412 LAFAYETTE RD - BUILDING INSPECTION The Coil)nonwe:dth of Massachusetts
)� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
?L: Revi.red.l Iur 2W I
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fami(t Dive(liuk
This Section For Offl Jul Use Only
Building Permit Number. D e:Applied:
tit" ng Otticial(Print Name) Signature p //
SECTION I:SITE INFORMATION
L i prppeftyress 1.2 Assessors blap& Parcel um n
h0.
L la Is this an:tcc d street?yes_ no Map Number a el Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'ropo cd Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.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 es❑
SECTION2: PROPERTY OWNERSHIP'
2. Owner]of R[ec/grd: (� � kA \
QNr1trU vOlc�QkCSI.ltS
one(Prin city.State,ZIP
No.and Street V relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ i Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ ,Accessory Bldg.❑ I Numberof Units_ Other ❑ Spccily:
Brief Des gcipti� Prop=':
,11
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs:
I Labor and Materials) Official Use Only
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City Town Application Fee
❑Total Project Cost'(Item 6)x multiplier .x _
i. Plumbing S ?, Other Fres: S
1. \Icch:mical 111\':\CI 5 List:
— — —
5. .Mechanical (Fire
_________
Suppression) S rot:d All Fees: S_ _
Check No. ('heck Amount: _ _ Cash Anunu t:
/ 6. Total Project Cost: S t{�� ❑ Paid in Full ❑Outstanding Balance Due: -
SECTION 5: CONS'1'RUC.TION SERVICES
5.1 Construction Supervisor License(C'SL)
t L ice---- - -
nse Number 1[cpirution Dale
Name of C'SI. I Inlder
List CSI.1)pe(see heluwl
-� _�---- - -- --- 'I) Description
No. andu Sir^t
I Unrestricted IlluiIdin gs u' to 15,000 cu. ft,)
R Restricted I 2 Family Dsccllin
City"uml,State.ZIP M Masonry
RC RoolingC'uvcrin
W'S Window and Siding
Q _ ,1 SF Solid Fuel Burning Appliances
1 Insulation -
Nic hone Finail address D Demolition
5.2 Re istered Uonne Improvement Contractor(HIC) 6'7%A-7 1j C( � '
FNA
v a
(wl^. .11 I IIC Registration Number fspu;nit n Date
I IIC C'h{y¢yry Name or I IIC'Registrant Name
Ap ,L 01rj� Email address
-1 t-V� 1 3 Gto
City/Town.State,ZIP relic hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I.\Ownera subject property,hereby authorizetin all matters relative to work authorized by this building permit application.
v Print Owner' Nt(Electronic Signature) qhtel
SECTION 7b:OWNER' 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 my knowledge and understanding.
Print(hsner's or Authorized Agwt's Name(Ficctrunic Signawre) 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. 1 2A.Other important information on the HIC Program can be hound at
wwm,n,;p.. n_o.�,i Information on the Construction Supervisor License can be found at������..niit :.!boy dp,
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. If.) ___-- _ Habitable room count
Number of lireplaces Number of bedrooms
Number of bathrooms Number ofhalf ballu
F pe of heating system . _._ . _- -- Number of decks porches
1'ypcofc kit)lingsy Ste III . FnClO)ed — Open
J. ,f'oud Project Square Footage-niay he substituted for"Total Project Cost-
11
CITY OF SALEM
aSN
PUBLIC PROPRERTY
DEPARTMENT
.I,III,M:I Y:11114 41
%INt41
I!:1trAHu.\1:IU.�ileCL•1' • idll•.W.M.11h.1r.ln ,1 I I,JI77,^,
1'I:1.'VVI-16•,i')y a 1',x Y7B•74C•'ISJ6
Workers' Compensation Insuruncr :Unduvit: Builders/Contractors/ElectrlciansiPlumben
\ 1 illcant In onnuflon
_ PI •41 P inf Le 'bl
V:Ilne Illuvl,u,yl)raanvuintvinJtrlduall:�tvc•c� `�
a
city,.sr:trc,/Ip. r \l 1MA a`(1(r(
.%re I flu an vmploycrl Check the appraprlulr bass:I.ClClI:un a umpluyer with 4. Q 1 mn a ycnural contraelor and 1 I)pat of project(squired):
eIpluyccs(cull ind/ur part•linle).• huve hired the Sub-cuntraclun ri• ❑Now construction
1 ial a tale prnpriculr or partner• liswd on the attached sheet l Q RII. I linE
Ship and have no Innpluycu's These subcontractors have
working lilt one in any capacity. wnrkera'romp, Insurance. a' Q nemolition
I NO wlirkcrs'cutup, insurance J. Cl We are p cmpontion and its 9• ❑011ildind addition
ruyuirud.) o09cers have eijureisad their 111.Q Electrical repairs or additions
7.❑ I am a horn uwnur doing all work right of umemption pus AIDE I L❑Plumbing rcpuin or additions
myself.INO warkun comp
,p, C. 132.¢l(4),and we have no
insurance required.) t umployccr.IKo warkeq• 12.0 Ruul'repairs
camp insuranuv nyuind.J 13•0 011ier
n1.;IphraY e,W checks INa*I mass alw rill uW Ihr vtchwt Iw:Ol Jvlwm I I I.m,n.wtrn who I141 this amdavir w f ilin I e Avis wwkwo'cumpmwiun pricy Inri,rtty "
•C,Mlrwnra IhtM thee,Ihts fqt muu unaAN Lin is Ilt Iy its Jowls al work and Ihal him uwsids eYrrlKlet•mwl.uhnil a nrw uRJaril irwlilattiny.Itch.
man� unsl.hvsr,Iluwine Ihr na1rN e/Ih1 rW.en
/errs an eulployer that lr pruelall"Ivarkers'rutnprnrm/ra him, rr/w iuy rtnp/vyrpyra"Saft and l hBdu v eir la the*stamps.p,llsy mthnnart a
iu/unnulkin1, /It u
Pla y nd/la1 ails
Insurance Company Vame: _
Itulicy is ur Sclr•ins. Lic.it:
EApirauan Date:
)lab Situ Address:
C1ly'Sla teZlp:
Attach it uupy Of the workers'cumpenaalluO policy deelarullun puye(showlnq the policy number and atpl►arlun data),
Pa11uro to sccuro wserays u required under Sccliun'JA ul'MU c. 151 can lead to that imposition oreriminal penalties Ora
tine up to S a rAI l day
Istur mle•year imprisunmcnt, a.r wc11 ar uivd pcnalllus in the loan Ora STOP 1YORK GIRDER and a fine
cup rn i?iQ, Mp;r Jay.Iyuinll Ihr vi eras. Ile advi.sud that a uupy urthis,Iutclnanl Inay be lur,varded lu the 011ice ul'
Inrrah�aulnb vl^' Iu OIA :6r In�Iu.mu .-vurayu ,criliu aUun.
/du lferrey t rrli�y tut, der pro r Ir
vfprr/try rhos sits io/brtaullow jury viJrrl u later is true raid correct� •!;I IIIII�
-76H- coo
IU/Ilciul if tf rat/y. /)d nnl Ivritr ur E urrla, to it ruyry/crrd sly city of rotten a//lriuL
IrlfYVf I'rrlra:
I,suiny .lurhurity (circle nne); Pcrmittl.lccnse e
I, 161 �tr
G 1)rhwr Ileallh !. Iludd6r; 1)t:p.lrrnn•ul I. (:il).'run rat Clcrk J. 'Icetriod lu )ccfur
I, i,
. vr L• PfuwWnq In+ycrrar
Phnnu V
Information and Instructions
v ciao In the servic Indcr Joy :untmct of hie.
Clls ll
\LUi.lelasenCrt LJwf ehJytef I J2 RgU1rCr all CIt11)ld)Cr7 e of another 10 pfOYlda workers cwnpensauun Ior their enlyldyees.
1'unuanI to lies.astute.in crnplurrd is Joined as".
e ery pc
lion
or Implied• oral at written."
In e)npluprr tc defined as"an mdtvidual,purtncnhip.assoeianoa,eorporalion ter other legal entity,or my two r t meta
cd m a otnt enterprlsa, and including the legal reprcscmativaslayin emplo)«.IHowcver the
I the I;xeguull{cnyag• 1 asrneahtp,assoe)atioo or other legal entity.emp Y, 6 ' D y,l of the -
,dcmvcrdrwaledof.Inindivi.ing p
owner eta dwelling house having not more than three apaAmenu and who resides therein,or the ace
appurtenant rionil �s I sot becausa of such cmploymcnt be deemed to be an employer."
owner
3 dwelling
of another who employs persons to Jo mainenance,cunsrruction or repair work ten such dwelling owe
or on the around+or building
\IGL chapter 152. §25C(6) also sloes that 'every state or local licensing agnney shall withhold the Issuance at
operate a business or to construct bull la the commaowgelre for required."
renewal of a Ilccnw or permit to of itsc cove al subdivisions sh+ll
aypllaano who has not produced acceptable
sbl ear deuher the onunonw rlth not any cane ycoverate subdivisions
kid itiunullyI �IGL draper 152, 3- l
enter into any contract Ior the pertoman o oeJbo- work the contracting a aothoriryvidence olcontyli ulce with the insurance
requirement$of this chuptdt have been p'
Applicantsing illsboxes to our situation and.if
Plcase rill out the workers' cumpatlsadon affidavit cols)and
phone number($)slang with their cartificalc(s)of
necessary.supply•rub-contractor(s)nrme(s),address las)and p with no etnployieft,other than the
worker' compensation imuronce. if an LLC or LLP does have
insurance. Limited Liability Companies(LLC)of Limited Liability Partners
(L
members or p tAnan, are not required to carry be submitted to the Depttrrmellt of Industrial
drllployeas,a policy is required. 9e advised that this affidavit tray
\ccidenld
is far confirmation of insurance coverage. Also be rare r ilea cad Jute the u sled, 4 The)%paffaavit shoo
liCatian for the permit or license is being requested, not the Ca war kern' of
questions regarding rho low or if you are required to obtain a workers'
he refill to the city or town that the upp companies should enter their
Industrial Accidents. Should all have any q ent+t Ibe number listed below. Self inslued comp
Compensation policy.please call the Depurtm
salt-insurance license number on the a ro riate lino.
City.or Town Officials tcd licant.
PICace be sure that the to t It oueein°h�`Yc�the O►tee of InvestigtiDons has to contact you regarding the provided u space ut tapp he bottom
411103 tfiJuvu fur y
hcations in an given year,need only submit one afiidaun indicating current
I'laasa be aura to till in the q nnitin the event
the which will be us�d as refere y e aun)bde In addition,an applicant
Ilat muat submit multiple yanniUlicellsa aPD '
policy IOCali
inl'ormalof I)e u%lduvi�hut has been offlc ally stad unddr"Job Site mped or markedss" tbyy Ile city Oretowe'nay be provided to thes in y or
each
town).' \cuPY
applicant w proof chat a vuliJ affidavit is on file lot future permits of licensas. to any new tusinest mat be 111Ied out venture
)dar. When a home owner or citizen
Icavese.)obtaining J pergo leis NOTtequired of complete this c tftdav imnereial venture
it to b
1 i.e. a .lug licence or pram � you ha�a.m uasuous.
I he )1IIeC UI Invevtlgattuns would I,"to think you In aJVanee for goof cooperation it'd should y Y 4
plea,e do nut hesitate to give us a call.
f hC UCparummu's address, mlcphund and Th JA Cn number:
of Mauat:husetu 1
Departrnent of Industrial Accidents
OMCS of IsivaUQatlone
600 Wilshirigton Street
80311011, MA 02111
I al. q 617-727-4900 eat 406 or 1-877-MASSAFE
Fax M 617-727.7749
J ;.+n.us www.mau.gov/dill
CITY OF S.�I.>r.�I, ,�LASS.�ICHL'SETTS
BLMDLNG DEP.1RT%LLNT
120 WASHLNGTON STREET, Y°FLOOR
T IEL (978) 74S.959S
RALx(978) 740-9846
KIJtBHRIBY DRLSCOLL
MAYOR THo.�tns ST.Pmjtu
DIRECTOR OP PLIXIC PROPERTY/SEMMLNG CONNISSIONER
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 MGL c 40, S 54;
Building Permit Is 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
l 11, S 150A.
The debris will be transported by:
e
(name of hauler)
The debris will be disposed of in
-- . Z3cc>
(name of(nudity)
(address of r3cibly)
V
iynu a of permit applt ' nt
Jut
LM1n..d,l,w
,1
-*� Massachusetts - Department of Public Safet
P Board of Building Regulations and Standards
Construction Supervisor License
License: CS 92362
s
JAMES M ODONNELL
3 JAMES AVE
MIDDLETON, MA 01949
Expiration: 4111/2013
('onnnivvioncr Tr#: 13629-
A s Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
f Registration: 167476
Type: Private Corporation
`Expiration: 9/24/2012 Tr# 203721 -
JIM O'DONNELL COMPNAY INC
JAMES O DONNELL --
3 DAMES AVE.
MIDDLETON, MA 01949
date Address and return card.Mark reason for change.
Address ❑ Renewal ❑ Employment Lost Card
OPa-OA1 0 SeM-04/04-G701,216,-.. -�
Office &Ions "X'ffe'tem fig iness ego a`1Po� License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration >167476 Type: I Office of Consumer Affairs and Business Regulation
Expiration 9/24/2012 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
TOiNNELL
,,OMANAY IM1tEj�71
JAMES ODONNF.�LI
3 JAMES AVE
MIDDLETON, MA 01$49^•:�:'.%� Undersecretary y of lid withouts gas
ACORo
� . CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDrYYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER 1 HI;
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE;
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZES
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATIO
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate doe N IS WAIVED, subject to
s not confer rights to the
certificate holder in lieu of such endorsements).
PRODUCER T
CT
: William Fflbri
Fabri & Rourke Insurance Agency, Inc. (g7B)223-4037o,ExO; FAX (9T8 2
153 Andover Street --- A/C,No)_ ) 23-4038
ss:w£abri@fabrirourkeina.com
Un1t 208 CER MER IDa00047942
Danvers MA 01923 INSURED --- _INSURERS)AFFORDI NG COVERAGEERA_Essex Insurance COmpanJim O'Donnell Company, Inc., RS:Phoenix Insurance Company 25623
DBA Unlimited Property Services INSURER c: ----
3 James Avenue INSURERD_______ -------
Middleton MA 01949 INSURERS_ ___-- ---- --
COVERAGES INSURER F
CERTIFICATE NUMBER:master 2011-12 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES UI 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,
INEREXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
.LTR --- ADDLS eR------""--
LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP --------
GENERAL LIABILITY MMIODM'YY MMIDOn'YYY LIMITS
EACH OCCURRENCE $ 1,000,00
_X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED —"
A
CLAIMS-MADE ��OCCUR 3DF3493 2/26/2011 2/26/2012 PREMISES 1Ea occurrence)_- $ 100,00
Al EXP(Any one person) g 5,00
PERSONAL&ADV INJURY $ 1,000,00
GENERAL AGGREGATE _� 2,000,00
GEML AGGREGATE LIMIT APPLIES PER — — _
X POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,00
AUTOMOBILE LIABILITY j - — $ - —
f-- COMBINED SINGLE LIMIT
ANV AUTO J
(Ea accident) $
—.
B � ALL OWNEDAlJT05 A-3955C306-11-SEL 3/21/2011 3/21/2012 _BODILY INJURY(Per person) $ 250,00
X SCHEDULED AUTOS I BODILY INJURY(Per accident) 500,00
1$
_ HIRED AUTOS PROPERTY DAMAGE
(Per accidenq $ 100,001
NON-OWNED AUTOS -- - —. —_
Orce other car Is
UMBRELLA LIAR Uninsured motorist BI split limit $ 100,001
OCCUR
EXCESS LIAR _L-- EACH OCCURRENCE $_
CLAIMS-MADE
DEDUCTIBLE AGGREGATE is
11 RETENTION SWORKERS COMPENSATION I $
AND EMPLOYERS'LIABILITY WC STATU- IOTH-
ANY PROPRIETOR/PARTNER/EXECUTIVE� I —.-T-ORy_LUALISJ _ER
_
OFFICEWMEMBER EXCLUDED? N/A E.L.EACH ACCIDENT 5(Mandatory in NH) �_
I( es,desaibe under E.L.DISEASE-EA EMPLOYE
$DESCRIPTION OF OPERATIONS below
EL,DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
JOanie Vievoudes ACCORDANCE WITH THE POLICY PROVISIONS,
412 Lafayette Ave.
Salem, NH 01970 AUTHORIZED REPRESENTATIVE
William Fabri/JFABRI
ACORD 25(2009/09)
INS025(200909) The ACORD name and logo are registered marks of ACORD RD CORPOR AT ION. All rights reserved.