51 LAFAYETTE ST - BUILDING INSPECTION (2) T e
The Colnrnoil�%ealth of IYgassurhusell --
y Board of Building Regulations and Standards I e IK
`\ i Nldssdchuset(S State Building Code. 780 ('%1R. 7"' edition sit S'R'll' \I Il 1
Building Per Application To Construct. Repair. Renosate (h Demolish a R, I;,rd.Loo; n
I Onr'- or Tna-'umih /hrrl/irlq
is Ion For Ofticial Use Only
Budding Permit Number: - Date Applied:
--
51 g n:u u re.
HudduiE('unvnisaoner/ In>prcwr of 13w duigs Iyair / . . .._..___.__.
SECTION I: SITE IN'FURML%'1'IUN
1.1 Properly address: 1.2 Assessors .flap & Parcel .Numbers
S f' 0 ili y0 f
__la Is Ill's :u�s t accepted slrec•C.' cgs__ no_— Map.Number Panel .Nuuibu �I
!.3 ?? coin^ Informalit'tt" J I Property Dirx,nr':;ns:
Zoning District Proposed Use � Lot Area uy iU, Ruutage iIL
iS Building Setbacks (ft) -- {
Front Yard .Side Yards Rcar 1':ud
Re uircd Provided - -
4 Required Provided Raqun ed I Pr... ded
1.6 Watar Supply: IM.G.L c. 40. §54r 1.7 Flood Zone Information: 1.8 Sewage Visposal System:
Public ❑ Private❑ Zone- -- Outside FLrod Zone:'
Check i(yes❑ Municipal ❑ On site disposal system ❑
_ SECTION 3: PROPERTY OW
NERSHIPr
F21, wners of Record:Prim Address lirr Service' --
Sienruerc 6(7 _y S
Telephone -
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) 1
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(,) ❑ Alteranon(s) ❑ ,AJJilii n ❑
Demolition ❑ Accessory Bldg. ❑ T Number of Units Other ❑
jLriel`Descoption of Proposed Work'':
I �s:.�u1:e Q l t'� (.,✓i k�c�w ��w 6 /wss _ --- I
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item F_snrnated Costs:
ILohor and NIalerialsl Official Use Only
I. 13uui�ing -- y 3 SOO,�(� - I. Building Permit Fee: $__ Indicate ll,m tie a drlrnninrJ
2. F.Iecn icol 5 ❑ Standard City/Town Application Fee
-- ❑ Total Project Cost' (Item 6) x multiplier .e _
i. Plumbing S ?. Other Fees: S
�1. :Mechaniral IHVACI `S List:
i. Mechanical (FireIs
-
Su r i-ession) Total All Fees:
Check No —_('heck Amnunl. (',uh
ai7 Ann nuu
y-60 .
o Total Project Cost: S -3
❑ Paid in Full ❑Outstanding Balance Due:
y,
t..
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
'7 Lteenx Nunther I[s pt r.uou D.ua
-cqq ante of C'SL- IIoIJar Lut CSL Tpe I,ee below 1 —
�-r Oo C�C �{' Tv a Dcscn nun
\ddre" 1 r \ C l nrrsIneled I u, to :i0ill)
� R R.1tiMeJ l&2 Fainik D„elline
ne
,. .. Rc,ld"n OnlyRC' RraJrnualRnohnc(It Idl \\': Ida„ ..IILi Sid SuhJ lircl BRC,IdetIII'll Dc"I"IIIIPII5me ImpruvrmenlCactor";a tl I I 02 —Regi,trauun Numhrr
I jCCO ally`Na Ie orFI1C Rc ulraN Nano --
AJJre , l 7�� 1 3 (.S_ rj 2- Ftl,irali.�u U:rl:
i .---_
ign relephune
alurc
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Fulura In prustJe
this affidavit will result in the denial of the Issuance of the bwlJmg permit. .
Signed Affidavit Attached'? Yes .......... 11
No ... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
1. ------ to act on my behalf. in all m:iuels
authorize
i
relative «, w.�,c authorized by this building permit application.
----- Date ------—_--- _--
Si nature ut Owner
SECTION 7b: OW'NERt OR AUTHORIZED AGENT DECLARATION
c C1/ 2c _ . as Owner or Authorized Agent hereby declare
that the statements.and information on the hxegumg apphcauon ale true and accurate. to the best of my knowledge and
behalf. C ` -e
to c '
N p�
Print e
Date j
S- nature o Itor:\uthonzed Agent
(Si ned u er the ams and enallies of er'u ') NOTES: it) -{
I. An Owner who obtains a building permit to do his/her own work, or :m owner who hires an unregistered c"ntra`u'r
(not registered in the Home Improvement Contractor IHICI Program). will not hove access , e it
L.
program or guaranty fund under M.Q. c. I-i'_A. Other Important intLrmation on the HIC Pro�ur:un and
Construction Supervisor Licensing ICSLI can be found in 780 CNIR Regulations I IO.R6 and 110 RS. respecusely.
' the information below:
When substantial work is planne m o u
d, pruvlJe
Total flours area l ia Ft.) (including garage. finished baseent/attl , decks r purrh'
Habitable room count
Gross living area (Sy. Ft.) Number of hednu one __. ------._
Number of tircplaceS Number of halt/hdths --
Nunnber of hathnx'nls Number of deck./ p,aches
T
ype of heating system
rype titi,Nihni ti\slem
l "Total Project StlUare Footage" may be sUbstlt Uled for "rotal Project Cost—
y s
CITY OF SALEM
'. PUBLIC PROPRERTY
44 r,..
'a: ` _' •�`" DEPARTMENT
Construction Debris Disposal Affidavit
(rctpuired lbr all demolition and renovation work)
In accordance N�ith the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
t t L S 150A.
The debris will be transported by:
-e-
��� (name of hauler)
a
1 lie debris will be disposed of in
I [o Colvi �N�wLs _Gvuty 54 ` e
(1lame of facility)
(address of facility)
-- 11 atUl'e Ut IK1I111I apl)Ilc❑OI
date
VI"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
N\ orkers' Compensation Insurance Affidavit: Builders/Contractorsi Electricians/Plumbers
\ f lllcant Information Please Print l.eeibly
N.IllIc Ilu.rii.. tq_.�nlv.tliun lu,6,:Ju,dC S-erU
\tldress:�3Co \ ��k S S�
c lt> srBe zip:
Ati ILA 91`2 2- Pholle 4
tire you an employer:' Check the appropriate but: Type of project(required):
'f:tin a employer+s,tail 15— y. ❑ 1 :tin a general contractor and I New construction
I ❑ ._ 6. ❑
,:mpluyees (full and'ur part-time) ha+,: hired the i ub-contrac(ors 7. ❑
p Remodeling
'.❑ 1 .uu a sole proprietor or partner-
IisteJ on the attached sheet.
,hip and have no employees Ihese sub-commctors bast 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. y, ❑ Building addition
I No workers' comp. insurance 5. ❑ We are it corporation and its 10 ❑ Electrical repairs or additions
required] officers have exercised their
ri tht of exem tiun per N16L I I.❑ Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work S P
myself. (No workers' comp. C. 152, e 1(4), and we have no 12.0 Rouf repairs
insurance required.I t employees. tic workers' 13.0 Other
Bump. insurance required.(
•:xny,applicant that checks box nl must also till out the section below Auwing their workers'compensation policy infuunptton.-
' I hm,,awners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�(',ntia+mrs that check this bus must aaecheJ in addmmnal,heel showing the name of the sub-contractors and their wurkers'comp, policy information.
l ant on employer duct is praviding worker''c'ofnpettxation insurance for ttty employers. Below is the policy and job sire
inJaromfian. � �
In;urance(bmpany Name:�SSoC c� vrn J(.Q S 5 elC'
Policy q or Self-ins. Lie. Or: Expiration Date:
$I � &)L 4 4 kS c ..11 2L GU to al 9 G Z
Job Site Address: c'�\+T �G ' City,State/7.ip:
.\Hach a copy of the workers' compensation policy declaration page (showing the policy number and etpi�e).
Failure to ccure coverage as required under Section _'SA of NI(iL c. 152 can lead 6t the imposition of criminal penalties of a
line up to S l.'utl.o0 and'or one-year nnprisonnient, as well as ci+il penalties, In the tbnn of a STOP WORK ORDER and a fine
„I Fiji to >'50 00.1 day against the +wlaror. Be ad+lsed that d copy of this statement may be Ga+varded to the Office of
I r,,esn e.tnon9 Ott tilt DI:\ I:,r insur.utce co+crage +cnlication.
l Ju hert•hy t.'rl Jr �theo.senalises of pepury that the utiarntarian prat ided abut a is freer and c orrec 6
Date -5- 30 v �
'iyn.uurc.
(I/Jiritd utr salt•, Do sat trite in this, area, to he completed by sii ur town aJJicial
( it% or l o%on; 7eclor
I%suing \uthority (circle Intl:I. ISoard tit Ilcahh Z. Building Dcparttucnt I ( 'Iv Townlerk J. I•:Iectrical In+pcoor 5. Pluni
6. Other - - - --
Contact Person: —_-- _- -- Phone
Information and Instructions
Mini II, l ii 11cr.11 1 .11„ :h.lptcr I `' I e,ltlll i, .III chip It),c I, IJ pro,ide „,rkcr'1 omllcn,mion for Illi Ir Clnplm cc s,
I':n.uanl w this .t.uure. .111 ern/l/urre 1, dclSned .Is c, :rN. lie i„ ll ut the ,vt,i:r of aroahcr under .m, ,onra:I of hue.
r,l,i k: , ,,r in I,!sell. ,,rail or „I iuen -'
\r. emldmer I, Jclmcd .Is ".m :ndll:,lua 1, p.0 n:crnhgr. .l„o:i.ulon. .orporation or „tier !c_al cut it,. or .into Ill„or inure
I the fool en_accd Ina bolt cntel pn,e. .uIJ leludmg the Ic_al I:presQntau,c, of a lie,caked cnlpl, ,er. or the
::.cn er or tru,teckit an mdI%IJual, p.0 tllcrnh 1p, a„u:utwn or of her Icgal enure, el rep Io,Ine crop Iu,ce., Ilo„e,er the
.'.,ncr „t.I .hoo cuing house ha,ilie not snore Ih.ln three apartments and lot hot rruJc, Ihcrout. or the oe:upint of the
d e!we Itou,c of it l her „till en tplu„ per,on, tu do m.untcnan:e :ow trurwin or repair „ork un ,u,h d„elhng house
,.I ..It the _ioun,1S Or bllllding appunenant t:eteto ,hall nor he:auw it.u:h emplo,nlcnt be Jeeured ❑, he an employer.
\I(,1. :haplcr I i_'. �'SC I(,) also ,late, that 'c,cry Nate or local licensing agency .hall withhold the issuance or
renewal of a license or permit to uperale a business or to construct buildings in the comnsonvvcalth for any
applicant who his tint produced acceptable evidence of compliance with the insurance cuserage required."
\JJmonilly, NIGL Ompter 152. j2S(1-1 ,rates Neither the c.nnnnmwrallh nor any of Its political suhdiv owns shall
eu(cr into any cunrract fur the performan:e of public „ork until acceptable e,IJcn:e of eulllpllance „tlh the Insurance
fell all ements of this chapter hove been presented to the:ontracting authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary. Supply sub-cuntractor(s) name(s), address(es) Lind phone numbers) along with their certlticate(s) of
insurance. Limited Liability Companies I LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' cumpensation insurance. If an LLC or LLP dues 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of the athdavtt fur you to fill out in the event the Office of Im'estigations has to contact you regarding the applicant.
Please be hire to till 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) and under"Job Site Address"the applicant should write "all locations in (city or
to„n).'• A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
.lpphcant as proof that a valid affidavit is on file fir future permits or licenses. A new affidavit must be filled out each
your- W here a home owner or citizen is obtaining a II:er15C or permit not related to any business or commercial venture "
(i c. a .log IlccnSC or permit to burn leu,cs etc.) said person is NOT required to complete this affidavit.
the (slice of In,cstigations would like w thank you in ad,ance fir your cooperation and should you ha,e any questions,
hlr.nr Jo nor he,uate nh gne its a .all. - -
I he D,p.utmcnt'+ address, relcphone.old fax numher.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Olilce of Investigations
600 Washington Street
Boston, MA 021 1 1
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia