113 LAFAYETTE ST - BUILDING INSPECTION 4
f v x�
The Commonwealth of Massachusetts V
;t Board of Building Regulations and Standards
1'UR
Massachusetts State Building Code, 780 CMR. 7"'edition NIUNICIPALI'11
z>� U S I
Building Permit Application To Construct, Repair, Renovate Or Demolish a Rei ocd Januh,i i
One- or Tiro-Faith, Duelling 1. TINS
This Seirwn For Official Use Only
Building Permit Nu r Date Applied:
SlgnatuP : �.�0,06�
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
i. ro rty :>,ddr 1.2 Assessors Map & Parcel Numbers
1.la Is this an accepted street? yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(It)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone?
Check it yes❑ Municipal ❑ On site disposal system ❑
2.1 9itvner�ty—of Record:
SECTION2: PROPERTY OWNERSHIP'
AXI
Name (Print) _Tci � fliev- Address fir Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1Accessory Bldg. ❑ Number of Units_ Other ❑ Speedy:
Brief Description itf Proposs5d Woy(k': c- b a .r 8 we.L ci, jt
CQ ff'n Cep
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and-Materials) Ofti 'al Use Only
I. Building $ o`J V 1. Building Permit Fee: S JQ "'Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire Y
Suppression) Total All Fees: $
Check No. Check Amount: Cash Ant:
(i. Total Project Cost: $ �l�S� nwu❑ Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 LL�oll
icensed Construction Supervisor (CSL) c,� ��� bb Us
e;,, .) _ License Number L'xpilanun Date
4-\ddr
- Holder � List CS Fypc (see below) 0
a Type Descn neon
U Unestricted (u to 35.000 Cu. FtR Restricted 1&2 Famil Dwellinc
�/� Idi � ' /� M MaxmrvOnl
�1 RC Residential Kaolin¢Cus'erIn_
Telephone \VS Residential Window and Sidinc
SF Residential Solid Furl l31 A t thanee Installawm
D Residential Demolition
5.2 Registered Home Improvement Contractor (HIC)
Registration Number
HIC tpanyaNantc o(-Hlq Registrant Name r b ' IO�
Address .i(qt � Expiration/Date
Signature Telephone -/
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 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 ...........
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I as Owner of the subject property hereby
to act on my behalf, in all matters
authorize
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER` OR AUTHORIZED AGENT DECLARATION
I - 7 , as Owner or Authorized Agent hereby declare
that the statements ani2lAnformation on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name U �i
Signature of Owner or Authorized Agent Date
(Si ned under the pains and penalties of 2era )
NOTES:
I. An Owner who obtains a building permit to o his/her awn 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 I IO.R6 and I IO.RS. respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenUattics, decks or parch)
Gross living area (Sq. FL) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open-
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
w14aT'ataY nal�711L1
1Lvvtta 12CWAs ruawwkwouTsTutuWm"Colatiis01W3
TW t &AS.aSeb a F.v::1~40.9"
Wwkws' Compenatlos Inuraa AAldavit. Buildon/CootrwUWWElaetr(gaoaa%mbon
an eo nlieant Infornligana Mean Moe t ogibly
Vametuuiac:aroraa.i,arinrtwr.�.11: �"' �v�
Add • 6
cityislsvz;a il o) ('haaaN _ rld'l � � 231N
.r. w aaphtyar2 t:k.ett e approprlw bqt
1 ran a eurployar wink 4. ❑ 1 am gtanmai eatrltanor sd t rype atpryed(roessiro r
B Q New
rarrpissyem(run answer purwima).• hove hired the wtb comrsctora
comattwtiom
2.Q 1 am a sole propriceor or partner. listed on she attached shoot 1 Q Remodeling
ship and hunts no amplayw. Teass ste-oona.aar.haw x p Osenwirion
Working for me in any capacity. wortsers.eorrtp. ittptranrea
(Ne ewrltew'comp. ,one" S. Q we an a aorporadess and its ° ❑building ae5ditio0
rcquirotll o117oas have esere(aod thou 10.0 Electrical repairs or additions
7.Q 1 am a hornoownar doing all work; right of asemption per MOL 1 I.Q plumbing repairs or addidom
myself.p►e workers'comp. e. 152.+l(4)6 and we have no 12.13 Roolrepain
insurance requirsd.J t empbycol.(A'o workers' 13.❑Otber
co'"p imumusesx requir�.l
•A,*uppheW eM e P ' a0 or saw ahe sa star Ma"dean Iruloar maw rare ewe..•rargaasatlw weer iairwriaa
'IpuanYmq WOOD sub"an wo'b rk Mooring Mar am dots dl Wave age due Was a" now anent a am ambrit wdleaiag rri
Cuerrearers iOOw rOOrerOO Min tes eDYrn arudral al adeatlaw mn.00oWiq Tana naeae arw and Mao ewkw'moF poultry in6rwagea
/aaa ON araployer That h proWdlwg r•orhpa'coaeposaaa(oa Lrtwaaei jot nq torp/attosm, edow is rho sessav Ym M alq
Insurance Company Varnr ✓ T i ( +— _
Policy a ur Self-ins. Lit.M ��Jam_J�A ]60 3 a g O�dOD gapirauon Daq:
Job site Address: _ Ic�`I'n�uV�(/`� '��
CityrSwwZTp:
Attach a cupy of the workers'e m naatlua policy declaration palls(showing The Polley number and capitation datoj6
I;ai Iuro w secure covorage as required under Section 25A of.IGL c. 152 can lead to tea imposition ofcriminsl yonalties of s
ri ne up es S1.500.00 jAwar one-year imprisonment,as well as civil penaltism in the form of a STOP WORK ORDER and a lime
elf up to 5250-w a Jay against live viola(./. Ile advised that a copy urthis sisictrune may be iurwardenl to the 01rca of
Lit ;aunro W'dir DIA for in. annex:ovcruiu s,"iticatum.
/do hereAj certify rrif t tried pent/Ira v1 per/ary rear the/Irjerarat/aa prowled •w true
and c""cL
Off1kial war.mitt 010 Der write/a the ereo6 to k rowp yed ip city or Arww oQ$"/a[
City or town: _ Pertnit/I kcaae M
Issuing Authority (circle one):
1. Ifoard of Ilralth 2. Building 0UPartineut ]. City/folio Clerk 4. Electrical Inspector S. Piurnbing Inspector
G.Other
if cmaact Persou: Phone 0:
w
Informattion and Instructions
MISSJ.-hu"'Us Gcneral Laws chaptee l52 requite•all employers to provide wortets' compensttiostfor r
is d R ,so-,.,e
very penrts is the service of another usder Y
of bige.
Pu.nuoas to this,';Ado an of writ
,y oral
enprsss ttepbu4
at other lew notify,of my two of mate
.A aO/MJ+!d Ballad•a 'r iediriOttap ies. sshi/►aeeee>saek e0n°A�ua'ves of a deceased employer.or the
of the foregoing engagal m a jars essetpruae.>d isehtsgag gal eysasm However the
receiver of mew"Gies iodividi"p�tb'�aYeOYaoa or other tool aaogt.emPfsYici ensplOYn•
era&W48logibots" noel mme rhos three spartwsom and who teaides tlumft K the exupd a<the
owner
ewemns house of sandier who employs Peru"ao do maiaum MM ut wucdort«repair work tat such ame mpl Rouse
«buildfetg PP�•^•se�~shed set Mtaree of arch eeplaymeat bf oieerrted to be as employer.'
,x on the grnuade •
MGL chapter 152.425g6)alas saws dins"orrery state K bed Brame der withboldl rho bewsai o K
a wan•K a nsatred btslWto a CM sysvesweahh foe MW
resowd of a Bceuaet K pn�a...*operatM ovtluw of compose"with the Isssrssee coverage rogta*W
appoesat wbo W art pasdattal aotopfahb �WIP of id PONcel ntblWisioae rbsB
.Additionally.Mt3L ch W 1152p.�asses the eomreoaweakY
Orion iota say ee�� *( work until acccP We ofcarsplituseo with the insures
rapsiromenss of fhb >"�bti P as the catttraetisg atrdtoelq
Appltteate
Please All me dw wa k@W eantPaNssdm&Mdxvit completely.by checking the brutes that apply to your situation and.if
w►eaaoaetos(•) e(ai4 adbe*es)and phase number(s)along widt their canilkaNKS)Of
nocensy.supply aarrtL «[Limited
LW MV PattnsWPo i.LLP)with so too other than the
mountrses. L=WW Liabi W Companaa(L wortem'a tstturaou if an LLC or LLP dose haw
member or pertmost,an nag required as catty
employees,a policy is required 9e advised alter this affidavit may be submitted to the Deparbmwu of Industrial
Accidents for confrmed=of insurance coveno Aloe fro low to alp sad date the amdavIL The affidavit should
be rctuurrted to the city or low the,the application for the permit or license is being requested. Not the DepNebmam of
I nt rcru el d to th cif Should yatt have any gtsatiose regarding the low«if you an requited ro obtain a worlters'
tall t6a a any q sal se the uwtsbor listed
below. Self-iaaaed companies should rater their
catnpaaatioa policy.pfnte lase.
self-insurance license not
an the
City K Tenn Ofllelate
fete and printed R:giby: The DepuurAnt hu provided a specs at the WOOL
oftheaifida a that the affidavit is comp the lira m
of the affidavit fro you to fill our is the event the Otltee of Investigation•has to contact you regarding sop
Please be sure to till in the permit/license number which will be used as a reference number. In addition,as applicant
that muN submit multiple psrmiulicense applicado"in any given year.need only submit one affidavit indicating current
polity m submit
ult(if necessary)and under"job Site Addren"the applicant should write-ail locarioNs is__laity or
Town)."A copy of the affidavit that has been officially atantpal«marked by flu city or tmy,be provbe
ideal to the
applicant as proof that a valid anklavit is on Ale for future prrmin or licensee. A new affidavit must bo Ailed out ash
yCU. Where a horn owner or c. . is obtaining a license or permit not related to any business or commercial venture
t i.e. a Jog license or permit to burn leaves en.)said penes is NOT required to complete this afAdavit.
t'he Otiite of lnvestig:utiuns would like to thank yew in advance for your cooperation and should you have any questions.
,:use du rwt hesitate to give us a can.
The Department's address, telephone and fax number
The Commonwealth of Massachusetts
Depattm M of IndusnW Aocideats
Odlgs of ItawsootNes
600 WUND6OW Street
Sodom MA 02111
Tel. 0 617-7274900 en 406 at 1-977-MASSAFE
Fax 0 617-727-7749
aeviacd 5-'_G-US www.mm.pv/dill
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and 41t
PROPOSAL
Thursday, February 14, 2008
Caritas Communities
Tom Nee
113 Lafayette st. Salem
Bodega repairs
Task A
Install two layers of 5/8ths drywall on ceiling and wall
- Put down joint compound and sand smooth
-Install trim as necessary
Reattach lights
- Paint walls,trim and ceiling w/two coats of paint
- install nail strips on floor
-Install padding
- install commercial grade carpet
TOTAL ............ ... ... ... ......... ... .. ......... .... .... .. ... .....$3,250
—TONY 781-727-3146—SERGIO 781-727-3147—FAX 781-842-4492—EMAIL TONYNSON@AOL.COM—
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