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39 LAFAYETTE PL - BUILDING INSPECTION (3) (7 Ll' ! CAS The Commonwealth of Massachusetts ° g Board of Building Regulations and Standards CITY OF �y Massachusetts State Building Code, 780 CMR SALEM - _ Revised Mar 2011 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: 31 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Proper ess: 1.2 Assessors Map&Parcel Numbers gq�n1dr 39 �� z#& plec'e 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: '- Zoning District Proposed Use - Lot Area(sq ft) Frontage(ft) 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# Private❑ Zone: _ Outside Flood Zone?. Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: ,/(/Ogni IZLI �r4NWf/I 63?rtSS ® / 9y3 Name(Print)QQ ff City,State,ZIP /,lct✓View( l�) ?U_qYo? Na(/�0 @ram 4j,a%h No.andand Sne� Telephone„ Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2, (check all that apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) rjV Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work z: iA�m� f 1"H (2(,�jdy�jC_—yReliff;c- 15k�Tyatlr� lnsyl JI� fl�t3� o /Yn� 1AR'if SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only abot and Materials I.Building $ 1 no 06/ 1. Building'Permit Fee:$ Indicate how fee is determined: 2.Electrical $ Vim a� ❑Standard City/Town Application Fee ni ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ gptl 74 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ py Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ V/�3Gtb1 ❑Paid in Full ❑ Outstanding Balance Due: �� f s I_YY�OYt'1 t� N T - �+✓� . sou D -ry tr�11>ti, �,� 8 IS SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 0 L14 9 � � y License Number Exp atio Date Name of CSL Holder 12 (-i-m vIW List CSL Type(see below) No.and Street Type Description !'ha�ih � O�D6 ry U Unrestricted(Buildings u to 35,000 cu.ft. c7 / R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances ��) L9� �vi�6/�3N�96tiS !�CnI I Insulation ele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 16(o Q3(/ r� ( elfs4 HIC Registration Number E pv tionDate HIC Compan Name or HIC Re istrant Name No.and treet Email address Novo M4 axb i w—klf 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 1,as Owner of the subject property,hereby authorize ko krk r-- 13Dh u; to act on my behalf,in all matters relative to work authorized b this building permit application. I Prim Ow er's Name(Electro gnature) Date SECTION 7b:OWNER' R 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 knowledge and understanding. Mgrh G- fiokid I <; Not 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths 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" CITY OF S U.&Ni, "NIASSACHLSETTS BUHMING DEPARTMENT ? 120 WASHiNGTON STREET, Van FLOOR TEL (978) 745-9595 FAX(978)740-9846 (QNiBFRf RY DRISCOLL MAYOR THOMAS ST.PIERRG DIRECTOR OF PUBLIC PROPERTY/BUILDIING comMiSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrie+ans/Plumbera Applicant Information 'J. / Please Print Legibly NaMC(Busim-s Milk*1 r ilk* /' IS4 Address: City/State/Zip: ShgiVV in( 0.206 Phone Are you an employer?Check the appropriate box: Ty pe of project (required): 1.❑ 1 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.P 1 am a sole proprietor or partner- listed on the attached sheet.t 7• O Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers'comp.insumatx. 9, ❑Bundling addition [No workers'comp.insurance 5. [1 We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions 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.l •Any appliram that checks box 91 most also rill rut the section below showing their worken'compensation policy information. t 1 hwneownas who submit this affidavit indicating they arc doing all work and then hire outside comment,rmat submit a new airldavil indicating suck <ommctots that check this box must attached an addilkwal sheet showing the name of the sub-contraomat and their workers'ramp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below Is the parley and job site information. /j Insurance Company Name:__ Awilrelo 2c44rich (YIS,mo,,y ca22 t Policy 4 or Self-ins.Lic.M.—//W&--0 1p 3 4D') '/ — Expiration Date:_ 6 ill Job Site Address: 71-1 `f470.y 'C { �Iqc . City/State/Zip: �k�<6N 6y(c�js ©�Q70 Attach a copy of the workers'compensation polity 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 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Ot7ice of Investigations orthe DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sittn,�ture• /r//y�/!9' rl,�/ �i� [)are, Official use only. Do nor write in Milt area to be coarpiered by city or(own official, City or Town: Permit/l.ieense# __ Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/rotvn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: ___ Phoae p: hTassachusetts go Gtnatu°tBuil P a-Suen anment s Sa t andgtac yti. 9u/ahon • _ fe hoe License:.CSF:q F_y� Famtt4 ° ntlarrts;� MARKFgpr. � 851 1 Sgi1ROENryIAW� . ; co r mmissioner �xptratlo0%oln 1y16/yO14< - r �- et f IIMPROVEME CO 13u� s(8r°lahonaefla xPiration:o: -106931 NTRA TOR MARK F ,,T/28{2016_ 1 Ty c . �BOTAISH -, -= Individual Marti Botaish 12 GlenviewOad - - i Sharon,MA 2067 # undersecretary 'v 3/4"FI4TMUSEMOLDING nil CHACE BUILDING SUPPLY M ]p W2736 W27 6 7 6 W2736 F636 Kitchen layout for Mark Botaish 7130/Z014 Schrock Entra cabMats: $3,833.50+tax p Berwick door, Amber Suede on Maples Post form counter tops: color d pr/co TBD v E2000 edge B30 030 SE DISH-106 03aDZ8 opprovedby: dote:30 f+-30" 30" 30"----�-24"--�-18"-►�l8"-