1 LAFAYETTE PL - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
11 Board of Building Regulations and Standards CITY
I / / OF SALEM
MaSsae'husCIU State Building Code, 780 CMR, 7*edition
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Building Permit Applicat' n o Construct, Repair. norrte Or Demolish a
,One-(11, Two-Family Dw ing
i ion Far 1cial Use Only
Building Permit Num - Date Applied: t (L
Signature ( d ' � ` l Q
Buildi Cummissioned 1 or of Buildings fate
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
L A I+ l*>G4GF
1.la Is this an accented street?yes u no Map Number Parcel Number
I..) Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arno(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40.§54) 1.7 Flood Zone Information: 1.8 Sawage Disposal System:
Public O Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
� � tt-.1_tC%
Nome(Print) Address for Service:
CL"� 03(6�1
Signwure F' Telephone
SECTION Si: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) Or Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description or Proposed Work': ~r
S��y< A4 1rf�l),ec),1
r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Of elal Use Only
Labor and Materials
1. Building S 1. Building Permit Fee:f Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
O Total Project Costs(Item 6)x multiplier x
J. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) f List:
5. Mechanical (Fire S
Suppression) Total All Fees.S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S,1-dOV00 ❑Paid in Full ❑Outstanding Balance Due:
14'a-IC TO Ml7- cvme"06� >
l �
SECTION 3: CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor(CSL) r s 1-39Q.—
C•%G r>Lli fJ ✓(Zr+ I.iccnse Number li.vpiraliun Oute
Name of CSI.-I lolder 1list(.'SLr)pe(-%vbelow) U
a/ ���xnc% .iiAS lt/L, l�fia3nlJjr f Oestri ion
Address _ —— U l InmctedJ w Jly D Cu.Ft.
�9t � R Restricted IAZ Famil lTvellin
Sign;r(urc M Mal
9795' (per>?�99 RC R�,idemial Routin Covering
TeieplrmeI WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Imtallatiun
D I Residential Demolition
3.2 Registered Home Improvement Contractor(HIC) NDS7�
S (yRs>SfPi 3C3r19'✓ Registration Number
I IIC Com y Name ur f11C Registrant Name
�21
Addn:
M
92 ?Gs-9?.9Q Expiration Dale
Signal - Tcleplaate
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 132. ! ZSCM)
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 .......... W No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize 2e7.v9'et,t-tJEP'`-�' to act on my behalf,in all matters
relative to work authorized y this building permit application.
Si urcofOwner 1" Date '
SECTION 7b:OWNEW OAR AAU-T--HORIZED AGENT DECLARATION
I, lti) t. L-t a\4� �'`I t L-C��`t.�l ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are we and accurate,to the best of my knowledge and
behalf. p
P i Nom(}l"VY< 'h- A
Signature of Owner or Aulhonzed Agent We
(Sisuicd under,the pains and penalties of 'u
NOTES:
I. 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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I I0.R3,respectively.
2. When substantial work is planned,provide the int'ormation below:
Total floors arca(Sq. Fl.) (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
J. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
' - DEPARTMENT
�1.w n la CI-.W nsluvt:fo.N STa ELT • SA I EM.MASSACI a .al:rr s 0197.
11•.1.:918-745-9595 ♦ T.sx: 978.740•9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
1ty ylicant Information Please Print Lecihly
Name lBusinessOrBannatiaNlndlvulua4:
Address: .
City,sl:uc;/.ip �7fi4fyC�l�t/ /'�A . Oi9ld� Phone i'-: 97b' 02 5�' 3R9
.%reyou an employer? Check the appropriate box: 'Type of project(required):
LK 1 am a employer with 4. ❑ 1 am a general contractor and t 6. ❑ New construction
eniylu ccs full and/or art-time).' have hired the sub-contractors
1 y ( P ❑
2 ncuv or antCer- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have K. ❑ Demolition
working for me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
No workers'cont insurance 5. ❑ We are a corporation and its
� P• officers have exercised their 10.❑ Electrical repairs or additions
required.] a
3.❑ I ❑m a hom11.eowner doing all work right of exemption per MGL ❑ Plumbing b repairs or additions
myself. LKo workers' chop. c. 152, ¢1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. LKo workers' 13.❑ Other
comp. insurance required.]
'A ny:ylpllcaul dot checks boll el mull:Ilbo Tilt oo,Ihl'w-c000 buiuw showmi;Ilivir work rs cumpeMmiwr policy infer halon.
'I lomcuwm"whu sllLmil Ihis affidavit indicating they,are Joint'all work anal then him uutside curameton muse ,uhmit a new al'fdavit indi"ing inch.
-C'onenclotl/hal check this box moil auachcd an additional.Axel showing the nmne of the sub-contractors and Ihen workers'comp.policy infurmarion.
/nor un employer that is providing workers'c•onpen.ration insurance fur my emplayeec, Below is the policy andjob site
inforatutiun. _
hisurancc Cornpany Vmne: � r>a�_
f2-9 ..— X7AJ ------
Policy 4 or Scif-ins. Lic. it: ------_- Expiration Date:
Job Site .Address: I G-A6r-A1r<t!' .ISI naCE CityiStateizip: S'A/rara ^eq.
.\each,t copy of the workers'compensation policy declaration page (showing;the policy number and expiration date).
vailure to secure coverage as required under Sedion'_5A uf.vIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.5110.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine _
Of up to 5250.00 it day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
InYcsmgauuni ul'the MA for iounarce coverage verification.
I do hereby terrify ender the pains died penalties of perjury that the imforinut in provided above is true tend correct.
SI loin Datc• �d —�O " f[°7
�� Ti
Ill + 979 962 -5-- 93P-9
Ofjiciul use only. Do not write in this area, to be completed by city or town ojJirial
City or Town: _ __ Permit/License 90----_.._
Issuing Authorily (circle one):
I. Board of llealth 2. Buildinq Department 3.Cilyi fowsn Clerk 4. Llectrical Inspector 5. Plumbing Inspector
6. Diller
Contact Person: _. . ._. Photic it:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is detined as"an individual,partnership,association, corporation or tither legal entity, or any two or more
of the t,regoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of :u individual,paitnership,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, w'25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewul 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
anter 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)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 affidavit. The affidavit should
be rctorned 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.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicense 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The 001ce of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Deparnnent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021 If
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax Of 617-727-7749
itcviscd 5-26-05 -
www.mass.gov/dia
L fI Y (, )r OALLM
f, PUBLIC PROPRERTY
' DEPARTMENT
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Construction Debris Disposal .affidavit
(reyuiied lirr :ill demolition and rcnuvation wurk)
In accordance lith the sixth edition ufthe State Building Code, 7SU CAIR section I 1 1.5
Dcbris, and the provisions ul"AGL c 40, S 54;
Building Permit H is issued with the condition that the debris resulting front
this work shall he disposed of in it pruperly licensed waste disposal lacility as defined by MGL c
I 11. S 150A.
The debris will be han,portcd by:
3n
t it. me of hauler)
Ile debris will be disposed of in
(mm�r ul tact tty)
•• F, i3 rl_'-�l 5f• 1'f�913n1��
lay dre..w facility)
¢name of pannit appltcanl
/o-la /o
tate
iiassacltuselts Dep:u'nnent of Public $:doth
"��YYBoard of Buildin„ Re
1f Construction supervisor License Licensei��fl tI ds
License: cS 83956
STEPHEN D CUMMINGS £
21 POCAHONTAS DR
PEABODY, MA 01960 1
Expiration: 10/l/2012
(bm"issiuuer
TrY: 5304
P� ✓�of lOOnvbz04t�l o�./�LadJaC�<taef a i
Omce of Cogsumer Affairs& asiness.tte a1 Uon
HOME IMPROVEMENT CONTRACTOR-
Registration:
ONTRACTOR Registration: 140576
Expiration: -10/2712.011 Tr# 289061
Type:,., DBA - -
CUMMINGS CONSTRUCTION -
. STEPHEN CUMMINGS: "
21 Pocahontas 6iMi
Peabody;MA 01860 . �' - - iladersecretnrg