15 LAFAYETTE PL - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mai-2011
Building Permit Application To Construct,Repair,Renovate ennolis a
One or Two-Family Dwelling
This Section For 0 tal Use OnI
Building Permit Number.i P/teAppfic d:J,.,
Building Official(Print Name), Signature Data
SECTION 1:SITE INFORMATION'_�. .
1.1 Property dress: 1.2 Assessors Map&Parcel Numbers
15 1140(AC"? Place 1
Lla Is this an acce'p'fcd street?yes no Map Nwnb.er Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
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 0 Private 13 Zone: Outside Flood Zone?
Check if veqO Municipal 0 On site disposal system 0
SECTION 2: PROPER OW TV , NERSHW!.
2��e ooalF��Jaa()Ona,Ck SoleM MA
Name(Print) City,State,ZIP
15 LaFagike p 1 0116- -444- 5*422
No.and Street __�Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'.(check that'apply)Y)
New Construction 0 Existing Building)d Owner-Occupied 0 1 Repairs(s) 0 1 Alteration(s) C73 Addition 0
Demolition 0 Accessory Bldg.1:3 Number of Units Other 0 Specify:
Brief Description of Proposed Work: 71_n5(�04 4101K
'�i,'SECTION 4:ESTIMATED CONSTRUCTION COSTS'
Item Estimated Costs:
ofrlcia,lusi only, -
(Labor and Materials) 01 I
1.Building $ I., Building Permit Fee: Indicate,how fee is determined:
2.Electrical $ 0 Standard Cityaown Application Fee,
0 Total Project Cost;(Item 6)X tuituphe'r' "x"'
3.Plumbing $ 2. Other Fees:,$
4
1 1, -XV A Ix
4.Mechanical (HVAC) $ List
S.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount
6.Total Project Cost:
tll Paid in Full '�,,;"" 0 Outstanding Balance Due:
_LL
�SECTI6N5:;CONSTRUCTION SERVICES'
5.1 Construction Supervisor License(CSL) CSOSo�s 4 a� �4
Fred HoPPS License Number Expiration Date
Name of CSL Holder
b150 Nor# rjt List CSL Type(see below)
No.and Street TTp.,. Description
Danvers MA 01ga3 U Unrestricted(Buildings u to 35,000 cu.ft.
Restricted I&2 FamilyDwelling
City/Town,Stale,ZIP M Mason
RC Roofing Coverin
WS Window and Siding
�v1
SF Solid Fuel Burning Appliances
(PR.335. alo(v S@ I IInsulation
Telephone Email address Q D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Me W oft more Group
H1CSu►t HIC Registration NumberExpiration Date
HIC Company Name o egistrant Name
25o ry. 5� A3
No.and Street 7��
-s)mYers MA 01CM5 a ,�8,3�1'7 Email address
City/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 tta, �,�iQ�yft04.;
to act on my behalf,in all matters relative to work authorized by tV building permit application,
m4c-
PrintOwner's Name(Electronic Signature) Date
SECTION 7b OWNEW 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 owledge and undetstandin .
X /l F/! /!f}�' /✓liA"t�Q C�v✓✓F� C l J
Punt 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.grv/dpss
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.It.) 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"
1
i CITY OF S.U1 EM. l'LxsSACHUSETTS
BUILDING DEPARTMENT
130 WASHLNGTON STREET, San FLOOR
Tom- (978)745-9595
FAX(978) 740-9846
{I)BFRf-F-YOR RY DRISCOTI
T
L HoNus ST.PiERn
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansJPlumbers
Annlicant Information Please Print Legibly
Namc(Busincs&Organizatiorvindividual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box.
Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet,: 7• ❑Remodeling
ship and have no employees These sub-contractors have S. []Demolition
working for me in any capacity. workers'comp. insurance. 9. El Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL i LEI Plumbing repairs or additions
myself[No workers' comp. C. 152, 41(4),and we have no 12.❑ Roof repairs
insurance required.)t employees.LNo workers' 13.❑Other,
comp.insurance required.)
Any appliguad that checks box pl must also fill out the section below showing their wurkeri compensation polity inrmmatiom
+I hxrnownen who submit this atRdnvit indicating they are doing all work and then hire outside contractors most submit a new aMdavit indicating such.
:Contractors that Owls this box most attached an additional sheet showing the mane of the mMoontracton and their workers'ramp.policy infornu ran.
lam an euployer that is providing workers'contpetisation insurance for my employees. Below is the poly and job site
information.
insurance Company Name:
Policy 4 or Self-ins. Lie.N: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. Ire advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
l do hereby certify under the puins and peuahles of perjury drat eke btfermallar provided ubuv is r ue and correct.
Skmal ire' n Data: / n�
Phonc r/:
Official use only. Do not write in this area,to be completed by city or town ofjlclat
City or'1'uwn: PermitA.lcense#
Issuing Authority(circle one): ,r —
1. Board of health 2.Building Department 3.Citylfown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other .
Contact Person: _._.............._._._.__ Phone K:
Office b0A6hjMftWA&fddf(W(W0 License or raeetration valid for 11241vidul use only
«'. HOME IMPROVEMENT CONTRACTOR before the expiration date, F{�mnd►oturn to:
Office Of Consumer Affairs and BW104IN Repletion n laktatlon: ,d01817 'IYPe�
Expiration: 'J * 012 68A 10 Park Plaza-Suite 5170
. oAIA BOttOo,MA02116
OPP$
FRED HOPPS �(o
�ei
18 WALCOTT RD. ` S '
BEVERLY,MA 0101 / 'aK,;, Dnderaesretarq Not valid vvkho ' store
i BUILDING PERFORMANCE INSTITUTE, INC,
107 Hermes Road,Suite 110
. Malta, 202Q ., r
csr M r
www
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Massachusetts - Department of Public Safety
1�,1 ♦ q 5
Board of Building . ' 9
Regarlations andSYandards 7 r� ri2EG r" `
t(rn,ai;�rcuuo Slrpt r+lpoi- �J r% BPIID*;601085E
License: CS-072528
FREDLHOPES N t t f r q ! yaauxurnvio-.nuuu, .noati� itmavamm
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15 WALCOTX EXPIRATION DATE RD • ;i
BEVlw1(*q 0291 CER797EDPROPMMMALDESIGNATEIN
p — !-I- l 0+/E7/m'1E
euada�gAnEl!*1 p1'Ot 08/1/V-13
• � . . M%dlapep,rolAlrL k oe//o/!)y
Wi c Aral bmtall-
Atr leak '
Commissioner Expiration
04J27/2014
BUILDING PERFORMANCE INSTITUTE, INC.