32-34 LAFAYETTE PL - BUILDING INSPECTION The Commonwealth of Massachusetts
+-.44 Board of Building Regulations and Standards ' * LEM
q � Massachusetts State Building Code, 780CMR aU1b 2 R�isgr(b620!!
Building Permit Application To Construct, Repair, Renovate Or emo is a ru
One-or Two-Farnily fhvelling
1 This Section Fbr.Official Use Only
Building Permit Number. Date Applie :A
Building 0llicial(Print Name). _ ' Signature: '_- L. - Date
SECTION t SITE INFORtMAT10N
1.MtY Add es A g -u r' 1.2 Assessors Map 5r Parcel Numbers
1.la is this an acce ted street?yes no Map Nwnber Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
M•
"Tuning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(it)
Front Yard Side Yards Rem Yard
Required Provided Required Provided I Required L 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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ p po y
SECTION 2: PROPERTY OWNERSHW
N$me(Print) City,State,ZIP
762 /M//V
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Cl Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed LVork=:
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Citylrown Application Fee CK -A6 6
2.Electrical S ❑Total Project Costs(item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4.Mcchanical (hiVAC) S List'
5. Mechanical (Fire S 'fatal All Fees:S
Suppression;
Check No._Check Amount: Cash Amount:_
G."tacit Project Cus1: S ❑Paid in Full 13 Outstanding Balance Due:
C '�4j '�b
t + e
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Lic1ense(CSL) oc��7 4 a2-2e
cr ✓Y`t /Li v License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
Type -: Description
No.,md Street _
COkIOSCA �/J 0� `0 7 U Unrestricted Duildin a to 33,000 cu. tt.
I R Restricted 1&2 Famil D+vellin
City/tbwn,S te,ZIP M Masonry
RC - Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
�n y^- I&o(6e� i,1(SC. 1 Insulation
Telephone Email address I Demolition
5.2 Registered Home Ira/provement Contractor(HIC) LM2
19 /wQ(V HIC Registration,Number Expiration Date
Ills any,��un or 111C Reg tram Name �'• ' T
CIA f%IC 0 AQ r
No. ul Street .�1 Email•:ddress
( ��� n rro l6
el, /Town State ZIP Tel e horw
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152.§ 2$C(6))"
rkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
affidavit will result in the denial of the Iskuance of the building permit.
Signed Affidavit Attached? Yes..........❑ No...........O
SECTION 7u:OWNER AUTHORIZATION,TO BE-COMPLETED WHEN!..
OWNER'S AGENT OR CONTRACT/O+ILAPPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize G� � 'N
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nmne(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 t ' plication is true and accurate to the best of my knowledge and understanding.
Print Owner Authorized A nl'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(f11C)Program),will rro have access to the arbitration
program or guaranty fund under bI.G.L.c. 142A.Other important information on the HIC Program can be found at
+vww.mass.•ov.!oca information on the Construction Supervisor License can be found at www.mas,.••o+ldns
2. When substantial work is planned,provide the information below:
rotal floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hall%baths
rype of heating system Number of decks/porches
Type orcooling system Enclosed Open
1. "rotal Project Square Footage"may be substituted 1'or"'rota) Project Cost"
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Construction Debris Disposo/Affidavit
(required forall demolition andrenovation work]
in aQoo&noe with the sixth edition of die State BuD&w Code, 7W aft sestbn ili.s Debris
and the provisions of MGL oW,,S54; MAW Permit p is issuedwith the
condition that the debris nesuft from this work shad be dispmed of in a properIV Ikensud
waste depost facility as defined by MGL c 111,S 151k
The debris will be transported by:
,Exk. C
(name of hauler)
The debris wiI1 be disposed of in:
ZYhV MA-`d )N l'
(name of facility)
(address of facility)
Signat re of applicant
Date
The Commonwealth of Massachusetts
Department of IndustrialAccidents
a I 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: (�. Anwol ))J
Address: 0-c .5—Sjc
City/State/Zip:rw SCO IVO Phone#: ;b2J S632-
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
orpan-time).* 6. ❑RestaurantBar/EatingEstablishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑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]* 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box 41 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#I.
I am an employer that is providing workers'compensation insu�r7ance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip: f�UM���e�� /1
Policy#or Self-ins.Lic.# IA.) ^ Gib -S�j 7�-XIN Expiration Date: �scf -20
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.
I do hereby certify,under t pains and penalties of perjury that the information provided above is true and correct.
Si nature: Date: /2 de� _Z,,`--,Z
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.mms.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-NIASSAFE
Fax#617-727-7749
www.mass.gov/dia
Term Revised 02-23-15
G.JANVRIN CONSTRUCTION&HOME IMPROVEMENT
306 ESSEX ST.SWAMPSCOTT.MA 01907-REG.125033
Phone 781595.8323-Fax 781-586-0500
CONTRACTUAL AGREEMENT,
THIS IS A BINDING CONTRACT, IF THERE IS ANYTHING THAT YOU NEED CLARIFIED,PLEASE DON'T HESITATE TO ASK GLEN JANVRIN,
PROPRIETOR,FOR CLARIFICATION. _
ATM.HOME IMPROVEMENT CONTRACTORS ARE REQUIRED TO BE REGISTERED WITH THE STATE OF MASSACHUSMTTS. IF THERE ARE ANY
INQUIRIES AS TO THE REGISTRATION STATUS OF A HOME IMPROVEMENT CONTRACTOR,PLEASE CONTACT:
DIRECTOR,HOME IMPROVEMENT CONTRACTOR REGISTRATION
ONE ASHBURTON PLACE,ROOM 1301 -
BOSTON,MASSACHUSETTS 02109 - -
TEL.617-7274593
PAYMENT SCHEDULE:FOR ALL JOBS,1/3 DOWN. 1/3 DUE AT In COMPLETION AND THE REMAINING BALANCE I DUE AT JOB COMPLETION.
ACCELERATION OF PAYMENT: NO CONTRACT SHALL CONTAIN AN ACCELERATION CLAUSE WHERE A BALANCE NOT YET DUE 1S DECLARED
DUE BECAUSE THE CONTRACTOR DEEMS HIMSELF INSECURE OF FUNDS. HOWEVER,THE CONTRACTOR MAY REQUIRE,AS A PREREQUISITE,
TO OONTINUING WORy,THAT THE REMAINING BALANCE BE PLACED IN A JOINT ESCROW ACCOUNT-
THE OWNER OF G.
ME
ATIVE
DELAY OR REFRAIN
IF THIS
CONTRACT IS LEFT U SIG ED. ONCE YOU UNDERSTAND AND AGREON& HOME IMPROVEMENTHAS
WITH THIS CONTRACT,PLEASE SIGN IT MAIL IT IANVIN
CONSTRUCTION& HOME IMPROVEMENT.
THE CONTRACTUAL JOB COST IS SUBJECT TO CHANGE IF DISCOVERY REVEALS UNFORESEEN STRUCTURAL PROBLEMS THAT WERE NOT
00 AY OLM THE CONTRACTOR WILL
�JOB COST M ALSO CHANGE IF CONSUMER REQUESTS ADDITIONAL WORK NOT LISTED ON THE IKVOICFIPROP'OSAL
THE CONTRACTOR AND THE HOMEOWNER AGREE IN ADVANCE THAT IN THE EVENT OF A DISAGREEMENT OR DISPUTE WITH THE COMMACT-
grE ARBITRATION
SERVICE M MAY
SU
CH UCHARBITRATIONESDWHC H SPROVIDEDBEAPPROVED
BY THE
OFFICE OF CONSUMER AFFAIRS. THE DWUTD40
PARTY
ALL WARRAMIFS ON WORKMANSHIP FOR I YEAR,LIMITED DO TO ACTS OF NATURE*.VOID IF THERE IS A DEVIATION FROM STO ULATIONS OF
THIS CONTRACT.. WARRANTEE IS NOT TRANSFERRABLE.
UPON SIGNING THIS CONTRACT,YOU ARE OBLIGATED TO HAVE THE WORK AS LISTED ON THE INVOICE NUMBER BELOW,COMPLETED BY 0-
JANVRIN CONSTRUCTION&HOME IMPROVEMENT. IF YOU TERMINATE THIS SIGNED CONTRACT,YOU WILL BE RESPONSIBLE FOR 10%OF THE
TOTAL JOB COST. •
SCHEDULING: EXCEPT IN EMERGENCIES.DETERMINING WHEN WORK IS TO BEGIN ON YOUR HOME CAN BE A DIFFICULT TASK. THERE ARE
OTHER CUSTOMERS WHO HAVE ENTERED INTO CONTRACTUAL AGREEMENT WITH G.JANVRIN CONSTRUCTION CO. . IT IS COMPANY POLICY
TO TAKE THE JOBS IN ORDER THAT THE CONTRACT IS SIGNED AND RECEIVED BY JANVRIN HOME-IMPROVEMENT.OFTEN WE CAN NARROW
THE TTME FRAME TO BEGIN WORK ON YOUR HOME TO A REASONABLE TIME FRAME. HOWEVER.INCLEMENT WEATHER AND UNFORESEEN
PROBLEMS PLAY A 810 ROLE IN DETERMINING WHEN WE CAN ACTUALLY START THE JOB ON YOUR HOME. ITB THE NATURE OF THE
BUSINESS,So PLEASE BE PATIENT. ���^
CONTRACT#—17 AMOUNT
CLIEMS SIGNATURE /P {/ -
OATEJ�_ /- 26/<
PLEASE PRINT NAME:
`� 0-�)/1�IC RETURN TO ABOVE ADDRESS WITH DEPOSIT. '-
PLEASE NOTE:CONSTRUCTTON:if your have an attic or crawl spas with any Oft of value SW either cover or n nave,we coo not help failing da-W and
contractor will not be liable for any daoege.SmING:do to the nature of coosttuction poo ding and,banging on walls.. is 0=5511Y pipe remove any thing of value
mknws,piowms etc.fiom wells to m irm than from falling off we wig wt be held liable.please take care.LANDSCAPING:we oover bushes sod �>
6owess we do out best to pmtea landscape,due to ladders and staging we canal be responsible for plant damage.
ELECTRIC anything electrical requires a license electrician and will be an added dage.PLUMBING:requires license plumber will be an added drerge.
we am not>cslansiblc for minstalling the Satellite Dish.*WEATHER:Hunicanes,unusual high winds,ice dams,snow damage,etc.
EXtM's are over and above said contract amount,will be added to invoice.( )initials please.
1
,p �,(xe�omvneaaxurea�z o��aaaac%uaeCA
�-\ Office of Consumer Affairs&Business Regulation
OMEIMPROVEMENTCONTRACTOR
- egi-tration 159038 - Type:
— Expiratwn:_ 3�&2`01g, DBA
G.JANVRIN HOME]MPROVEMENTr'
-
GLEN JANVRIN �Ml
306.ESSEX ST �`�� �i ,4
SWAMPSCOTT,MA 01907a —`
Undersecretary -
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