192 LAFAYETTE ST - BUILDING INSPECTION t I The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 20//
Building Permit Application To Construct,Repair,Renovate Or Demoli
One-or Two-Family Dwelling
This Section For Official Use Only
Building
`Permit Number: Date Applied:
7 �/ V
Building Official(Print Name) t Date
SECTION 1:SITE INFORMATION
1.1 Property Address: _ 1.2 Assessors Map&Parcel Numbers
Llalsthis4n ac6pted street?yes_ no Map Number Parcel Number
13 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yesEl
SECTION 2: PROPERTY OWNERSBIPt
2.1 wnert of Record:
G P� V F vrr!O
Name(Print/) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building EKI Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition OfAccessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brie a cription of Proposed Work :
.diNi�.�W O/J �i�� 4L f' /�i/ d'//� N// r •zS ✓ 4 i�
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:
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 $
Su ression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $lei (J ❑Paid in Full ❑Outstanding Balance Due:
,Alt..
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�'S�G.3 6 F
License Number puati n Date
Name of CSL Holder
� List CSL Type(see below) /1
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
��1 ' i� �y� his aei�
H HIC Registration N E
IC Co y Name or HIC Registrar Name umber nation Date
No.'and,Sc' t 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 fthe 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 authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true aar umte to the best of my knowledge and understanding.
o '/ / u/
Print Owner's or Authorized Agent's Name(Electronic Signature) ' Dates e
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 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.massgov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) 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"
i CITY OF SL1 ENE, X'L'f,SSACHUSETTS
BUILDING DEPARTMIENT
130 WASHINGTON STREET,San FLOOR
T EL (978) 745-9595
FAx(978) 740-9846
KI,NIBERLEY DRISCOLL
MAYOR T HOMAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDMG CO%L%MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information j� /� / Please/nPrint Legibly
Name(Business,Organizatiotvind U ividual): U. /<eS,l-/G/ G()y/ v[
Address: ))/J��
City/State/Zip: //!/rI rJdr✓ , Phone #:___7r�/
Are _o an employer?Check the appropriate box: Type of project(required):
1.Er,am a employer with t'�l 4. 0 1 am a general contractor and 1
. employees(full anNorpsrt-time).
• have hired the sub-contractors 6. ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet.: 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity, workers'comp.insurance. 9. 0 Building addition
(No workers'comp. insurance 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.0 1 am a homeowner doing ail work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' I3.❑Other,
comp.insurance required.]
•Any applicant that shocks boa xi muss also fill out the section ts;low slowing their worker'compensation policy information.
t I tomeownon who subunit this affidavit indicating they are doing all work and then hire outside contractor must submit a new affidavit indicating such
!Contactor that shock this box must attached an additional shun showing the name of the sub-contramm and their workers'comp.policy inf nniadoe.
lam an employer that Is providing workers'compensatlan insurance for my employees. Below is the pollty and fob site
information,
Insurance Company Name:
Policy#or Self-ins.Lie.#:l 'lyT `��l�y� Expiration Date- �/8�/J `
/9�Job Site Address: �i%i.% r�jf�P / City/State/2ip•�C/c'�H! /Y/� Q_1c/;;7-d
Attach a copy of the workers'conipensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition ofcriminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonmentt 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 copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
i do hereby c_�errlf/j under the pain%�� pen /es of perjury that the information provided above is true and torrent
Signature• /�G/ir o�/ /� �i�/ Date,
Phone#: �0 J��l—
Official use only. Do not write in this area,to be completed by city or town nfficfaL
City or'ruwn: PermitfLicense#
Issuing Authority(circle one): ^
1. Board of lleuith 2.Building Department 3.Cilyfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
ClientfF:68489 DOCGEN
DATE"1"1" YYYY)
ACORD. CERTIFICATE OF LIABILITY INSURANCE 2/23/2012
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.
IMPORTANT:If the certificate holder Is an ADDRIONAL INSURED,the pollCyties)must be endoreed.If SUBROGATION IS WAIVED,subjeM 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 endomement(s).
PRODUCER N E: Sharon F.McCaffrey
Rogers&Gray Ins. Kingston N N.F,n:508-747-4292 � No: 877-816-2756
63 Smiths Lane q4RfUr�LBB, smccaffreygrogersgray.com
Kingston,MA 02364-3700 INSURER(S)AFFORDING COVERAGE NAICO
508 746-0055 NsuRERA:National Grange Insurance Co.
INSURED INSURER B
DOC General Contracting,Inc INSURERC:
10 Draper Street,Suite 17 INSURER D:
Woburn,MA 01801 INSURER E: EEI
INSURER F
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 CONTRACTOR 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.
LNSRD—DL SUR—R POLIO POLICY LIMITS
TR TYPE OF INSURANCE IN D POLICY NUMBER MMID MMID
A GENERAL LIABILITY MPT4684D D211812012 02118/2013 EACH OCCURRENCE Et OD0000
NC
MERCUILGENERALLIABILIrYWijjsT eE T.E°nra $500 000
CLAIMSANDE OCCUR MEDEXP(An,oneperson) $10000
Ded:250 Painting PERSONAL A ADV INJURY $1 000 000
GENERAL AGGREGATE s2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2,000,000
POLICY X PRb X LOC $
A AUTOMOBILE LIABILITY MIT4684D 2/18/2012 02/18/201 COMBINED tSINGLELIMIT 1,000,000
BODILY INJURY(Per person) $
ANY AUTO
ALL OWNED XSCHEDULED BODILY INJURY(Per a dent) $
OW
NON-0WNED WEMPLOYEE
Y DAMAGE $
nt
X MIRED AUTOS AUTOS $
A X UMBRELLA LAS, OCCUR CUT4684D 2/18/2012 02/18/201 URRENCE $1 000 000
EXCESS LIAR o.cc, -MADE TE $1 000 000
DEO X RETENTION 10000 $
WORKERS COMPENSATION TATU- OTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNEWEXECUTIVE Y I N ACCIDENT E
OMCERIMEMBER EXCLUDED? NIA
pAandebuy In NH) SE-EA EMPLOYEE $Hyye9deeaibaantlerSE-POLICY LIMIT E
DESLrRI. NOFOPERATIONS below
1
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AndNanal Remarks SNadule,N more space Is requlmd)
"Please note that evidence of worker's compensation shall follow directly from the insurance carrier
CERTIFICATE HOLDER CANCELLATION
INSURED COPY FOR INFO ONLY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
0198 -2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD
f/S78150/M78149 SFIi
Office o��o�ome`�ii�a�Bc Bv�sive�n eg
HOME IMPROVEMENT CONTRACTOR
Registration: 132647 Type:
Expiration: 3/15/2013 Private CorporaGf
f;FNF..RAL CONTRACTING INC
DANIEL O'CONNOR
10 DRAPER ST SURE#17. . Q _
WOBURN,MA 01801 Uvderseeretary
Massachusetts- Department of Publi. SafetA
X Board of Building ReLmlations and Standards
Constru-non Supervisor cznse
License: CS 86368
DANIEL F OCONNOR f I
5 ARCHSTONE TERR#107 �4
READING, MA 01867 °-
Expiration: 7/20/2013
t rmai.+inner Tr4: 18743
CITY OF S.U.&M, 2NLksSACHUSETTS
Bt:tI=NG DEPART\MNT
• 130 WASHNGTON STREET, 3e FLOOR
T E1- (978) 745-9595
Fmc(978) 740-9846
KIJIBERLEY DRISCOLL
MAYOR T Hop w ST.Pmma
DIRECTOR OF PIBLIC PROPERTY/BUU DINIG CONMSSIONER
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:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
dc6rivtida:
O�
MMOR
Genral C0olraCtlnp
10 Draper A /#17 Phones: 781-376-9100
Woburn, MA. 01801 Fax: 781-376-9101
DOCGQa,)AOL.COM Nov; 20.2012
AGREEMENT
Chet Jenkins
192 Lafayette St.
Salem, MA. 01972
cienir[a)comcast.net
Contractor proposes to supply all detailed material and labor necessary to
professionally perform the following Home Improvements.
Work to Be Done
Rear Third Floor Porch
• Obtain Permit...
• Secure& isolate work areas.
• Dismantle,remove and discard existing rails, deck& ledger framing.
• Install new ledger boar 2 x 10 against house with lag bolts.
• Install blocking to stabilize existing floor joist.
• Open wall areas necessary to properly flash new ledger&decking against house.
• Install new 5/4 x 6 ph decking.
• Install new 4 x 4 post lag bolted into floor joist.
• Fabricate& install new 2 x 4 baluster railings.
• Apply(2)coats of semitransparent stain.
• Remove and discard all job related debris.
• Job site kept clean, safe & orderly.
i Option: /Composite decking 5/4 x 6 Azek
Rear Second Floor Deck
• Obtain Permit
• Remove and discard existing structure.
• Install insulated, flashed rubber membrane roofing.
• Install p/t sleepers.
• Construct deck and rails matching third construction, details& finish.
`Option: 5/4 x 6 Azek Decking—Additional
10 Draper St#17
Woburn,MA 01801
October 24, 2012
Dan O'Connor
PROPOSAL
Chet Jenkins
1.92 Lafayette St.
Salem, MA. 01972
Contractor proposes to supply all detailed material, labor, permits and disposal necessary
to professionally perform the following Home Improvements.
Work to Be Done
Front Stairs
• Obtain permit.
• Secure & isolate work area.
• Install wood framing to support & stabilize front entrance roof.
• Remove wrought iron post & railings.
• Dismantle, remove and discard existing stairs, platform. Brick & block foundation.
• Excavate & remove existing footings.
• Excavate 10"x 4' outside comers to accept new footings.
• Pour concrete footings to code & 4" concrete pad to accept new stair stringers.
• Frame platform to code with#I pressure treated 2 x 8 timbers set with metal joist
hangers.
• Fabricate stair stringers from #1 pressure treated 2 x 12 timbers.
• Frame beneath new platform with #1 pressure treated 2 x 4 & enclose base & sides of
stairs with azek trimmed vinyl lattice panels.
• Install Azek stair risers & platform trim.
• Install 5/4 x 6 Azek decking with stainless steel screws.
• Repair wrought iron rails adding new bases to properly attach [bolt] to new stairs &
platform /Prime and paint with industrial enamel.
• Job site kept clean, safe & orderly.
• Remove and discard all job related debris
Option:
• Remove second floor wrought iron railing & install new rubber membrane rooting.
• Prepare, prime and pair wrought iron & rest.
Phone:781-376-9100 Fax:781-376-9101 Email:doccontracting@verizon.netcom Website:www.doccontracbng.com