35 MARLBOROUGH RD - BUILDING INSPECTION Nit, _ [lie Gimintm%te 0th uF Nlus,.trhusJtfs Li ilt
F Iit,urJ t,l 13wlJinc RC�111:111Un1 ,utJ Stund:uJs \II NI( II' \III 1
\ ,y �Ia,s.tchuselts Stute 13u+ldinc ('ode. 7SO CMR. 7°i cclition I
131111ding I'ern,it :\hPli .tlit,n Tu ('t,n,tru t. Repaii. Rcnotatc Or Dello,l+,h u I R, „l 4im„n
I llnr- rrr7lur-hruniltl)nrllirtt l _ ns'
Thu S non it Official 11Ne (hily --
Ru+IJ+ne Permit Numher -_ _-_ _ bate \ppbr/d _-- �C • 7k O
yi�.0 -- -
HwIJwF 1.'0111111 L.I uev In.lw•Lwr of ul n
- - SECTION 1: SITE INFORNIA FION -
1.1 Property Address: j 1.2 .Assessors Nlap S Part III Numbers
111�3P[-&SRO 1P1d - ---- ---- -
\la, \unihcr 1'.uNrl \umhel
I I.t I, ihu .m accepted ,trees:' ,a,—_�
1.3 Zoning Information: Id Properly Dimensions:
Zonu,g Dnm,:; Propt„ed L'Ne Los Area ny It Frun+aec I III
1.5 Building Setbacks (1170
j Front Yard tilde Yards Rear lard
F-
' KeyuueJ Provided RcyuucJ PnnIJeJ Requited I PiuuJrJ
r16 ater Supply: iM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
�/ Zone: _ Outside Flood Zone? Shmiapul ❑ On Nuc JIs1,oNal Ny,inn ❑9 Pn gate❑ Check it yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 .Owner'of Record-
Namt i Pnnt, Address tun Service:
Stenaatre Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) —J
_ I
New Curo;ntctiun ❑ Existing Building Owner-Occupied ❑ Repao,t,l_ I .\iter:+Hunt,) ❑ :\JJrtum ❑J
I Demolition ❑ Accessory Bldg. ❑ Number ut UnitsOther ❑ Speclty
Brief Descripntm t,tPrt,p(,sed Work': U / 13?lu/(i �/L l-�/�L7� _ �F J
IGf i WAfuZsi 0 � A� L SYI)NU £. �SY2 �IsP�I/ALT wily,
SECTION a: ESTINIATED CONSTRUCTION COSTS
Item Estimated Cots: OFficial Use Only
(I.ahor-and %latenalsi ___ - - - i
I Bnildine 5 / I. Building Permit Fee: S_ Indicate how sac IN dcteunu,CJ
❑ Standard City/Town Application Fee
2. Electrical 5 ❑ Total Project Cust' (Item 6) x multiplier
). I'lumhine 5 _'. Other Fees: S
4 Mechanical iH\'ACi 5 Lot -__----_-- ---
5. Mechanical i hi
focal All FeeN: S
Su , rrC,,I nI
('heck No _ ( IteCk Amount ( '.i,h \motill
o fut.1 Project Cult �C3U
0Paid III Full Full ❑ Uutet.utdme 13.iLuxr (hie
SECTION 5: CONS FRt CHON SFR% ICES
5.1 Licensed ('oiistructiosiSijper%ist)r ICSL)
Int Sl l,jV,,CCh,1 lout
I I 111"ill't'-d !�p,o Oil t
Lt,
RIL R,"J'f-ilal Roohll�
S V,-1111 1101JI IIILJ s'11111�'
sl- ft, \kd:j I lul, 1, \j) 11
.' egislered Home Irnpr)� nn eenl Contractor (111C)
M6PT1ttAC'r -- --./-7 0 7-6 - - --f
I at I oh�l
Illy Cis �Ia tine of "I" 11,0,41s"all %t I JIUJV.
.9040b
\ddr,
D"t,
l0cpholle
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT ItNI.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be omiple(edand suh..0 iced "t(h this appli,ao-m l:.IIlLaCt0j)ILI1Ide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached.' Yes .......... � No , .. . . 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED "HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as (-)\%ner of the piopeit-v hereby
oIth,-,Ize to act r'll Ill,t h,1):dt, ll; ,Ll! IlIallels
;c!.:jj%c tk) ,.%orkat-ahorized by thc building permit application.
Stlatia(ure of Owner Date
SECTION 7b: OMNER1 OR AUTHORIZED AGENT DECLARATION
I. A04V2.A t_ . a*. -()roe )rAuthotized :',gent hc,chy JeLlaje
that (he siarements and Information on the loregoint: application are true and accurate, to the best (it my knowledge and
behalf. A)
ehalf 14A) A-e-giAj 7-t
Print .Name
S'Llfldl .. of
0 nerorAUtttt ill/ctl Daic
(Suited under the pains and penalties of NOTES:
I. An Owner who ubtams a building permit to do his/her own work, or an owner who hires an Unle21liCled omliacfol
-trio( registered in the Home lmprosement Contractor (HIC) Program), will twit ha,e at:,cN, to z1heathiti3tion
program or Lpuarantv fund under I.G.L. c 142A Other Important intormationon the HIC Progi....i and
Construction Supervisor 1-ccrising 1('Si.) can be totind in -80('SIR Regulalions I I(). R6 and 110 R5. rr,pe lock
When substantial work is planned, pros ide the inlin manon below,
Foal lloorsarea;Sq Ft P im,ludirly garage. finished ha,emenf/ani,s. decks t�r ji,a,h,
foln"area lsq
I Fr.) Habitable o,om count
Nuiriberct nieplaces--_ NILIIIbCr I It hcdro,,in,
Nlnnher M l"Iffilo.'rils NLljiihcrof hal: hJ!hl
I healing ,%,tern III 11CLk" 1),-i h%:,
I pe
I-,tal Prl,jeci Square ( ,,,cage' 171a.v tVIL1111111LITed for T1a.i1 Ph'1400 ("'11
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I2^-WASHI\d1ONSIXLLr * 5 Y.+,M,\NN\0aitiis0197^C
'fc1:978-715-9595 it 17sx. 978-741C.A46
Workers' Compensation Insurunce Affidavit: Builders/Contractors/Electricians/Plumbers
f licant Information Please Print Lepibly
Nain( l0uwtcsy OrganiratioNlndro tlua4: �r77Yr`t G/� �' r a "' �
Address: --r{ -- _
City,stareizip !� l�r/?' rnR Phone0:
I
:arc u an employer! Check the appropriate box: Type of project(required): -
A. ❑ I :un a general contractor and ! 6. New construction
I. I am a employer with�_ ❑
employees(full an(Vur part-tints).• [lave hirod the sub-contractors 7. ❑ Remodeling
7.❑ 1 am a sole proprietor or partner- listed oil the attached shcet. :
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
INo workers' comp. insurance 5. ❑ We are:1 corporation and its MC] Electrical repairs or additions
required.] officers Ilave cxerciscd their
ri ht of cxcnlptinn per MGL 11.❑ PI robing repairs or additions
3.❑ I and a luimcuwner doing all work S
myself. LKo workers' comp. C. 152, S 1(4),and we have no 12. Roof repairs
insurance required.) t alnployces. LNo workers' 13.0 Other
comp. insurance required.]
1m:5glbunr thin checks box MI must:dsu sill Out these below shuwiny their wurktas'eumpensatiwl policy iofurmativa
T i lamatwnem who submit this aniJavit indicating they ate doing all work aiuf then hire outside caurxton must.uhmir a new al'f:davit indiurmg such.
-('>mrxmn Uwt chuck this boz moor niachod to additional.sheer hawing the name of the sub-sintmclors and their workers'comp.policy infix marion.
l still an employer that is pro vrdittq workers'c•ouipensation insurance fur illy employees. Below is the puhcy and lob arte
iuformatron. j -,
Insurance Company Vame:L�, �C UAL fW
Policy a Air Sclf-ins. Lic. ----t-- . .-- Expirauon Date: `2] 4I
p
Job Site Address:_ —9!— City;StutG"Lip: SQL H 1 631� d� /�6
Allach it copy of the workers' compensation policy declaration page (showing; the policy number and expiration date).
Failure to Secure coverage as required under Section 25A ul'>IGL c. 152 can lead to the imposition of,criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil Penalties in the t-orm of a STOP WORK ORDER and a fine
of op to 5250.00 it day •tgaltlst the Violator._ He advised that a copy of this statement may be forwarded to the Office of
In\'i]Ilgal U>rlf of dt; DID :Or inYtoarice coverage \eritic.11ion.
l da hereby rertrfv under due p urns and prttrrl ice of perjury that the information provided above is true and correct.
Dare. 4-�a—o e
O(Jrcinl use duly. no star Quite in this area, to be cunipleted by city ur tolvn 11Jivial.
City or Iblvn: -_ -, PcrtnitiLicense x_ - ..
Issuing Authurily (circle one):
I. Iluard of Ilvallh 2. Iillildiug Dcparuncut 3.CitJ,rl'onn Clerk 4. Electrical Inspector 5, Plumbint; Inspector
6. Other
Contact Person: -- - -- Phone ti:
Information and Instructions
Massachusetts Gcncral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined its-...every person ;n 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
„f the tarogouig engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee uf:m 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(rouse 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."
.%IGL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of u 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, viGL 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 compliance 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) nanme(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 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 the affidavit for you to fill out ;n the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill ;n the penniblicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennitAicense 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 chat a valid affidavit is on file for future permits or licenses. Anew 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
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Otlicc of Investigations would lice to thank you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OIHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE
F
itcviscd i-_16-05 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
a � PUBLIC PROPRERTY
DEPAR"I''VIENT
'.I R I'C \C.;;iun;,.,wS IR1I r • SAI rat. \1\.;v .., " I
'I'I'I ')78-'4;:);4i ♦ 1:\,\: 978.174�_-484e
Construction Debris Disposal Affidavit
(required li)r all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Dcbi is, and the provisions of MGL c 40, S 54;
Building Permit if 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:
two oL4�/ lJt�rP
_-
(name of hauler)
The debris will be disposed of in
(name of facility)
address of Iacilav)
}ignaturc of pe nit t plicant