436 LAFAYETTE ST - BUILDING INSPECTION �•� � SZ'123�
The Commonwealth of Massachusetts Cr6t'�
Board of Building Regulations and Standards
SALEM
Massachusetts State Building Code,780 CMR
Revi IKV O 1.
2p;
Building Building Permit Application To Construct,Repair,Renovate Or Demolisja
One-or Two-Family Dwelling
Q This Setdan For :Use .
�' Building Peik.Ntmibea Date APP .
1 Bui!ding.offlo f(Pratt a➢: Sipsiece e
SECT 0N.l:MT!£Il+T Dt1lMIAT101`1
1.1 P rty dress: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted Areet9 yes_ no Map Number Parcel Number
13 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public❑ Private❑ Cbeck if es❑
SECTION 2:
0ItOY1SRTY OWNERSHIP,
2.1 Owner'of R :17 MA Q
Mdl u�� cNC er �Q l� .. /►( 19 3
Name(Print) City,State,ZIP
,{36 lit ��TrR �t �/$ 28'S�SaS i(tcin'Af&O,aSAue-Lo_nt. .®5
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction 13Existing Building r3 Owner-Occupied E3Repairs(s) ❑ Alteration(s) ❑ Addition 13
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify.
Brief Descrile
ption of Proposed Worl2: Nd fz i, i c. _e r doll b
v o�i�.., d
SECTION 4:ESTAlATED CONSTRUCTION COSTS
Estimated Costs: Oficial Use Only
Item (Labor and Materials
1.Building $ 1_ Bulkling Penult Fee:$ Indicate how fee is determined:
t]Standard City/fown Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2, Other Fees:
4.Mechanical (HVAC) $ List
S.Mechanical (Fire
r6,1Tatal0ject
$ Total Ali Fees:$
xo Check No. Check Amount: Cash Amount:
Cost: $ J2. 550 p Paid in Full ❑outstanding Balance Due:
1014 — No Pia — io G .C .
aw - Doo _Yn�6 - ISI
SECTIONS. CONSTRVCI'IO1N VICES
�[ rounruction Supervisor License(CSL)
/ / A . le /; LicenseNumber Expimti Date
List CSL Type(see below)
T)Pe Description
tti D 6 U rpt/ Nl,4 4� R ted l&2 ed(Buildings
miDwelling
o00 Family „.tL
6ty/rown,State,ZIP M I Masonry
RC Roofing Coveting
WS Window and Siding
SF Solid Fuel Burning Applia9ExZpirmiDate
/ Q 5 �'� Mar iv cowf7l/C I Insulation
Tel hone Email address 'n"'j0 9.® D Demolition
5.2 Regisf ered Home Improvement Contractor(HIC) 5A-A-1-ca. r�Q,Z/O -;2-7
�rt('ty'/N a✓ �^t4 e-ft — C HIC Registration Number
II�C Compao�ame or HIC Registrant Name �q
/0�1 7/'2r'o�. T �/� 1 "p'i 't/
No.sed St �, 6 y� Email address
tle 6L 2!,Ci /Town Sta ZIP 9 16 r1ar1'u G�Nf !/f/1 Oj✓M� �6 f .(� -
SECTION f:WO1t Ml&COIF MMATION IT SURANCE AFFIDAVIT(NLG I c.152.3 2SQ,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........... O
7a5 OWNER AUTHORIZA TO BB C6AdPLETED WH>N
OWNER'S 191 OR OR F41R 13MMM PUMM
I,as Owner of the subject property,hereby authori
to act on my behalf,in all matters relative to work authorized by this building permit application.
PrintOwner's Name(Electronic Signature) Date
SECTION 76:OWNER/OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
-
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
wtivw.mM og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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"
r-
IRLOffice of Consumer Affairs&Business Regulation
� UME IMPROVEMENT CONTRACTOR
i_ ration r40218 Type;prratroa�10/2%101.6 Corporation fR{
. " MARIN CONSTRUC�Y(OW4WN8 j+iu
NAYHARA PERETUO ��
104 TREMONT ST
APT�'3
PEABOD !` -
Y,MA 01960 Undersecretary `
1
. i
� I
The Commonwef►O ofAfarspchusem
Deparhneitt ofbrdnst WAeadents
1 Congress Sfivg Suite 108
BoM.%M.402114=2017
www.ma=govMdia
Vj Workers'Compensation Insurance Affidavit BuilderstODntmdors/Elechicians/Plombem
TO BE FUM WITH THE PERMIZI'MAUrROArrY.
AnplteaM Informs tioa: Please Print JAMY
Name(Basinmagammumolnmv dtt : /�G�i�l �/ G✓�/f�l/fJC7� .L C
Address: / 'Tr(f/M ,✓l 5-1 q
City/State/7ip: /U4A „ 60Phont>#: . �X
Are you m emptoW Ciera the appipprfate-bo:: � Type of prof P.e!(negalr d):
1. Iam a employer w;m_� (roll marmpan-t®ej - • 7. ❑New consrttwtion
2. lam gmktaoppiekrmpmWaskip®plavewemploXgm worl�g fmmem g; oRcoodelin ..
myet@aeity:(No wadses''aomy.ieaoioee ra9a6'edl .
9: Demontiba
3p!.manomeo.roedftaoworke>yxc(No worima•camp.;os�.a�ra .)1 topsw�mogsii�au.
4.01®eeom6wrcim wi11ImhkingeanVacuntocandManworkWNWpoperly. i.nl
em dmt an wmaaas either ha wwkm'wvpemmon mnoa mm mle 11.0 Elect icel reps or additions
y op;erpa.wimao.myloyeea 12'OPlarift coahsactiddiddns
s.❑i.magmasl wa�md lhsveldret me eubtmasefur luoeb on me ddbat: 13 ❑Raofrepairs.
7Leaeanb-conaaeoma6m®ployas aodheve wo>)rm comp-�^=^�t- .
6.0 We m a cmpomli®avd tk otSemslwe eamciaed thwkrigla ofeaemp0a®pcldGL c.
14.QOthec .
15$17(4),end wetisFeroemployeta:pto x'oikda•2bmp.me�vmce.�agesaA.):� :
•AmyVOir%immeladobou"map akoame ey
0 om teaitm kakwikowmg irtrkers a pok - ,
t Homebwuem Who wleait db&Tmldviti riimgSO am&fig A worker meaibi6 aaiude maer"saLmf�triewatbdevai gsuch
tCamanemia mat eLerJitkiitioumat etWSlKdaadfiGmalaheetaLawmg Poaemme.,:ofa�E aub�atiu+a�amte�ulidffimnmtA�iooiita eve
employees.Ifthe,sub-conaac_tP.naeveemp]oyx4 iaeX must poridrt8eu wnaas'eamp.PaMpammme-. -.. :�:... . -
I am an eaployer Ow irpwigns warkars'eompasnow isswaseefor�y empl . Below is the poGryaa4/obShe- "
ltmmant a Company Name: 2�^'� ` ( C V .f/fy(/m c
Policy#or self-ins.Lie.# I— S 3 �� Btphation Daft-_V1
Job Site Address: CRY p. -
Attach a copy of the workers'compensation polhy declaration page(showing fire policy number and erpirstlen date).
Fajure to sewre cove sge as iegiSed under MOL c. 152,§25A is a criminal violation punishable by a fine up to$1,50000
and/or one-year imp nsom .ft as wen as civil penalties in the form ofd STOP WORK OR1)BR and a fine of up to$,?30.00 a
day spiral the vioLitw.A copy ofd&statement may be fol wailed to the Office oflsiveaugatiama.ofthe DIA fan inaueace
coverage verMeadon:
Ido hereby eatify ander Aepaors and penahim ofpajary that the Information pmpided above a hwe and correct
S:_at..e Date: Eve/
Phone#• `) ;)-X & ? C `1 7 y (/
Official ase only. Do no mile in this area,to be eoropleted by city or town oJ/feisL
City or Town: Permlt/idanae#
Issuing Authority(thele one):
1.Board of Health 2.Building Department 3-City/Town Clerk 4.Electrical inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for the employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofbire,
express or implied,oral or writtep."
An employer is defined as"an individual;partnership,associstiem,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 in individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more them three apartments and who resides therein,or the oecupsnt of the
dwelling house of mother who employs persons to do maintenance,construction or repair work am such dwelling horse
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 15%§25Q§)also states that"every state or local licensing agency shat 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 far 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 chectdng the boxes that apply to your sinietion and,if
necessary,supply sub-contractor(s)namo(s),adilress(es)and phone anmber(s)along with their oxrtificate(a)of
insurance. Limited Liability Companies 91or 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 titres leave
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 peanut or license is bang 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-irsured'compmies should enter their
self-insurance license number on the appropriate lime.
City or Town Officals
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 pemntBcense 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 oarreot
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 dqg license or pemrit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Depertment's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017.
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
/// A RIN PROPOSAL
CONSTRUCTION, INC
58 REAR PU;ASKI ST UNIT L6
PEABODY, MA 01960
978-826-4196
marinconstructionma@gmail.com
Name/Address Date Proposal No. Project
Maureen T Mercer 07/21/16 1647
436 Lafayette St Salem, MA 01970
Item Description Quantity Cost Total
1 Roof- Demo 8 SQ approximately of Decking Floor& Rubber 6,900.00 6,900.00
Roofing layer down to exposed Slab Cement, Install Insulation, 3x3
Aluminun drip edge, &Install 8 SQ approximately of Rubber
Roofing
1 Deck- Framing (PT) 1,900.00 1,900.00
1 Deck- Install 8 SQ of composite decking Flooring (Labor Only) 2,900.00 2,900.00
1 Permet Fee 250.00 250.00
1 Disposal 600.00 600.00
Total $12,550.00
signature: � �
OTY OF SALSA N ASWASET7!
BtnDMDsrAXMkMrr
JMWA9MCMSVM7jrROCJt
DL"745-9595.
Fix 740-M b
$IA�BRiBl'DL
MAYCR 7?saresSzP�ncE
Dnwcrc#t crrt=xnKr=T/BumEiwaxaosgcisn
Construction Debris Disposa/Affida►vit
(required for all demolition andrenovation work)
in accordance with the sbcth edition of the State Building Code, 780 CMR, Section 111.5 Debris;
and the provisions of MGL coo,S 54; Building Permit 8 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111,S 151.
The debris will be transported by:
(name of hauler)
The debris will be /disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
r,
�W
Mass Only
authorize Marin Construction to pull permits using my
CS License # "_ — 090[1,'
7 and my
HIC Registration # 02, 1'S
Any questions please call me at 9 71a [ — U 5!:�
Installer Signature ��—
1
Company Name 4(L t N bNS u i a.0
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-099871
lonstruction Supervisor
MICHAEL A DEFELICE JR ` t '
54 DAY CIRCLE
WOBURN MA 01801
Expiration:
commissioner 0612912018.