76 LAFAYETTE ST - BUILDING INSPECTION (2) What is the current use of the Building? �—
Material of Building?�T If dwelling,how many units? U
Will the Building Conform to Law? uR S Asbestos?
ArchRed's Name
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# c o$&1 q HIC Registration#
Estimated Cost of Projed$ �� Permit Fee Calculation
Permit Fee$ S Dv Estimated Cost X$71$1000 Residential
Estimated Cost X$111$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date Z
N
O
F a b ov V >
a o•
J6ee �anvrruazwo,2ltli a�✓�ad�arclwna,�
-� BOARD OF BUILDING REGULATIONS
�€. License: CONSTRUCTION SUPERVISOR
_ Number: CS 086143
y Birthdate: 11/O111964
ExPires:'11101/2007 Tr.no: 86143
Restricted: 00 _
MICHAEL G BERNIER
16 CHANDLER ST- -
NEWTON. MA 02458 Administrator
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
cnNattus,r oaacott
MwYM
110 WASICNOr tsttnar.JUZK M"LU trt:sttta0lVM
Tlls M74s.9M.PAm gW40.9W
Workers' Compensation Insurance Allldav* guilders/Contrut8nMftMelatta/nu=bm
ADngcant Information
Name 1 y C6 , LLC
Addres
City/StateMP: v."7�e 177 fl D�-2SIBPlwne It G1? 6 z
An yom an.apksyvt Ckeek tb appropriaq bass
1.❑ I am a employer with 4. l:J 1 am a amoral contractor and I Type of PMjG"(
employees(!WI"at part dme).a have hind the subtonnaesrs & ❑Now construction
2.❑ 1 am a sole proprietor or patmeo- Hood on the atsoEed do t,t 7. ❑Remodeling
ship and have no employees These haw S. ❑Demolition
working for me in any capacity. woriteet8 camp,iamaanee.
(No workem'camp.mammon J. ❑ We are a carporatiap mad is 9. addition
required) offices have exercised their 10•❑Electrical repaint or additiaw
3.❑ 1 am a homeowner doing all work right of atsuption per MOL 11.13 Plumbing mpavt or additions
myself INo workers' 1J comp. a 2, l(4
4 [ and the bow no
12.❑Roof repairs
urauranee �•1 t employoer,(No Workers'
comp,WWUM mphI&i 13.Q Other
fAar dirt ch.ssw tin rl mar alas Kee as dr asedoa twlow r wrQ ihalrwarkma'oNmyaamdNa galley hKasmriaa
Hamaowea vha VA"tags aaldeva Indicating;dW an dalet d Wadi ad so him eSedda aaearon mar aihsdt a eve al!ldaolt
tCeaaaemm dw aback dda tin MINK almehod a addt doed sham shaalst des ems of dw amhtoomom ad dwk vertma'comp, iaawmatlaa
!f an enapbrya►that bprovidlnj workers'cowponmadon L wancO jor my employees Blow is rib pobeay srd j b sb7r
!n orwaalora
Insurance Company Name:
Policy N cr self-ins.Lie.w_
Expiration Data. 3/ C7g
Job Site Ad&=s 7b L�� CitrlState2ip:
Attac
h
a copy of she
workSn'compewtba pod"deelantioa
Page(showing the policy number Sad axpbnd.- data),
Failure to secure coverage so required under Section 25A of MGL a 152 can lead to the
fine up to S 1.500.00 and/or one-year impriaonmenk as wen ma civil ns tim of criminal Penalties of a
of up to$250.00 a daya Penalties in the form of a STOP WORK ORDER and a Ana
g tiro vioLtor. Be advised that a copy of this sstemem may be forwarded to the Otllce o!
Investigations of the DIA for inuwance coverage veri}icstia4
!do hereby cordh under rib Pains and sides,alper/rup that the in jaraaadomr provide/ Is due and eorreea
X
2� o
S � - Z1Slo
offle'af u$e on"A Do not write La Ikh V94 to be completed by cdy of town oQfchd
City or Town: ?of OLIMetaso N
Issuing Authority(eireb one):
I. Board of Healtk 2. Banding Department 3.City/row■
ti.Other Clerk 4- Electrical Inspector J.Plumbing Inspector
Contact Person: Phone 0:
Client#: 35588 RCGBU
ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
01/15/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INSURANCE MARKETING AGENCIES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
306 MAIN STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
WORCESTER, MA 01608
508 753-7233 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Crum&Forster 42471
RCG Builders LLC INSURER B: Associated Employers Insurance Co. 11104
c/o RCG-LLC INSURER C:
17 Ivaloo Street,Suite 100
INSURER 0:
Somerville, MA 02143
INSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
S TYPE OF POLICY NUMBER POLICYEFFECTIVE POLOYEXPIRATION
LTR NSR DATE Whili DATE MMIDDIYY LIMITS
A GENERAL LIABILITY GL0091105 03/31/06 03/31/07 EACH OCCURRENCE $1000000
X COMMERCIAL GENERAL LIABILITY PREMISE TO RENTED $SD DDD
CLAIMS MADE 51 OCCUR MED EXP(Any one person) $
X BI/PD Ded:15000 PERSONAL BADV INJURY $1 DDD DDD
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $1 DDD DDD
POLICY PRO LOC
ECT
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO La accident)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-FA ACCIDENT $
ANY AUTO OTHER THAN Esi $
AUTO ONLY: AGO $
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION AND WCC5005531012006 05/10/06 05/10/07 X WC sTATu- oTH-
EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT s500,000
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Re:76 Lafayette St.,Salem, MA
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Dodge Area LLC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _10_ DAYS WRITTEN
c/o RCG-LLC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
17 Ivaloo Street,Suite 100 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Somerville, MA 02143 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001/08)1 Of 2 #131597 GCE 0 ACORD CORPORATION 1988
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I,% of,, 120 W.VNHIN I'ON SMEET •SALF.M.NtASSACi ,SLTtS 01970
Tr :978-745 9595 ♦ F.+x:978-74G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CMR section 111.5
Debris, and the provisions ofMGL 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
t 11, S 150A.
The debris will be transported by:
S-haulzrC)'
The,, debris will be//disposed of in
(name of facility)
t address of facility)
------- s]"nature of,permit applicant
dl to
.:ct:rs_:Lfrc
EI`f'Y BF�rYLE� — -
PUBLIC PROPERTY
DEPARTNiF.�iT
KINUM RY DUSCULL
MAYOR 13D W.WUNGMW b'MEET•SMak M.tuAarLSk1-M 01970
1f7.:972-745-95"•FA7t:976740.96r6
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building: C6n'l
Property Address:-_`?&-- --5 ---------
------ -._.. .--
Property Is located in a;Conservation Area YM AJ Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: 7�/ cr�
Telephone: &1 7 G z .6, 7 7 y (/ -7 S 2 22b
3.0 COMPLETE THIS SECTION FOR WORK IN EX131ING BUILDINGS ONLY
Addition Existing 1/
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing 2 (�
Approximate year of Area per floor (sf) Renovated
construction or renovation ! qQv
of existing building I I I New
E&I Description of Proposed Work:
MA
Mail Permit to: