197 LAFAYETTE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY OF
UlfBoard of Building Regulations and StandSALEr (#j {
Massachusetts State Building Code, 780` t 1'1L rSER. ' -evised Mar42011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling 10Ib JUL ( I A $ 0 1
(� This Section For Official Use Only
Building Permit Number: Date Appl' d:
/ 7l3/
t Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property pAddress 1.2 Assessors Map&Parcel Numbers
1 ��U
l.l a Is this an accepted street?yes_ no Map Number Parcel Number
I — 1.3 Zoning Information: 1.4 Property Dimensions:
2-
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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'o Record•
pr. la>J 114A rAN
Name(Print) I/ City,State,ZIP
7 AL, L-7
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) R Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2: �f f G, ruo
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ IO (o 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ /p oco 13 Paid in Full 0 Outstanding Balance Due:
CITY OF SALEM, MASSACHUSETTS
n ` BUILDING INSPECTOR
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
Dr . SKi o,,u
I °I -1 L�r�•�E-rrE. sT
SPt� M Pc O ��t'►o
SECTION 5 `CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) b �"1 117
Wp r(`fI) re .-50) License Number Exp rats ioa Date
Name of CSL Holder 1
List CSL Type(see below) y
No.and Street Type - Description I
Poq 1 nA 01�/ Unrestricted(Buildings u to 35,000 cu.ft.
Y?O tJ , I'`I ` b� Restricted 1&2 Family Dwelling
City/Town, State, IP M Masonry
RC Roofing Covering
WS Window and Siding
G SF Solid Fuel Burning Appliances
q-7�'-7 Zr3� 1 Insulation
Telephone Email address D Demolition
5.2]/R�e�gistered HAme Improvement Contractor(HIC) )v�-1 q
HIC/Registration/Number E pi ion Date
HIC Com,ppany Name or H[C Registrant Name
No andt9jr, M n 01.1/ Z°�-�Y Email address
City/Town, Sta ,ZIP P b Telephone
U
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 wil I 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 authorize Zivolrftn/ PN-56JJ
to act on my behalf,in all matters relative to work authorized by this building permit application.
7/)o/lG
Print Own ame(Electronic Signature) Date
SECTION 7b: OWNERS 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 applicat�o ' true and accurate to the best of my knowledge and understanding.
Print Owner's o&i uthorized Agent's Name(Electronic Signature) Date
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
mnn .mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dQs
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"
CITY OF SALEN4 MANSSACHUSETTS
s
BUILDING DEPART%lENT
120 WASHINGTON STREET,3ao FLOOR
TV- (978) 745-9595
FAX(978) 740-9846
KI\iBERL.HY DRISCOLI
MAYORT�IOMAS Sr.P13=nRB
DIRECTOR OF PUBLIC PROPERTY/BUMDINIG CO\LMSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Busintstiga OrnizatioN;ln1dividual): � / ire^) o�
Address: 11WJMdmo` 5�-.
City/State/zip: �rn��4 , ���d Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1. H 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
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for mein any capacity. workers'comp.insurance. 9, ❑ 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' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' l3 Other,
comp. insurance required.]
•Any applicam thus checks box N I most also fill out the section below showing their workers'compensation policy information
*I Iorrreowrxns who submit this affidavit indicating they are,doing all work and then hire outside contractors must submit a new,altidavit indicating such.
=Contractor that check this brae mint attached an additional sheet showing the name of the abcontractora and their workese'comp,policy information.
I am an employer chat is providing workers'compensation insurance jar my employees'. Below is the policy and job site
information.
Insurance Company dame:
Policy#or Self-ins.Lie.#: 4 A P-1 S 4ti17 Z6i� D Expiration Date: 7?)9O 61 l
Job Site Address: Iq 7 `Afr0. dy 5V Ciry/StatelLip: !�, 6M t
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration elate).
Failure to secure coverage as required under Section 25A of MGL 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under/r the pains and penalties of perjury that the information provided above is true and correct
V�..,..-v Sienature0 / /,.,o Date'
Phone#: q-2*-7yd zd3�
OJrcial use only. Do not write in this area,to be completed by city or town ofciat
City or Town: Permit/I.1cense#
Issuing Authority(circle one):
1. hoard of health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
i CITY OF S.ULE:,NI, NLksSACHUSETTS
BUMDLNG DEPARTNCLNT
120 WASHINGTON STREET, YD FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
1CI\iBHRIEY DRISCOLL
MAYOR THomm ST.Pw-M
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%aSSIONER
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
-7I/a)/�
— 'date
a.nt,riravc
MEEM GH_IN1957C BUSINESS
LAUGHLIN HOMES-INC. � ''���/ MASS REG. 0 103394
MEMBER BE ERE-reR BUSINESS BUREAU OMW. (�(•{X�',p1/ FED ID 9 41-2054355
MEMBER SEVER LY CHAMBER OF COMN.ERCE 9 Charles S*se-.xP.d.Box 252
MEM.e FR BEVERL� i1tVVAN:S Beverly MassachLse 01915 WARREN PEAR.SON C£i_ 0 CS40996
SINCE 1978 • 9'78) 828-3979 Hic Lic.. a 107a94
,� f% �Gam✓ �"J�' GP �i .7� . I fir')
SPECINCArIC'NS susmn'TED TO: ^�f/p! l PHONE:
Q .�
STREci: / JOe NAME: t�G
CSY.STATE,ZIP: t. G. /✓JOB LOCATION:f
ARCHITEC:T:_+C�! [5 / DATE OF PLA . 2 3 �C� JOB PHCN'c:__-__
� rn0--t f �v��rQ rne .ti
Installation of a complete Cedainteed ,�� p—i f-ri-a- Shingle roof to the ertir3e house. �,. G
Color: j�A y u L 2
1. Includes step all old shingles we haul all debris,clean jobsite thoroughly and pay ail dump fees. jJe czt e cx p--r
Includes Instal!: rJ yam!
-ice and water membrane to main house eaves,around chimney and in Valley 6 ' 7
-tarpaper base and flanges to stacks
-V' aluminum dripedge to all edges. Color: 'Icj//!i 4<_; aL J` " z—C&e C
-starter shingles to all rakes and fasoas C } . T y1 J U
-nabinFei . ts 3� /ti.e.e /': t�i C Y"O G 3' � LLV.�Y.r - J'-repair, reinforce as necessary and neatly seal chimney flastdngs, any step and apron flashings.
-we procure permit, customer reimburses permit
/cost. /I/07t / C cc Ccr
45/
option IL Zu e %/ /4jc Aetce-ei-Jz,'rrrb��crs!�
Re-roof: same specmcatiorts as above, but we will go over(no st ' ping)the existing roof and excludes ice and water
membrane,and tarpaper base.
Color:
J �r�S✓2Firfi,.J ai.t f'Ls S�R, �7-c/Yt�^ �cu rt/Ji Cc..ry<_!
/Q. C G✓7t/ JGr &W IV:hr . r c-z •
GL&4� fist-r.e 4
- �Z�C'e4e-"-j
Customer responsible to covsNtarp attic items and clean resulting debris i c. %�
s ,c�GI
Ten Year workmanship guararitet? ,B (f�,?.r am--- ry t /`Ii CWe-J
We roos hereby to furnish mater al and labor�complete ' accordance with above speed ications for the sum 0 .
Cis U �j pp�d ���� f�0 00
eat to be made v follows: �'J?i d h d /-t' C fJ 7`-c s�t.�1 'ZG`,2 - C Gp p f-
0� �/3 start, t d balance upon com leticrl.Thank you. f-Ctyt.�r � �/!��c
fGGGIlnyval ammmpmh n.y afimApawkmM uepktcainw Fm l eouex (. -
a'm,Virg OsarlvvN L�clittcAmnneaon nrderi,i•n bar.ebrna q�xuaa'Ja vnoh4p q /%/
cox wm wia R uw-,uci M.v upm w,ilm udm,etas waIDmm.-.m xan.Avgeuvm /�lifllOr;7.Cd
VY WnTItC dime.an apmxn.cm:m�n:npmar':e+:.aaa,u n-m.y.=�rnn� /��`� Signatera`.
..-tame Orrt w emy fis,m.mrb a,#qaa nermvn�rwmnce.0.rxs.km ue wweA l Y
yxorlars mni:nolbv isanrcc. \ n
rmposni maiM
,]aweogrcd 0n in.he.m,Mh hmcF.nr Nw unwzt l,nl�S nvkhwinm.Cneimme¢ay ��/•� µ;gdsavr
Mi us Xrola p rct nilbin ,LT_brand twev[r Fie p•.wHr.f'SX1 arh[omvatryixmfn al:naaa dn�rnEsfmrhn6aah f� f.
Acceptance of C ct � •r / ,r ����
'fhe above pri ,specifications d conditions are satisfaeto Simla U �Z
and orc by y accepted.You I authinir�to do the work / < �Q.Q�
as spetf d-Payment will he as outlined above. ! / `•+�
Damn Acceptance ,e r
You may ancel this Agmcment if it:tas not been consummated by a party therto at place Duper tan an aedre<_s of the Seger,which may be his rnain office
or a branch ref,provided you notify Seller it,writing at his main office ar branch by ordinary❑wil posted,by telegram sent,or by detive mat later thici
midnight of the iness dewing the signing of this ag:'eemmi. "
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PEARSON BUILDERS
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tAfemmnA.Pewwn
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1�! Massachusetts -Department of Public Safety
�f Board of Building Regulations and Standards
Construct—hm Ssnens:.r -
License; CS4140996
WARREN A PEA"O
TSORWINONA � , P i -
PEABODY MA 017(� S
Expiration
Canunissioner 0411212017
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WARREN A-F
Way Pearson
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