39 LAFAYETTE PL - BUILDING INSPECTION (5) The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
CIP Massachusetts State Building Code. 780 CMR. 7"'edition MUNIL11:V.I'I'1'
Building Permit Application To Construct epair, Renovate Or Demolish a Ret'Ised 111ttt11tr1
f U One- or Tiro-F dly trcdling
This Se• on For ficial Use Only
Building Permit Number: ate Applied:
Signature:
a3/-1
Building Commissioner/ Inspe,or -Buildin, Date
SECTI 1: SITE INFORMATION J
1.1 Prop rtv Arldre, nib s: 1.2 Assessors Map & Parcel Nucrs
iq A �,d
1.la Is this an accepted street? yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Proppert�y Dimensions:
�Q b-
t Zoning District Proposed Use Lot Area(sq to Frontage i I o
1.5 Building Setbacks(ft)
'rant 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?
Public � Private❑ Check if yesk Municipal 0 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'2; QwneFtof Le Rind to P&A LLC A- NLv ?1CG(XI s4,/, Vt7)Iv1 eu-96
N m (Print) dress for ervice:
,
LC (4:2PT -
Sign lure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(,) ❑ Alteration(,) Additi�m ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
Ro p l f a 21 peUe l I er tL Nvvu
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ f.� CX) 0 W 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ i
❑Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $ /
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount Cash Amount:
6:Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
' ' SECTION 5: CONSTRUCTION SERVICES 9
5.1 Licensed Construction Supervisor(CSL) Y5'46113 7/41 Z
o/, I& 5 License Number Expiration Date
Name of CS . Hulde List CSL Type(see below) /�
2 U_,Ntl � i) �oriu&s �/�
ttllvvyy�� T c Description
��11 n X2vl
U Unrestricted(Lip to 35.W0 Cu. Ft.)
R Restricted I&] Family Dwelling
Sj_eti�t Masonrc 9� ? _ t�q Z3 �t Reside Only
C� 1 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel 13untine \>>Icmre In[Llllallon
D Residential Demolition
5A(Re g! redYm mpro2ement Contractor (111C)
hh .U�M �vwSIC�
HIS Comp ny Namur HIC R tran�a neMq Registration Number
ft G!i��l¢ 1 �vrxlA n ) (0 / `1 bfZ.
Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 25C(6))
submitted with this application. Failure to ruvlde
' n Insurance affidavit must be completed and .Lib p WorkersCom Compensation p PP
P
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... [5�_ No .__..... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT y�
p 1 60791`2511
I, -�r.»�� TjQ✓LISb�At/ as Oavrter of the subject property hereby
uthorizel, to act uulw-6*l+elf. in Lill matters
relativ to work authorized by this building permit application. j
Si nat re of Owner Date
SECTION 7b: O'WNC-W OR AUTHORIZED AGENT DECLARATION
I r_pke-p1 At-_ Twnl1E A-V , a&JUmaw&ar Authorized Agent hereby declare
—�'
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
YX
Print N 5C 2.
Signature of or Authorized Agent Y Date
(Signed under the pains and penalties of perjury)
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations 1 lO.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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 halt/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for"Toud Project Cost'
er o/.1v/dvii 'rimer sru] VIM Tor LIMIBUW8K1 W 9,1-97e.777. 139.1 Yager vuL
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(M�DAYYY)
06/30/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
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 rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTA
NAME:
Tarpey Insurance Group Inc P"�N; E : 978.774.8040 ryo:978.774.3581
491 Maple St (Rt 62)-Suite 304 Eno aE.
PO Box 183 PRODUCEER RID�: 00006447
CUSTOMDanvers, MA 01923-0383 - INSURER(S)AFFORDING COVERAGE NNC9
INSURED INSURERA: Endurance American Specialty
Chester 3 Dembowski INSURERB: Safety Insurance Co 39454
P.O. Box 412 INSURERC: Liberty Mutual Ins Co
Danvers, MA 01923 INSURERD:
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 2011 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
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE INSR WVD POLICYNUMBEIR MMIDD MA]p LIMITS
GENERAL LIABILITY TBA 07/01/2011 07/0112012 EACHOCCURRENCE IS 1,000,00
X COMMERCIAL GENERAL LIABILITY
PREMISES Ea NILD nce $ 50,000
CLAIMS-MADE [X] OCCUR MED EXP(My one person) $ 5,000
A PERSONAL&ADVINJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP ASS $ 1,000,00
POLICY 7 jET LOC $
AUTOMOBILE LIABILITY 161308201129/2011 01/29/2012 COMBINED SINGLE LIMIT $
(Ea accident) 1,000,000
PNY AUTO BODILY INJURY(Per person) $
ALL OWNED AUTOS BODILY INJURY(Per aceidera) $
B X SCHEDULED AUTOS
PROPERTY DAMAGE $
X HIRED AUTOS (Peraccidert)
X NON-OVYNED AUTOS $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLAWS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION WC1315321513021-A 06110/2011 06/10/2012 wCSTATu OTT+
AND EMPLOYERS'LABILITY YIN TORV LIMITS ER
L OMY FFICEOPRIETER EXC UDEwD CUrIVE ❑ NIA E.L.EACH ACCIDENT $ 100,00
(Mandator,m NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 -
If yas,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ - 500,000
OESCM"ONOFOPE"MONSILOCATIONSIVEHICLES (Aaach ACORD 101,Additional Remarks Schedule,It more apace is required)
;ENERAL CONTRACTOR
CERTIFICATE HOLDER - CANCELLATION
FAX: 978.777.7397
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORRED REPRESENTATNE
Dawn Pa arrechail
O 198E-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
��
Office of Consumer Affairs and Business Regulation
10 Park Plaza Suite,5170
Boston, Massac setts 02116
Home Improvement for Registration
Registration: 100098
Type: DBA
z Expiration: 6/9/2012 TrfF 297379 -
CHET'S CARPENTRY a
Chester Dembowski c
2 VALLEY ROAD F
Danvers, MA 01923 _ �e
a
Update Address and return card..Mark reason fur change.
Ej Address ❑,Renewal Employment ❑ Lost Card
wn� 4 5OM-0 omc101216
Massachusetts- Department of Public Sufetc 1
Board of Building Regulations and Standards 'I
Construction Supervisor License
One-and Two-Family Dwellings
License: CS 55465. s �r
A ,
CHESTER J DE146t7WSKl
2 VALLEY RD.
DAbIVERS, MA 01923 w. i
- —Y"-- 'Expiration: 7I70/2012 .
28971
('ommissioner
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