15 LAFAYETTE PL - BUILDING INSPECTION (2) {
The Commonwealth of Massachusett F�ht 6r i V V ICES
I t Board of Building Regulations and Sta& CITY Massachusetts State Building Code, 780 CMR SALEM
rf: ,�1tIII1t,S � 24 A 'Med,tlur_'
011
O Building Permit Application To Construct, Repair, Renovgt" molish a
One-or Tivo-Farnily Dwelling
This Section For OfTicta se Only
• � 11 Building Permit Number: Date pplie&
Building Official(Print Mane). - Signature - Date
t SECTION 1:SITE INFORNIATION
,
i 1.1 Property A dress: / 1.2 Assessors Map&Parcel Numbers
�
r 1.la Is this an accepted street?yes" no Map Number Parcel Number
V _
y 1.3 Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
j Required Provided Required ProvidedrMunicipal
equired Provided
i
1.6 Water Supply:(M.G.L c.Jo,§5d) 1.7 Flood Zone Information: wage Disposal System:
Zone: _ Outside Flood Zone? �On site dis sal s stem ❑Public ff, Private❑ Check if es❑ p0 y
SECTION2: PROPERTYOWNERSHIPG
2.1 Ownert of Record: D
Tt/O'k4s .tea c rho ti4r.A S r✓� �tr9 D 9 7
t N7 anc(Print City,State,ZIP
/_ g- lT8?�t� -7� rr7o s2 Zs3 � �
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner Occupied ❑ Repairs(s) O Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work":c r C4 7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 'a's-060 a 0 I• Building Permit Fee:$ Indicate how fee is determined:
r e ❑Standard City/Town Application Fee
?. Elenrical S a + ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S Z G^C'i 33 Qther Fees: S
d.Mechanical (1-IVAC) S List:
5.Mechanical (Fire S Total All Fees:S
Su ressiun)
eG Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S 36 , ❑Paid in Full ❑Outstanding Balance Due:
Y
I
I
' SECTION 5: CONSTRUCTION SERVICES t
,
5.1 Cmistructiott Supervisor License(CSL) Q kii 1 -7 6!
1 U� I C �� � License Number Expiration Date
Name of CSL[folder 1 1 List CSL Type(see below)
"Type Description
No. ;md Street s
U Unrestricted 2 Farm s tip to Dwelling
cu. tl.
R Restricted I&2 F:unit Dwellin
I City/Town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
r;
SF Solid Fuel Burning Appliances
78/ 3 71*6 1 insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC), 3 gZ� 3 1
��, �-`- • +,,�L A <k-y- a Vt HIC Registration Number Expiration Date
1 HICi Company Name or HIC egism at Name
1s7ilY`f n 1nr y `Vl�
I No.atJ Street Email address
ICI Q DI W 29 7 S./ 6 3 i 7/r9 R
Ci /Town State ZIP Tele hone
SECTION 6:WORKER$'COMPENSATION INSURANCE AFFIDAVIT(Iv1.G,L c.ISZ.g zsc(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 lsluance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERM IT
1,as Owner of the subject property,hereby authorize_
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) a1e
SECTION 7b:OWNERI 6RAUTHORIZED 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.
3 /2 3
Print Owner's or Aut torized Agent's Name(Electronic Signature) Date
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 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.uov:!oca Information on the Construction Supervisor License can be found at evww.ma� _
2. \Vhen substantial work is planned,provide the information below:
'total floor area(sq. ft.) ~ (including garage, finished basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'rype of heating system Number of decks/porches
'rype ofcooling system Enclosed Open_
3. •'Total Project Square Footage"may be.cubstituted for"Total Project Cost"
'Massachusetts -Department of Public Safety.
Board of Building Regulations and Standards
Construction Supervisor `
License: CS-066176
;.
°,.
FRED L DESCHE!•lES
1SOUTHERN1MG
ESSEX MA 019A
J C . -,X ,rro i. Expiration
Commissioner 09/27/2015
j 1. ��ze�Oanvnearu�sea,�,l�oiraelt
Once of Consumer Affairs&Busr/b/��
oess Regulati0o
OME IMPROVEMENT CONTRACTOR
egistrabon: 138262 Type:
xpiration 3/1312015 - - Ltd Liability Corpf.
F L DESCHENES CONSTRUCTION LLC.
i FRED DESCHENES ",
.4 1 SOUTHERN NIGHTS - g
t9 ESSEX,MA 01929 Undersecretary
The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street, Suite I00•.
Boston, MA 02114-2017
www.mass.gov/dia
`,fiorkers.Compensation Insurance Attidavlt:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERIDBTTING AUTHORITY.
Applicant-Information!`; '7 Please Print Legibly
Name (Business/Orgaiiization/in(lividual):
Address: 1 sett "C pd �1 gi k
City/State/Zip: Phone#:
Are you an a pliryer?Check the-appropriate boi 'i4 Type Of project(required):
L am a employer with t employees(full and/or part-time).*- , I - -
7. []New construction
2. 'I am a sole ro rietor or armershi and have no employees workin far me in
❑ p p p vg 8. RlIkemodeling
any capacity.[No workers'.camp.insurance required.]
+' r 9. ❑ Demolition
3. t❑l am a homeowner'doinp all'Ada myself.[No workers'comp.insurance required.]t
4.❑.I am a homeowner and will be hiring contractors to conduct all work on my property. [will ]0❑Building addition
•ensure that aiPcontraetors either have workers'compensation insurance or are sole 1 L❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurances 13.E]Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lConnactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �. � T- L
Insurance Company Name: G t1 0.Y` t/l Y-o`YI
Policy#or Self-ins.Lie.#: FL-0 G -S 3 Z-191 Expiration Date: Z
Jab Site Address: �5 Lk4 ky Fi41 f% KaL �� City/State/Zip: S 4XjM Mk Mq 70
Attach a copy of the workers' comp nsation policy declaration page(showing the policy 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 form if a STOP WORK ORDER anda 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.
I do hereby certify under the pains and penalties ofpre(r/jury, that the information provided above is true and correct.
Signature Y.t/LI L�%�ei' "��i�'� Date:
Phone#:
Official use only. Do not write in this aiea,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle,one):'..,,,, ,
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: 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 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'l52, §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-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 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 permitAicense 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
i
QTY OF SALEM, MASSACHUSE TISS
BUTAING DEPARTAENT
120 WASHINGTON SIMT,3w FLOOR
11;L.(978)745-9595
KRaERLEYDRISCOLL FAX(978)740-9846
MAYOR THomAs ST P ERRE
DIRECTOR OF PUBLIC PROPERTY/BUIIAING OMIMSSIOMR
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit#
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 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
x . a
(name of facility)
(address of facility)
Signature of applicant
Date
i