used penuilies of periury that the inforinutino provided above is/true rust/correct.
SIV:nlinre: Gi Date•
I'11"re;, 1w_ _ — ac)( v
()fJiciul use only. no not write in this area, to be completed by city or town ofJiciul.
City or Town: _._ .. Purmit/License At-------- --
Issuing Authority (circle one):
I. Board of llcallh 2. Iluilding Deparnncut 3.Cilyi fowu Clerk 4. Electrical Inspector 5. Plumbing Inspector
G. Oh her
Cnulact l'crsou; . --_ Phone th
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 employer 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 an 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 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 if 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. NIGL chapter 152, a25C(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 ofconipliance 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) nume(s),address(es)and phone nuniber(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-insurcd companies should enter their
self-insurance license number on the appropriate line.
City or Town Offlclals
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 till out in the event the Office of Investigations has to contact you regarding the applicant.
['lease be Sure to till in (he permit/license number which will be used as a reference number. In addition, an applicant
('tat must submit multiple perinidlicerse 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 (hat 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 filled 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Office tit 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
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax Of617-727-7749
KcriseJ >-2G-Us
www.mass.gov/dia