184 LAFAYETTE ST - BUILDING INSPECTION (2) la
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One- or Two-Family Dwelling
U9 This Section For Officia e Only
Building Permit Number: Date plied: /
0
Q0 Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
_n 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
i 0 & rF,4Y�77C c57-
1.l a Is this an accepted street?yes ll no Map Number Parcel Number
v
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
ty, c . RC l7i4sl/y E2-C ,U
Name(Print) City,State,ZIP
A-f 146/_TEh! C57_ e-70
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORICZ(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work: D rS�/ GU 'T0 d- )cSLAI
zN1.J "aoo
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ S -00 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑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: $ S1 ZO-Q ❑Paid in Full ❑ Outstanding Balance Due:
M I�t t t -� 'S'l t -z.-
,y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) G,g ,U 2y.7 y 1- b /Zy
i(•l (K� C(T/fit/tt/ License NumberJ J Exptrauon DateO
Name of CSL Holder X/
List CSL Type(see below)
lz W NUN?:2. 5T.
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
Ci /Tohw,State,ZIP `7 R Restricted 1&2 FamilyDwelling
City/Town, M Masonry
RC Roofing Covering
WS Window and Siding
7 2 SF Solid Fuel Burning Appliances
78� ) Z�j✓� /u<</CO t?�Cp/QL I Insulation
Telephone mail address heD Demolition
5.2 Registered Home Improvement Contractor(HIC) ( 3 Z12 y
I"1 ^ L Nt G�/�N HIC Registration Number xpirati n Date
HIC Company Name or HIC Re istrant Name
No.and Street 1.1 — Email address
3/ - 3
«Z r2fM �+�d�(� X711 g Zrs3
Ci /Town,State,ZIP 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
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.
No2ekeA & QC-
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby st un a pains and penalties of perjury that all of the information
contained in this application is true nd ac ur e t the best of my knowledge and understanding.
1 Wziz c Le6b* 4 r- 9 - 3 -J117
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at w�ov/dps
2. When substantial work is planned, provide the information below:
Total floor 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 CommonweaM ofMassacltusetts
Department ofindustwa ,4ccidents
I Congress Street,Suite l00
Boston,MA 02114-2017
wwwmassgov/dia
WVVorkers,Compensation Insurance Affidavit:Builders/Contractors/Electricians&lumbers.
Applicant Information TH
TO BE FMn WITHE PERM TnNG AUTBORrry.
' Please Print bt
Name(BusmeWOrgammtion%dividuan: /�L.�Trit/.rJ ('�A / e'
Address: Z
City/State/Zip: /Z /
CI hone#: _ �'/ 7!�—3/eL — 5
Are err emP40Y Check We appropriate box:
l. am a employer with�_eaupbyces(fWl and/or . Type otproject(required):
part time]' 7. ❑ w construction
2.❑I sin a sok paopoietor or patmuship and have no employees woridng for
in
any capacity.[No workers•comp,issuance regmM] 8. Remodeling
3.❑Iam a homeowner digun wodc myself[No workers'comp.mqurance required]t 9. ❑Demolition
4.❑I am a homeowner and wan be hiring cmuwtors m conduct as work on my property. I wig 10❑Building addition
eaaue that eU rnmhaerom either haw workers,armee `m msssuce or are sole 11.❑Electrical repairs or additions
FMMcrom with no employees.
5. I sm a 12.0 Plumbing repairs or additions
❑ general enol and f mvehuM the rub-rosome me:limd on the aaachea shat
These subcontractors have�P1oYes and have worker'comp,mstsance: 13.❑Roof repairs
6.❑We are a cmporaUm and is officers have exercised theuright of exemptrcm pa MGL c 14.❑Other
Is2,§I(41,and we mve no employees.[No workers•comp.intueoce required]
'Ary applicant thin rkaks box ill mut also fir ora due radon below showing their workers'eompensadon puolicY foformad®.
t Homeowners who submit this afidmt mdicomug they am doing all wuk and then hue ouuide conuwtm must submit a new affidavit uslicadog such,
tConsaemm that check this box must m ached ao additional shat showing the name ofthe sub-cont apms and state whether or not those entities have
employees. "'the subcontractors have employes.they mut provide their worken'coogr.polkynunber.
J am an employer that isprovidnrg workers'coaspensanan insurance for my employees Below a thepolicy andjob site
hrformadon. , /
Insurance Company Name:__ /VI � OV 11VA �d S
Policy#or Self-ins.Lic.M Expiration Date:
Job Site Address:
hry'Attach a copy of the workers'compensation polity declaration page(showing thepolicy
number and expiration date}
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
iso kereoy certify anderr thepam- s aa/ndpeennaa�hhl otf wy that the mformahon provided above is true and correct
Simature• ���!/1Lrr.('<<-- ' Date
Phone#:
FFOther
on({e Do not write in this area to be complied by city or town official
Town: PeradVUcense#
hority(circle one):
ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
on• Phone#
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 m 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 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 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-contractors)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 a1lJdavit. 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 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 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 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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