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187 LAFAYETTE ST - BUILDING INSPECTION (3) 1\� The Commonwealth of Massachusetts \� �< OF Board of Building Regulations and Standards CITY Q M ass Machusetts State Building Code, 780 CNIR SdMar 1, Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divelling This Section For Official Use Only Building Permit Number:' Date Applied';. . 444 Building Official(Print Name) Signature : Date SECTION 1:SITE INFORMATION 1.1 Property Add ess: 1.2 Assessors Map & Parcel Numbers 7 a u eil2 �b+ 1.1 a Is this an accepteJ street9 yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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 L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private El Zone: if yes[] Municipal❑ On site disposal system Cl SECTION 2:. PROPERTY 0WNERSHIPi' ` 2.1 Owneri of Record: �( SOIrVS Sokok ord Name(Print) City,State,ZIP A5/ T t-tM c, 1 s 1 S. ,\-e 8,�:oS 781- 666-1o57 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF.PROPOSED WORK (cheek all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': Fifz I�vhaye teCk.r. Skde4-c c-k- 0. i ncc Ic.btoh Ceoo,-e( MAII . SECTION 4: ESTINIATED CONSTRUCTION COSTS: Estimated Costs: Item Official Use Only Labor and iVlaterials I. Building $ /iC7t7d L.Building Permit Fee. $ Indicate how fee is determined: 2. Electrical ,S ❑ Standard City/Coven Application Fee.` . ❑Total Project Cost',(Item.6)x multiplier x 3. Plumbing 'S I Other.Fees: $ 1. Mechanical (I-IVAC) S List: 5. Mechanical (Fire S .( �u � ression) Total All Fees: $_ Check No. Check Amount: Cash Amount. G. Total Project Cost: S 1,(VcX2 ❑Paid in Full 13 Outstanding Balance Duo: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS_ 10 Z cl b u/ z 4 f5 Name of CSL 2h older� License Number Expiration Date List CSL Type(sae below) U No. and Street Type - Description '\ U Unrestricted Duildin s up to 35,000 cu. ft.)G14'1 b R Restricted 1&2 Fainily Dwellin City/Town, State, ZIP IVI Masonry RC Rooting Covering _ DVS Window and Siding SF Solid Fuel Burning Appliances �V'IaA - I Insulation "I'de hone Email address D Demolition 5.2 Registered Home Improvement Contractor(111C) HIC Registration Number Expiration Date MC Company Name or IIIC Registrant Name No.and Street Email address City/Town, State, ZIP 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 'x OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property, hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. n 141 Print Oder' i ame(Electroniii Signature) T Date SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at wsvw.mass.,,ov/oca Information on the Construction Supervisor License can be found at vvww<nmss.eo�� lm 2. When substantial work is planned, provide the information below: Total floor area(Sq. ft.) _(including garage, finished basement/attics,decks or porch) Gross living area(sq. ft.) _ _ Habitable room count Number of fireplaces Number of bedrooms -- _ Nmmbei of bathrooms Number of halt%baths _ fvpe of heating System --- Number of decks/ porches -- type of cooling system-- _-- Enclosed--- - 3. ''Fotal Project Square Footage" may be sub;titute!d fox'Tw d Project Cost" _-- —_— - 0C 1 1 l Vf CITY OF S.U.EM2 -I.-1 &kcHUSETT'S 1)L'ILDL\GDEPARTMENT 1201Y-ASHINGTOY 'O� STREET, 3 FLOOR TEL (978) 745-9595 KENMEZRI Y DRISCOLL FAX(978) 740-9846 1'L.%YOR Tumw ST.pIMUM DIRECTOR OF PUBLIC PROPERTY/BCRDDiG 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 1MOL 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 NfGL c 111, S 150A. The debris will be transported by: ----_ (name of hauler) The debris will be disposed of in sake-0- -WGS0.\ (name of racility) (address of facility) 5t9n re of permit a plicant a3iyr> date i CITY OF SM.EN1, , L1SSACHliSETTS BuMiNG DEPARTl1E.NT 120WiSHIINGTONSTREEI, 3 FLOOR T EL (978) 745-9595 F.v.0(978) 740-9846 (U.NBFRT F.Y DRISCOLL T MAYOR. �IObtAS ST.PIE.QltiY DIRECTOR OF PUBLIC PROPERTY/BUQDLYG CONLMRSSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information 1 Please Print Legibly Name tBusiiwtss.Otpnizatiorvindividual): ru erg,_ \.,((��V" ` Address: y/ guf(er S� City/State/Zip: 5,Lt ., )'its b147O Phone#: 70 - E157- 86C, Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 e mployees(full and/or part-rime).• have hired the subcontractors 6. ❑Now construction 2.C9 I am a sole proprietor or partner. listed on the attached.sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have a. ❑ Demolition working for me in any capacity. workers'comp.Insurance. 9, 0 Building addition (No workers'comp,insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.(No workers'camp. c. 152, $1(4),and we have no 12.❑ Roof repairs insurance required.)t employees.[No workers, I3.[70lhor Qepa:r comp.insurance required.) •Any apPllcam that chocks box e I must alsa 1111 out the sectloo below showing Choir waken'compensation policy inrurmatton. t I hmeowm"who mhrnil this affidavit indicains they aro doing all work and thm him oulaidttcantmeton muse mbmis a new allidavit indicating such. :C,mtmctats that chc<k ibis box muse anachcd an additluwl ohms showing the none of the mb iao ion and Choir worker'comp.policy influmnnon. l cam an employer that Is providing workers'compensoden insurance for my employees. Below is the pulley and fob site information. Insurance Company Name: Policy 4 or Sell-ins.Lic.ih Expiration Date: Job Site Addruss: City/State/Zip: Attach a copy of the workers' compensation pulley declaration page(showing the policy number and expiration data} Failure to sucure 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 undlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S230A0 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Oftice of Investigati�nsul'ihaDlAfdrinsunneacovcragevcriticaliutt l do hereby certify under the pains ouci penahlet of perjury that the Inforaratlon provided above is true and correct. icnanue /AAiti /��^^7/ Data: 0�4//3 P o ,7, U/Jlcial use ant/. Do not write in this area,robe courpleted by I city or to wm n/Jiclud i City nr'1'uwn: _._...._ Permiit, rise 1* Issuing Aulliorily(circle one): I. hoard of lleallh 2.Building Department .t.Cilyfrown Clerk 4. Electrical Inspector S. Plumbing; Inspector 6.Otter ._.. Contact Person: Ph" N: 9SHAR02 OP ID: DO CERTIFICATE OF LIABILITY INSURANCE DpT 02/19D/YYYY) 02/19/13 _ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED � REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 1 IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER CONTACT Phone:978-745-3300 John J Walsh Ins Agency,Inc NAME:PHONE FAX -- P O Box 4407 Fax:978-745-9557 AXC No Eii Salem, MA 01970-6407 E-MAIL John J.Walsh Ins.Agcy., Inc. ADDRESS: INSURERS)AFFORDING COVERAGE NAICa INSURER A:United States Llab Ins Co INSURED Eugene Prey[ dba Sharp INSURER B Building& Renovations - -- 41 Butler Street INSURER C: Salem, MA 01970 INSURERD: INSURER E INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AD L SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR MD POLICY NUMBER MM/DD/YYYV MM/DD/YYVV LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000I A _X COMMERCIAL GENERAL LIABILITY CL1589525 12/14/12 12114119 PREMISES Es occu ante_ $ 100,0001 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 _ PERSONAL&ADV INJURY 1 $ 1,000,000 I! GENERAL AGGREGATE 5 2,000,000 GEML AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eoaccdenp_ $ ANY AUTO BODILY INJURY(Par person) $ I A O SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS I ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident S UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE i—AGGREGATE $ DED 1 1 RETENTIONS S WORKERS COMPENSATION WC STATU- OTH- ANDEMPLOYERVLIABILITY YIN O(B'YLW I:[$_ ER ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH)If y s,describe under E.L.DISEASE-EA EMPLOYEE $ e --- DESCRIPTIONOFOPERATIONSbelm E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Athich ACORD 101,Additional Remarks Schedule,If more space Is required) Carpentry—Interior— JOB LOCATION: 187 LAFAYETTE ST. SALEM, MA 01970 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 120 WASHINGTON ST AUTHORIZED REPRESENTATIVE SALEM, MA 01970 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD