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29 LAFAYETTE PL - BUILDING INSPECTION "17 �cx TEr 0— Che Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM '_TI WIE" Massachusetts State Building Code, 780 CMR 101b,N VRn&dArr&flf t Building,Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling (� This Section For Official Use Only Building Permit Number. Date Applied: . t Building Official(Print Name). -. Signature Date I— SECTION C:SITE INFORMATION' Lt Pfpperty AJ a s: 1.2 Assessors blap&Parcel Numbersi t Li4 rF�WYe T lW ce- I.I a Is this an accepted street?yes- !. ', `no Mop Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arco(sq Ill Frontage(11) 1.5 Building Setbacks(R) i s<! !e J Front Yard Side Yams Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: r Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ SECTION 2. PROPERTY OWNERSHIP! 2.1 Owner of R ord: p suse iIIt) ��Fi /T �1m (Pool) City,state,ZIP a-J- LpyF 761,51s I No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration($) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:S-11�1 P'tPQ9#16LACr Brief Description of Proposed Work% )Zip i SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials 1. Building S a 0 �p I. Building Permit Fee:S Indicate how fee is determined: ❑Standard CityfTown Application Fee 2. Electrical S ❑Total Project Costs(item 6)x multiplier x 3.Plumbing S 2. Other Fees: S 4.Mcchanical (HVAC) S List: / 5, Mechanical (Fire Total All Fees:S Su ressimt) Check No._Check Amount; Cash Amount:_ 6.Totai Project Cost: S �'® 0,00 ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 0 `'f'11(4w� TR Lbicense Number Expiration Date Name ofCSL[folder � �,` ListCSL'rype(see below)AF _ P-IS-V ER OP*51 Type Description . No.;md Street LTf✓Ar /I a �` .y0c l U U Restricted 1 2 Fa ii s u el ing cu. Il. l '] `� R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Sidina SF Solid Fuel Buming Appliances 78159��a,.1/ 1 Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement Contractor—(HIC) 1-719% G A jn ILA` 7r l CD"J A— HIC Registration Number Expiration Date f C Comp;a me or IIIC Regist ant Name �-15- V� R,DA�4 T Nyfy1't, Dro� Email address City/Town, State ZIP l TA hone SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 15Z.§ 2SC(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 Isluance of the building permit. Signed Affidavit Attached? Yes..........W No...........1] SECTION 72:OWNEKAUTHORIZATION,TO BE.COMPLETED WHEN: OWNER'S AGENT OR CONTRACTOR APPLIES FOR13UIaLDIING PER-MIT 1,as Owner of the subject property,hereby authorize W��L 1,/- 1 1�M Am .} t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner'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 any knowledge and understanding. W:Pt T-A-n,- -TPAI An-7 i f-g JC7 Print Owner's or Authorized 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 Loa have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be round at www mass eov:'ocn Information on the Construction Supervisor License can be round at www•.nass.,ov:'dus 2. When substantial work is planned,provide the information below: Total floor area(sq. R.) (including garage,finished basementlattics,decks or porch) Cross living area(sq. R.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches rypeorcoulingsystem Enclosed Open J. "I'otal Project Square Footage may be substituted fur"Total Project Cost" \ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: `JX U-TA-ft`- l &-T 0_1_� C9t-bl Address: �_1.S'_ UE� RID rV+ Sr City/State/Zip: L 7/✓!,- P-\4 011ytf Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1.P I am a employer with110 employees(full and/ 5. ❑Retail or part-time).* 6. RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(me].real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers'comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care ttll /uI'' with no employees. [No workers' comp.insurance req.] 12.❑Other �9 : J 45Ah A-& *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. 1 am an employer that is providing workers'compensation insurance for my em loyees. Below is the policy information. Insurance Company Name: CpP J�Vl7�,1 QNe?!✓ I q(.- C—As I-, M 7 Cq Insurer's Address: 1 ,7 p-1,�.,5 4 p p j `60 j/b ;L 15— k)FAOA1 -5T City/State/Zip: (✓�my - rn rf- M©tt Policy#or Self-ins.Lie.# (.;;15 J p U13 )�f))l t 05i IF Expiration Date: 04-07`2 7 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 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby,c'erttiify, under the he'paitn�s and Ides ofper�j^uyryrthat the information provided above is true and correct. Signature: t� (� I_.� p�` �lr� lA' Lam- Date: Phone#: Official use only. Do not write in this area,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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia 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 152,§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 your insurance company's name,address and phone number along with a certificate 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 permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). 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 burn 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Fenn Revised 02-23-15 aiYOFSALi K MASSAa.Nm 7 > nJW 12DWASWZMSMW,30FLOOR rum LEYINLTW= Flu[ 7�i4lW6 MA7t,1R 7YsorasSr.Paasg D crpLKEAWrkay/Buumm C®essiruCdon Debris D1sposa/AffldV7V1t (required forall:demolition andrenovation workj In acaxdmw with the SW edWm of the state&Mng Code, 7W a^ Secdw 111.S Debra& and die provisions of MfGL oto,S S4; Bn►ldhg►Permit p is lswed wh the coradftn that the debris resulting from this work shall be dhposed of in a prepe*ricemed ' waste depasit facifityas defined by MGL c 111,S 15K The debris will be transported by: bumf TRZ clti. 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