185 LAFAYETTE ST - BUILDING INSPECTION r e
ii
The Commonwealth of Massachusetts
Department of Public Safety
` J .\Ll"adIlls"INSlatl Bulkitog Code(i81)(MR)
Building Penuif Application for any Building other than a One-or'I'wtrFamily Dwell iog
(I his Set tion For Official Use 011ie)
Boildiug Permit,Number' _ ___ [),Ile Applied: ._ --- ______- holding Official:
SECTION I: LOCATION(Please indicate Illock 4 and Lut p fur locations fur which a street address is not available)
o ond Stn'vt City ;Totvtl lip Code Name ifUuildmg(if
,applicehlc)
Sr:CI'ION 2: I'ROI'OSED WORK
Ldilioll of MA Sl,mr Code cord ._ If;New C llstrutlion theck here 0 orcheck all that apply in the tiro nnes boluw --
Fxixlin); Iluildht);❑ Repair ,\Itenttiun ❑ AddilmoC3 I Demolition ❑ (please fill out and submit.\ppvudix l)
C11,ntl;eofUse ❑ ChangcofOe......mcY ❑ Ofhcr ❑ Specify:._-----
Are building plans and/ur eunstruction dax'unrt'nfs bcingsupplied as part of this peroot.1ppllc0ion? Yes ❑ No ❑ ---- ---
Is,ua htdgvildentStruatinil Engineering Peer Review required? Yes ❑ No ❑
Bricf Dcseriphon of Proposed Work:_-._
St%.110N Jt COMPLGI-E THIS SECTION IF EXISTING UUILDING UNDERGOING RENOVATION, ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an existing Uuilding Investigation and Evaluation is enclosed (Sec 780CMR.N) ❑
Emsling Use Group(s): __---_ — Pnapused
SECTION 4:UUILDING MIGHT AND AREA
Existing Proposed
No. of Floors/Stories(include basement levels)tIr Area Per Fluor(sq. it.)
I'utal Area(sq. ft,)and rotai height(ft.)
SF-CrION it USE GROUP(Check as a licable)
.\: Assembly:\-10 A-20 ,Nigltdub 0 :\J 0 :\-I ❑ :1-i❑ U: Business ❑
G: Educational ❑
P: fade F.I ❑ F_'❑ H: Hi h Hazard 11.1 ❑ If-2❑ I I,i ❑ 11-4❑ 1.1-5❑
I: Institutional I-1 ❑ 1-2 0 1-3❑ 1-4❑ M: Mercantile❑ R: ItesidenHal R-I❑ R-_'❑ Rai❑ R-4❑
tiperial L'sc
ti: .Storage SI ❑ S-'_❑ U: UtilityClS
pecial Use 13,111d please dcsrribe below:
SECTION 6:CONS I'RUCrION INI'E(Check as a licable)
I:\ 0 IU ❑ IIA ❑ flu IIIAO IIIU ❑ IV ❑ VA ❑ 1'11 ❑
_.-- _ SUCTION 7:SITE INFOR.MAIION(refer to 781)C,\IR I 11.0 for details un each item)
Water Supply: Ilood Lune Information: tivwage Disposal: Trench Permit Debris Itcuanval:
IitbliC❑ Cnrk d aulsidr hood Zone❑ Indit,oc mmlitip,ll 0 A trench trill not be I I tconst•d Pty'lsal�ih'❑
I'm.dc❑ or indc old\ /ono. n.,1,1 d ❑nr Ircnclt or,prcdv.
1'rrnul is rnt lord❑
Railroad right-of-w,ay: I Ilarards lm Air.\ac ig.atiun: ,
\'ol ❑ Is�lrm lino o Hllm.iirpott ll'pro.nh.i True hlhrir rrt�o nildrh d' .
rr( ,gnrnt to lludd,'m lowd 0 1 lr, ❑ „rA'o0 lr,❑ \, 0.
tiFC1 ION 9: ('ONI I..NI'OF CI It 111'IC:\rI[uPct('CCI'.\.VCY
! I ,I,In it Ml-, dv L otany'I,I
� I' t ,nl.inl l, .,,l prrlLr ..I
It, r, thr PmlJnil;„'ut.uo.m 11'111lkl,r tit.Irm' �pru,11 '4Iq'll 1,1 lion,
SI:( IION9: PROPH(ly OiivNI:It ,\UI II(MILAI ION
Ad less A Pr kc IN ois our
tip
N,mie(Print) No—and Street City/ rows
'rorvIlY O%Vllk.r coilta,t Information:
e-mail address
Title l*,luphooe No. (business) relt-plitow No (Cell)
II Ippi ic.,I,I it-, the it-properly owner hereby tit I I,ori/vi
Name --street AkItIC05 City/rowsState Zip
te,lk t on the property Owner's behalf, in all matters relative to work authorized by thl.j 111111dirg permit application,
SECTION 10:CONS TRUCI[ON CONTROL(Please fill Out Appendix 2)
If is less 111,1103,000 cu.ft.of enclosed lowd%"Ice'I Ild/or not under Construction C01on I I thoi check here 13 and ski p SCO it ILI I 1 1)
10.1 Registered Professional Res pon ible for Construction Control
— Registration Number
Nome(Registrant) 1'elcphonte No. u- tail addries.4
titrrct Address City/rum, 'I e Lip Discipline Turation DaL
10,2 General Contractor
- ll 5 AA V, rh C) -n I
co harry Lnle N,,a me`
1 ' � 4
Name of Person Responsible for Construction License No. and Type if Applicable
State Zip
k 'C) C(S4 Ck
City/Town
2-0
------
relyiihoot No. business rebollhorte No. (cell) to-mailtiddressi
I It 1\ IN,q IM.G.L. c. 151 ( ))
Bepartment of lndustrial,kccitlellts��Iullc6
t becomplelvdand
A Workers'Compensation Insurance Affidavit from the MA
submitted with this application. Failure it)provide this affidavit will result in the denial of the issuance of the building permit.
Ima signed Affidavit submitted with thi5application? Yes 0 No 13
— SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item end Materials) Fatal Construction Cost(front IIQIII 6) '5-
1. Building S Building Permit Fee'Total Construction Cost X (Insert here
Electrical SS appropriate municipal factor)'S-
7. Illuillbiol" Note: Mininitin,fee-5 --(colitlict
i.T",-I'll (I V�\C)
i. \Ictlialic.11 (Other) 3 1:11(low dictic parable to
it I*olol Cost
• it writekbetknumber
SLCTION 13:SIGNA I URE OF BUILDING VEw%trrAi1IILicAN,r
Ii.v"Ilt"I'll1l; llic Imille[It-low, I hViellY anc.st under the paills'llid I'vilaltivi of j,vrltiry that all of the infort . I'm III, Iwd III this
i ippli,mion is iric-mid oc,ur,itv to the[,,t of 111% knmJrdµeald tirtivrstoodole,
I ck it it 11 D'Itv
fit lilt lod '1gli limlit.
�t.lte
`I Fret Wdlv�s
A
Inspector to fill nut this section upon application approval:
9A-
10
CITY OF &U1 EM, WSACHUSETTS
13uiLDING DEPARTMENT
,r 120 WASHNGTON STREET, 31O FLOOR
T EL (978) 745-9595
FAA(978) 740-9846
KI\fBERL.EY DRISCOLL
MAYOR TrtOht►s ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BCILDNG COh6\IISSIONER
Workers' Compensation Insurance Afl7davit: Builders/Contractors/Electricians/Plumbers
Annlicant Information n/� J Please Print Legibly
Tattle(Business Organiratiomindividual): /—r'ld' O yL
Address: / 9 0, t/ G i mac-
City/State/Zip: �r� � K Phone#: 16720
Are you an cmployer?CheckJthe appropriate box7cantractor
Type of project(required):
I. • am a employer with 1 4. Q I al contractor and 1 6, Ncw conswctionemployees(full and/or part-time).' hae sub-contractors2.0 Iam a sole proprietor or partner. lisattached.sheet.t 7, ❑Remodelingship and have no employees Thntractors have 8. []Demolitionworking for me in any capacity. wop.insurance. g, DuiWing addition(No workers'comp,insurance 5. ❑ Woration and its
required.[ officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. C. 152, 41(4),and we have no 12.0 Roof repairs
insurance required.[° employees.(N'o workers' 13.❑Other
comp.insurance required.]
•Any applicmt dud checks box of must atso till uul the uctim belowshowing their workrus'compenurion putiey inlurmation.
I Nweuwners who submit this aB?dnvit indicating they arc doing all work and than hire outside contmcmn must submit s new allldzvit indicating such.
:Conuacloo dial cheek this box must attached an additiunul sheal showing the name of the sub-contractort and thalt workers'comp.policy ooc,,nlion.
/um an employer that is providing workers'compensadon insurance for
my employees,yee
nrmaeioa Below Is the po/ry sadfob site
Insurance Company Name: / W_ ✓ ✓ Sr /i &
/ ^7
Policy 4 or Self-iris. Li`c.d: Expiration Date:_?^
� U �-,t J
Job Site Address: 1 �� r�F� e 7 IT f City/State/Zip: <C f J eon y'- r - 1
Attacb it copy of the workers'eompensatlon policy declaration page(showing the polio number and ez Ira Y p lion data).
Failure to secure coverage as required under Section 25A of bIGL c. 152 can lead to the imposition of criminal penalties of a
fine 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. Ile advised that a copy of this statement may bo forwarded to the office of
Investigations of the DIA for insurance coverage verification.
/du hereby c• r Jy under dra point sad penultle/s off perjury t/ru//t f�ire infunnudon provide)above is true and correct
5'� I t • ` ' Q,, I/�l NV Data — Z .
y iL
P o ,l, 576) -T' 3 Z Y Lea [2—
[cr
al use wdy. Do not Ivrite in this area,to be completed by city ur town o flelat
gAulidority(circleone): -----rd of health 2.Building Deparmnent 3.Cityfrown Clerk 4. Electrical inspector 5. Plumbing Inspectorct Person: Phone n:
(
CITY OF SM F-M, iNL-kSSACHUSETTS
BUILD4\G DEPART10NT
3 � N 120 WASHINGTON STREET, 3� FLOOR
`�. TEL (978) 745-9595
F.ux.(978) 740-9846
KI\iBF.RLfiY DRISCOI.L
tiLjYOR THo.%w ST.PtERRE
DIRECTOR OF FLBLIC PROPERTY/Bt;IMNG COMMISSIONER
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 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
111, S 150A.
The debris will be transported by:
ArL`� . ;qI S -t 1 lw
(name of hauler)
The debris will be disposed of in
CA J We) �� �✓ / Gl� I_✓rS
(narncot'facility) II
, P e'4 j -7
(address of racility)
0,1natureofpnmi applicant
- ZY � lZ -
date
dean„pit'.a,k
;yL_Massachusetts-Department Of Public Safety
lY/Board Of Building Regulations and Standards
_ C mlrucll $P -
r
License:CS-0N742 i
pl li
ANTHONY JSA&LAYRO `
19 RADVBOWI a'
PRABODY hJA%960 w
commisvaserner Expiration
g1/07/201A