21 LAFAYETTE PL - BUILDING INSPECTION (2) The Comnwnwealth of Massachusetts
Board of Building RegulatiOnS and Standards
Massachusetts State Building Code. 780 CNIR, 7°i edition hlt Vll II'.�Lfll
1• s I S1:
Building Permit Application To C OnStRICL Repair. Renovate Or Demolish a Rr o,d.homo,t
l One- or Tit a-Famih Duelling
in For Official Use Only
Building Permit Number: Q Date Applied:
signature: zLed-
d d g Cununissioner/ Spector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property :address: 1.2 Assessors Map & Parcel Numbers
I.la Is this an accepted street? yes no Map Numher Parcel N'alnhCl'
1.3 Zoning Information: _ 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fU Frontage I it)
1.5 Building Setbacks(f )
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''
On site disposal system
Public❑ Private❑ Check if yes❑ Municipal ❑ ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
i�/�g �ylARct LIB N lD C Di2 5%JaASwuxi4 N.Y.
Name(Print) Address for Service:
Signature Telephone
SEC ION 3: DESCRIPTION OF PROPOSED WORK(check all at apply)
New Constru' ion Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) Alterations) ❑ Addition ❑
emo ition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2: _ '—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
-(Labor and Materials)
I. Building $ I. Building Permit Fee: $ - Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
i
3. Plumbing $ ?. Other Fees: $
4. Mechanical (FIVAC) .$ List
5. Mechanical (Fire $Suppression)
Total All Fees: $ 'y7-
�I Che No.1'7s7Check Amount: _1Z—_Cash Amount _
j 6. Total Project Cost: $ ��V V Paid in Full 0 Outstanding Bal:mce Due=_ _
SECTION 5: CONSTRUCTION SERVICES /�
5.1 Licensed Construction Supervisor(CSL) CS 7O$ G —_(
��IC4 `p G License Number lixpiiaoun )ate
Name of CSL- Ihtlder ��7>
�'��W.A t7 vl, Ly,�N .,fd List CSL,r\'pc (see heltm) _
\ddres T c Description
C ('nrestncled (Lill to 350)O Cu. Pt.1
R Restocied IBC'_ F:oud N Dtkclline
Signature ,M Nhisonry Only
7$ 5qD, RC _ Residential Ruohne Coserme
Telephone \\'S _ResiJenu:d \Vindu�.enJ Std�n_ _
SF Residential Solid Fuel Burnmc \ >>l1:mcC Inst.tllau"m
D Residential Demolition
5.2 Registered home Improvement Contractor(HIC)
HIC Cumpany N(� yr HIC Rc, iVrant, ame Cs Regisu"auon Number
y -F
Addre:1yJ > —
'7�( 4 2 6/�/ xpiratiA Date
Sl-gnature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed Lind 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
1, , 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.
Signature or Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, _, as Owner or Authorized Agent hereby declare
that the statements Lind information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Prim N��
Signature of Owner or Authorized Agent Date
(Signed under the 2ains and penalties of perjury)
' NOTES:
I. An Owner who obtains a building permit to do his/her own work or an owner who hires Lin unregistered contractor
(nut registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 1�13A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5, respectively.
'. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.I (including garage, finished basement/attics, decks or porcht
Gross living area tSq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms _ Number of halt/baths
type of heating system Number of decks/ porches
Type of cooling system Enclosed _"— -- Open _ ._-"-,--
3. "TotLd Project Square Footage- may be substituted for "Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1t t. v'g--(9_gc,l" • I�,\: '1'g.'r_ 'LVJn
Norkers' C'unlpensatiun Insurance Aftidacit: Builders/ContractorsiElectricians/Plumbers
lil 1 ilfcant Infurmatiun
Ple•tse Print I e ie my
C ity State.Zip:
LY(aL / Phone : 7iv
\re uu plover° Cheek the appropriate bur: Type of pro'ect(required):
I ant a employer w ith� 4. ❑ 1 mn a general contractor and I I ew construction
employees(full anrl'or part-time).' have hired the sub-contractors 7 ❑ Remodeling
listed on the anached sheet.
_'.❑ I am a sole proprietor or partner- I hcsc sub-contractors have 8. ❑ Demolition
;hip and facee no m employees workers' curttp insurance. y. ❑ Building addition
working for me in any capacity. 5 ❑ We are a corporation and its
iNowurkers' comp. insurance 10.❑ Electrical repairs or additions y»
officers have exercised their e,r
required.] 11. Plumbing repairs or additions a
3.❑ I am a homeowner doing all work right of exemption per MGL ❑ g P'
myself. [No workers' comp. C. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13 ❑ Other
comp. insurance required.]
•;\ny.q,plicant that checks box NI must also till out the section below showing their workers'compensation policy information. icating such.
_
a I lomeuwners who.uhm it this uffidav it indicating they are doing all work and then hire outside contractors must submit a new affidavit ind
('�nuacmrs that:heck This hue mst u attached an additional sheer showing the name of the sub-contractors and their workers'comp, policy information.
/ant an employer that is providing workers'compensation insurance for any emp/oyees. Below is the policy andjob site
infurnraarion.
Insurance ( ompany Name:
Policy x or Self=ins. Lic. is:
We- 2 315 32« Expiration Date:
Job Site Address:
2- 1 1 A FA-y-,i F t� City,State/Zip: !�A OCK ✓Y
.\tl•ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). _ _ --
failure to secure coverage as required under Section 25A of bIGL c. 152 can (cad to the imposition of criminal penalties of a
line up to SI.Soo of) and'or one-year imprisonment. as well ;Is cicil.penalties in the form of a STOP WORK ORDER and a tine
,d tilt to\250.110:1 day against the %iolator. Ile advised that a copy Ot tills statement may he f'orvarded to the Office of
Ir,,c.ng;uinns of the DI:\ for insuranec.ht\crage \cnticanon.
l Jo hereby rerri/i'under the puia�nJ pendlfies of perjury that the iarfiarrnafioau provi,led abtn,e is true rood correct
Date y /�
�uyn,nur
re�tne _
__O/dicta/u,e onlr. no not it rite in this area, to he a(nupleted by city or tuuvt ofJiciuL -
Cif% or foss
Issuing \uthnrily (circle line):
1. Board of Health 2. Building Department 3. ('ih/fown Clerk 4. Electrical Inspector 5. hlunlbing Inspector
6. Other ----' -. —.___. _---------_._
Contact Person: -_. _-- _-- Phone -__--
Information and Instructions
vlj"a,1,u,eus l icncral I .live chapter 1 s rrquocs .nil crapIo%cI, to pro,nde iiorkcis' conipcns.tlon Ihr flx r cntplovees.
PHI.u.uu III dos .(.ltute. .ul ctn/dot'ee I, dctincd is - c%cry per,on tit the ,cry Icc of.wodicr unJcr,uty :ontract .if lure.
\hi:s It implied. oral or"riticn."
\:: rrnph,term rn
Is dctincd is "an di%:dual. pa :cr>hgi. .i,mlcl.inon. :orporation or other kcal enrty. or .im two or more
,.I the fore almg engagcd in a Joint cutciprt,c. and Including the Ir_al rcprrsentahv cs of a Jccca,cJ cmpll' or the
ccencr or tru,ice of in InJn JJual• p:omcrsllJp. .i,soclauon or other legal entity. cmpiov tie employees. Ilowcvcr the
ota dwelling house hating not snore Ih.ut three .rp.Iruncnts and who resides therein. or the occupant of the
.h,ci!Ine hou,e otanother who emplo„ person, to do nialntrnance. construction or repair work on ,Lich dwelling house
III on the -,rounds or building .Ippuricn•rrtt thereto ,hall not hec.tnse of.uch cmplo,mcnt he decmed io be an rnlplover.^
\Il il. chapter I5_', �25(.Uo1 also ,late., that "'every state or local licensing agency .hall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the ctimmunvvcalth for any
applicant who bus not produced acceptable evidence of compliance with the insurance coverage required."
A ddilionally, N161. chapter 152, 5 250-) ,fates "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable ev ticnce of compliance with the insurance
rcgwrentents of this chapter Mace been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely. by checking the boxes that apply to your situation and, if
necessary, supply sub-contractorls) 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
nlcnibers 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
,elf-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the at tidavit 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
(own)." Acopy of the affidavit that has been officially stamped or marked the city or town may be provided to the
applicant as prout that a valid atftdavn is on file for future permits or licenses. A new affidavit must be filled out each
I,car. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
1 i.e. a Jog license or permit to burn leases etc.),aid person is NOT required to complete this affidavit.
I he ()liice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
I,Ica,e do not he,Itate to give its a .all.
Ihr IkpauJne N's address, telephone.md tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. p 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
CITY OF SALEM
'` RI PUBLIC PROPRERTY
mod•;(.,� ., y a
DEPARTMENT
„� �Kn;iu>:�,:,•>:,t:udr .
l-1:1: ')78-,'4J 9595 • fAN: 978-1740)846
Construction Debris Disposal Affidavit
(rcyuired 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 c 40, S 54;
Building Permit d is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal 13cility as defined by MGL c
111, S 150A.
The debris will he transported by:
(name Lit hauler)
I he debris will be disposed of in
[� —
Z —" -
(name of lae�hty)
(address of facility)
_-_..--. .signat�t applicant
--- date --_---
Irbn.�:''dn
i
Ile
,/ r �I
2 iz¢ Ifs 36 Nib �� p f> C . NeW
J t GF
tt
ry
Lb
t4