Loading...
90 LAFAYETTE ST - BUILDING INSPECTION (6) .,'\\ I Zh The Commonwealth of Massachusetts FOR ► Board of Building Regulations and Standards MUNICIP,U.I' IP Massachusetts State Building Code. 780 CMR, 7'h edition 1 II l' .51 Building Permit Application To Construct. Repair, Renovate Or Demolish/ Revised Juttum, 1, 'rx)3 This Section For Official Use Only Building Permit N ber: Date Applied: Signature: bQ B ding Commissioner/Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property Add ess: 1.2 Assessors Map & Parcel Numbers q D l-C To rn-t e S� :A4 b o Z I.la is this an accepted street?yes ✓ no Map Number Parcel Number 1.9 Zoning Inforrnatlo � 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.1.c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Public❑ Private❑ Check if yes❑ P j SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner of Record• R<Cs 5n L� ti Yr� _ LLC 90 Na ant)� Address for Service: 1 /X"" & l7 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) _t New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s)AS Addition ❑ C� Demolition ❑ 1 Accessory Bldg. ❑ Number of Units5 Azi Other ❑ Specify: Brief Description of Proposed Work': O S ztill - © SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building 1. Building Permit Fee: $ Indicate how fee is determined: Standard City/Town Application Fee 2. Electrical $ `ko 02 ❑ Dial project Cost (Item 6) x multiplier x 3. Plumbing $ i,,o4 0o v 2. Other Fees: $ 4. Mechanical (HVAC) $ :yob D o O List: 5. Mechanical (Fire $ vD Suppression) � Total All Fees: $ r7� ?j2 q Check No. 4% Check Amount: 5%1 Cash Amount: 6. Total Project Cost: $ 4�9'9' 0aa Paid m Full ❑Outstanding Balance Due: Suzy I SECTIONS: CONSTRUC11ON SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Eap ration Datc Name of CSL- H'o^ld�er In^'� �/ List CSL Type(see helow) CS ' U -7 YVaI/J«� )lam Type Description Address j L ,„_ /) �i U Unrestricted(up to 35.000 Cu. Ft.t R Restricted I&? Family Dwellin Sign atu M Masonry Only RC Residential Rool'ing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Insi.dlapon D Residential Denuwhuon 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address _ Expiration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 9 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 ...........0 No ........... O SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING `PERMIT n r { f Rec 74� Aguas Owner of the subject property hereby authorize 'fin 1 0 ( c5--C v t i�e to act on my behalf. in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION I as Owner or 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. Print Name Signature of Owner or Authorized Agent Date (Si ned under the ains and nalties of riu ) 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 noj 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 110.116 and 110.115, respectively. 2. When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) � 8�' (including garage, finished basement/attics. decks or porch) Gross living area(Sq. Ft.) &0 5 Habitable room count X:1 Number of fireplaces Number of bedrooms < Number of bathrooms Number of half/baths O Type of heating system JAe P.eo� Number of decks/ porches h Type of cooling system C Enclosed Open 3. 'Total Project Square Footage" may be substituted for"Total Project Cost" i iw�D CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT KISIIII-Rl11) IIKNC0I1. SLUNK 12-, WA.SIHN(i'It)N SIR[ IF • SAI ENI, MASS.\(]lit Sf,I Is C1970 111:978-74,5-9595 • FAX: 978-74C-9846 Workers' Compensation Insurance .affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Narre (Businres,Org:mizatiorvindividual): ZLI)< / C_- :address: ) ? Wit.;j 10 a �v e /ob �A ✓;1 City/State/Zip: Phone #: 6) 7 S 92 225 :tire yno an employer? Check 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 nn 2.[11 am a sole proprietor or partner- listed on the attached sheet. 7. tUl 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' cum insurance 5. ❑ We are a corporation and its [ P 10.❑ Electrical repairs or additions I officers have exercised their 3.❑ I am a homeowner doing all work .right of exemption per MGL I LE] Plumbing repairs or additions myself. [No workers' comp. c. 152, §t(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] -Any applicant that checks box NI must also till out the section below showing their workers'compensation policy information. ' I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. �Cuntmchvs that check this box must attachod an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. p Insurance Company Name: 04�,A �J�I7Vr�f't �RS Policy #or Self-ins.�L!+ �cfi ic. #: Expiration Date: 1"7 /� Job Site Address: O Cy�-Q City/State/Zip: S satzlo? 1A Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cerrifp under the pains nand penalties'of perjury that the information provided above is true and correct. tii n tture a/Z6�a Date? � �g 1h ll / s' qz 011icial use only. Do not write in this area, to be completed by city or town official. Citv or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an errtphgvee is defined as .....evcry person in the service of another under any contract of hire, express or implied, oral or written.- An emph rer is defined as "an individual, partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of:mother who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." .\IGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." :\dditionally, bIGL chapter 152, �,25C(7)states"Veither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfomtance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does 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 be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of die affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicense 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 (own)." A copy of the affidavit that has been officially.stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. "file Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. - The Department's address, telephone and tax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT �1.�.• 1 C W.%S CW.JMf Uff•fALE W WAV[1tt M %*4 To;9t1waam•F.%*'1W4&"A r- CoastrucNos Debris Disp"it Aft1davit (rcgaimd AN an densolitios and enovatios work) is=miases with the sixdt edidos of dts Sets tlLeiWb*Codsl,730 Mi t sactios t l 1.S oebt*and dw provisions o(MCM a 406 S A Swid ai;Few* 0 is issued wridt,dw eoodtetos that the debris r9WAWns ft W this wait shall be disposed of in a property licau d wasse disposal fbcility as dented by MOIL o It1.S15" The debris will be transported—rby. I�aree air hoalM) a rho&-bris will be disposed of in : w ACORD CERTIFICATE OF LIABILITY INSURANCE a2/2008' PRODUCER (978)356-5511 FAX: (978)356-0214 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bernard M. Sullivan Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 12 Market St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 568 Ipswich MA 01938 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Essex Insurance Co. XSB003 RCG Builders, LLC, DBA: C/O RCG LLC INSURER B: 17 Ivaloo Street wsURERC: INSURER D: Somerville MA 02143 INSURERS CERAGES 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. AQ R A T H REDUCED PA INSR ADD.L POLICY EFFECTIVE POLICY EXPIRATION LIMITS TYPE OF INSURANCE POLICY NUMBER DATE MM/DDNY DATE MM/DDIYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMSES(Ed occurrence) $ 50,000 A CLAIMS MADE OCCUR 3CW6956 3/30/2008 3/30/2009 MED EXP(Any oneperson) $ 1,000 PERSONAL$ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 1,000,000 X POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea..dent) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS , HIREDAUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per amidenp GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAA C $ AUTO ONLY: AGO $ EXCESSIUMBRELLA LIABILITY EACH OCCURREtIQE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION S $ TWO LIM OTH- WORKERS COMPENSATION AND TDRY EMPLOYERS'LIABILITY EL.EACH ACCIDENT $ ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE$ If yes describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I$ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Re: 90 Lafayette St Salem, MA 01970; City of Salem is named as additional insured CERTIFICATE HOLDER CANCELLATION (978)356-8909 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Salem EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Bldg Inspector 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Salem, MA 01970 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE J Lewis, Acct. Exec./ ACORD 25(2001/08) ©ACORD CORPORATION 1988 one t nr o INCn9A m,ne,no.. BoaarBoard d of Building Regulatio sand Standards . ;, Construction Supervisor License License: CS 86143 Expfratlon: 11/1/2009 Trp 9354 'Restriction: 00 .. MICHAELG BERNIER 68 JEWETT ST + NEWTON, MA 02458 Commissioner