39 LAFAYETTE PL - BUILDING INSPECTION (4) i0 g 3
I'lie COnununsve:lih of ibl:usachusctls
y
Board ul'lluilding Regulations ;u)J Standard CI'1'1' OF s
l' .•I wlassarhusetts State Building Cude.-M C NIR SALEM
Building Porntii Application 7O C'onsiruct, Repair, Renovate Or Demolish a
()Ire- Or Trvu•Piunsh' Utrr/limp
This Section Fur Otflc• C.,� O
BuilJin it Number: Uat Ap ied:
IlwWmyOninallPnnlN�unc) Si utu
I
SECTION 1: SITE INF
1.1 Propert A refs' 1.2 As sson,%lep ft Parcel Numbers
I.la If[[his an ace fed street? a no w t Number Parcel Number
1.3 Zoning Information:6L
eal
1.4 Property Dim enf Ions:
\ m"1111y 0—1sirict-- I'ntpmeJ Cl�.0 { Lnl Area s It 1 4 1 PrnmyelRl
1.3 Bulldln acks(rt)
Front Yard Site YardsRryuimd Required Side
Rear Yard
Required Provided
6 Water Supply:(M.G.1.C. 40. §Jy) 1.7 F d Zone Informations
Nubllcf� PricueO
Zane: Oubide Flood Zone? I'a Stwa�a Disposal System:
Check i6es0 Municipal on site disposal s)stcrr O
SECTION2: ROPERTYOWNERSHIP'
2vA/I��ec N,m�t lP ��C /7 ) 1 1
^ C1'.Slate.ZIP
No.and Sim• /�C//7
fclep l:lra,l AJdress
SECT(ONls 0 IPTION OF PROPOSED WORK'(check all that apply)
New Constru O E.ristingBuildin Owner-Occupied Repaints) ❑ Alteratlon(f) Addition O nw uion O Accessory Bldg. Number of Units
Brief sctiplion (Proposed Work': 2 Other O .Speciry;
0
SECTION 4: ESTIMATE0 CONSTRtfCTION COSTS
liens Estinmted Costs:
(Laburund.\Luerialf) Oft NI Use Only
I. Building 5,��'D I. Building Permit Fee: f Indicate how fee is determined:
'. I'lecirical S �•5 0 O Standard City!Tuwn Application Fee
t I'lunihutg S ❑Twat Project Cost'I lien 6).r multiplier _
'. Other Fees: S_
J. \leehanical ill\ W) 5 List:
' � \lcchaniad i Fne _ '— --_—_---�---•---f�J �.
1u •nruian) S fatal it revs: _
r• fatal Pritject CU,t: ChccA \'o, -- —_< heck .\nunmt: Ca,h -\tiw a l:
�d. (]P.iiJ in Full 1711u1s4wJing Ilal.mce Due:
SF:("I'll)N S: ('1)Ntil'RII("flO,V SF.HYI('FS
97 fib.. . #/ iSupgriNur Linen e — j (i T,lio
I Icenee Nuwher
-----.._.__ I Ist CN. 1'\Ile I.ac hclu,s --
\.unc ul'CSI , I,ler
.L, Ihicriplion
J Sue t ,,, JJJ /J II llnrcstriocd tllul Win s ti to 14,UIIQ lu. IL1
ItathoW IX-' P.unil D,wllin
Lit)if,'m n,StaIe,/II' KC Klnnin ('lncrin
µS Window aid Sidio
Sp Solid Fucl Ilurning APpllanees
///��� _ I Insulation
I) I)cn,7j u,lition
I'eie bona hm:ulaadrcs ?
t,2 Re Ingtr veme U
t Cu ntcto (HIC)
egistered Ilu� mbe
I C' ItgI11rltiun Nur / iµ,i IlionDJ19
yT,�.
I IIC' -nopao ante tr I IIC lie I+Ir. t lamp Cmail uJdress
No. un Stn
role hone
Ci own, Stale Z
SECTION d:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. IS]. 23C(
Workers Compensation Insuranca aMdavit must be completed and submitted with this application. Failure to provide
this atfldavil will result in Ilia denial of the Issuance of the building permit.
Signed Alpdavit Attached? el OW.,FR A
No...........O
SECTION 7as OWNER AUTHORIZATION TOB COMPLETED W HEN
OWNER'S AGENT OR CONTRACTOR APPLIES
FOR FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorise
to act n my behalf,in all matters relative to work authorized by this building permit application. r�
X Date
rs\
Print owier's Nu ne Ytceetwuc., •w
SECTION M OWNER' ORA UTIIORIZED AGENT DECLARATION
By entering Iny name below, I hereby attest under the pains and penalties of perjury that all of the information
go and understanding.
contained in this application is true and accurate to the best of my knowled /v
I'riN q,,ner's ar:\uthorinJ,\�ent's N;unu Ililaanmie Signauvel
NOTES:
�n registered inbhelHume In pruvermit to don isIurIHICI Pro gram). allni f who
access to thearrbitraitioncred ttractur
progmnt or guarlltiyinfa n> twn on he Caostructirorm
an Super\sor Li Other jinportant cense can be fo nd attion on the r Prugram'can`be round at
l'
\\hen substantial,wrk is planncJ, I------the inI'u'tinctlu n elo rt e, finished basement attics, dicks Or porcltl
y5 b
fowl flour area t sy ll.l --- H;Ibitable ruunl count
ilIg Irea I sq. Il.t . .. .. \uolher of hedroanls . . .
\un,bcro0-trcl1laces .. .. _ - -- \untherofhullhalhs
\unlherol'hathnwlus . . \un,hcrolJccki porchei
ltpcn
1.\I,,:oI hc.lung >)+tcm I'nclO+cJ ,
I'.%Iw„i a,ohng q umn
l .. "I.d Proic't \,IlIme 1'001.1ge II1;I\ be Nth+IIIIIIed ItV I OLII I'fU�aet(Olt'•
I
CITY OF SALE. I, TAxsSACHUSETTS
3 BL'ILONG DEPARTMEINT
\ t 130 \' ASHIINGTON STREET, 3iD FLOOR
TEL (978) 745-9595
F.4x(978) 740-9846
ICIJtBERLEY DRISCOLL
I AYOR THONUSST.PIERRB
DIRECTOR OF PLBLIC PROPERTY/BCILDNG COMMISSIONER
Construction Debris Disposal Affidavit
(required 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 NfGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris/will be transported by:
(nam ot'hauler)
The debris will be disposed of in
--- (name of facility) -
of facility)
signature f permit applicant
--�'oe —
date
CITY OF S:U EMs 2%LASSACHtiSETTS
BUILDING DEPkwr%lF_NT
V t< 120 WASHNGTON STREET, 3}°FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
Kn(BFRT F.Y DRISCOLL
MAYOR. THoatns ST.PiF-Rm
DIRECTOR OF PUBLIC PROPERTY/0UMDNG COS0RSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A i tlicant information Please Print Legibly
Name(l3usiixsa//OrganizatiorvinJividuaq:
Address: fl j '
City/StatCMD: J ' Phone ✓E:���c��
Are you an employer?Cheek 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
1 am a soft proprietor or partner• listed on the attached sheet.t ?•Remodeling
✓ ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. Building addition
(No workers comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10-XISlectrieal repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I-(Plumbing repairs or additions
myself. (No workers'cutup. C. 152, §1(4),and we have no 12,0 Roof repairs
insurance required.) t employees.1N0 workers' !3.❑ Other
comp.insurance required.)
-Any applicant dud checks box f l muar also rill out the soctim below showing their worked'compensation policy information.ration.
'I heneowm"who ruhmil this affidavit indicating they are doing all work and then hire ouisida contractors mtul suhmh a new afiMdavil indicating such.
:Coromtors that check this bus most attached an additiuwl.heet showing the name of that sub.contrscto s and their workers'comp,policy infonrution.
lam an employer that is pravidltrg workers'comPetssadan insurance jar my employees Below is the pulley and Jab site
injarrnarion.
Insurance Company Name:
Policy p or Self-its.Lie.d: Expiation Date:
job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to sucurc coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/ur one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to SM.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations ofthc DIA for insurance coverage verification.
l da hereby e'enij alder rile pains an allies a r' th t that in/armatlon provided above is Ir jee and c'arrect
Darin
Phone
IOJjicial rue only. Do not write in this area,to be completed by city at town ojjlciuL
CitynrTown: ._._.. . Fermit/l.lcense
Issuinn Authority(circle one):
1. Board of llcahh 2.fluildlnq liepardnent 3.City?own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: .____ ..... Phone M:
�R�) Massachusetts -Department of Public Safety
�✓ Board of,Building,Regulations and Standards
Construction Supervisor
License: CS-097056 r
t'CV
BRUCE'MCFARiAND,-`. of
67 PINE TREE DRIVE
SOUTH HA*TON MA 101982
y
Expiration
Commissioner 0112412014
�/ 6P ulation
1�&Wmaf,irs gu'siness Reg
Otfice.of Consumer Atf 7rCONTRACTOR Type: ?.
HOME IMPROVE
MEN DBA
_ Registration ;14p782
e Expiration 1112012013 '
MC ARLAND CONSTRUCTION, �^
BRUCE MCFARLAND '� T
y. 67 PINE TREE �nder— secretar7
S.HAMILTON, 1.
I
I
i
i
i
I
Circle Insurance Fax:978-777-4898 Oct 19 2012 09:34am P001,/001
,��Or CERTIFICATE OF LIABILITY INSURANCE � 1o.:9t 21
T HS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BOLDER. THIS I
CER?iFiCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES i
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT! If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer right t� )'✓rR
certifiicato hoMier in'iie)J of such endorsemengs).
PRODUCER NAIVE: . I
Circle nusiness Ina. Agcy, Inc PHONE Fau (978) 777-4898
(978 777-5619 ,ryl�n:
247 Newbury Street NOEL I ADaxEss: PaulaHalas@CirclaZnaurance.ret
Danvers, MA 01923 •-INSUREWS)AFFORWNO COVERAGE ..__ NAIC9 I
I INSURED - INSURERA:Travelers Insurance
.... .... INSURER a: T
DcFarlarad Coaatruction I1 URERC: _
I 67 Dine Tree Drive
INSURER D:
South Hamilton, MA 01982
I _
INSURER E:INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER!
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I
I INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WrrH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSION'S AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IINSR'. .._........ __.. AOOL•SUBR.-_.__._. ...._.. PTSLTCPEFF YOl1C'IXP ................
X . CO?LLIABIALCENE R4LLW21UTY r IMM IOO�YYYY� Llhe•(S i
LTR TYPE OF INSURANCE INSRIMNp POUCY NUMEIER (MMIDOIYYYYI
A GENERALLIA8ILITY 68042 rJ409 12/}/11 12/1/12 EACH OCCURRENCE I > 1,000 000__
PREMISE TO S(Ee. ED q
� - PREMISES( a o ngaOC 1
CIAIMs-MADE CI e•OCCUR WO E $ 000
PERSONAL&ADVINJURY t 1,COG L000
I GENERAL AGGREGATE $ 2,000,000
I EN L AGGREGATE LIMITAPP LIES PER PRODUCTS COMPIOP AGG i5 2 .000,000
$ POLICY L PRO- LOC S
AU-OM091LF LIABIUTY I I IT
AIJYAUTO 600ILY IryJURY(Par persnr:: �. T
ALLOWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per 6„q1grq'1 $
NON-CWNED i PROPERTY DAMAGE-- 3
41REDAUTOS _AUTOS rPERT 0 _
3
UMBRELLA LIAB OCCUR LEACH OCCURRENCE 3 "
IXCE55 LIAe CLAIMS-MADE AGGREGATE � S
DED RETENTIONS $
A MARKERS COMPENSATION 'UB76SOX403 4/1/12, 4/l/1.3,. X WD STATU- OTH-I _
AND EMPLOYERS'LIABILITY
I AY PROPRIETOR/P ARTNEWEXECUTVE YIN 'e L.EACHACCi OEM 3 10O,GOO
OFFICEFNJIEM5EP.EXCLIAEO? Y
(Meo9amry In Ny) E.I.OISEASE-EA EYPLOYEEi $ 1GU,OGG
IDE$GJRI1 under
0FOPERATIONSOCIow E.L.D'S EASE-POLICYLIM IT PTION T $ SGO,GCG
I
[E SCRIPTIONOFOPER MONS/LOCATIONS/VEHICLES (Attach ACORO tm,AMILonal Remm*9 nedule,If more xpoe o Mquratl) i
I
CERTIFICATE HOLDER CANCELLATION r
SHOULD ANY OF THE ABOVE DESCRIBED POLICES Pc OANCELLCO BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL sl' DELIVEREC W
City Or Salem ACCORDANCE WITH THE POLICY PROVISIONS. !
Building Department
AUTHORIZED REPRESENTATryR A 1.
247 Essex Street
Salem, MA 01970
' Shelli Graves/CSR 1 )(` ` ; / IV I
® 1988 2010 ACO PORATION. All rights re erved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Phone: Fax: (978) 740-9846 E-Mall'