219 LAFAYETTE ST - BUILDING INSPECTION ov --4 �111
1 t Tiie-Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7m edition0ohsh
OF SALEM
R<�s�ised Jnonmn'
i Budduig Permit Apphcation To Constmct.Repair. Reno%-ate Or De /. 2008
One-or Tiro-Fmnily Thvellirog
r
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Prope h- dress: 1.2 Assessors Map&Parcel Numbers
01�y ; �r��,,'?T .� �3-- os.8 - 94O 6!o.-D�
l.l a Is this an acdepted street?}'es no Map Number Parcel NunAvr
- 1.3 Zoning Information: 1.4 Property Dimensions:
3.90 -�/3
Zoning District Proposed Use Lot Aria(s4 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?
{ checizifNesm Municipal§�On site dislxssnl system O
SECTION 2: .PROPERTY OWNERSHIP'
2.1 Owner'of Record: ''
Al S�
Name(Print) Address for Service: -
X a15 617 Si � 7 5rI7 $
Signatures V �,� Telepbone
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
Ness Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)X Alterations) ❑ Addition ❑
Demolition ❑ Accesson'Bldg. ❑ Number of Units ';2 Other ❑ Specify:
Brief I>escription of Proposed Work` VC3 s ro c,'iq
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item /Id$11,✓d2 Estimated Costs: Official Use Oniv
Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate host'fee is determined:
❑ Standard Cil9Tosyn Application Fee
2.Electrical $ a
❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC $ List:
5.Mechanical (Fire
Suppression)ression X $ Total All Fees:$
t i Check No. CheckArnoumt: CashAmoumt
( 6. Total Project Cost: $ y O(�,d `�
p paid in Fall ❑Chitstamding Balance Due:
J
SECTION 5: CONSTRUCTION SERVICES
ti 5.1'Liceenssed Construction
Supervisor(CSL) C, -75///
j"—r-u'IC5 S. c%./ ./ License Number EyJuunnou��
Kame of CSL-Holder
�S� List CSL Type(see belou)
P/
Address qq TN Desch tion
I¢$ / "/ U Unrestricted(tit)to 35,(HN)Cu.Ft.)
Signature V R Restricted 1R2 Famih DicelGn
M Masons-Onh
RC Residential Roofing Covering
Telephone INS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
51 Registered Home Imp vement Contractor(HIC)
HIC C —many game or HIC Registrilint Nam Registration Number
7 JT175; S7 SGU /5. //V U/96j
Address /U JcTI— 70G—9G e� spimtion Date
Signature j- Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compewadion 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. Z,Q CA I �ip.J L as Owner of the sub.ect property hereby
authorize —���L 171A P /0-1A.t py to act on m} behalf in all matters
relative to work authorized by uihding permit npplica on.
Signature of Owner % _ `- Date I /
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
I. J .as Onner or Authorized Agent hereby-declare
that the statements and into rmatio the foregoing application are true and accurate.to the best of my knowledge and
behalf. C/ n
Pf... V
6 Y/) chi
Signature of Owner or Authorized Agent Tate
(Signed under the painsand penalties of gun)
NOTES:
l. Art Owner who obtains a building permit to do his/her oAA'n work.or an owner who hires an unregistered contractor
(not registered in the Home-Impr``Jvement Contractor(HIC)Program).will not have access to the arbitration
program or guar nth.fiord under Iv—1,c. 142A.Other important information on the HIC Progrwn and
Construction Supen-isor Licensing(CSL)car be found in 780 MIR Regulations I l0.R6 and I MR5.respectively.
2. When substantial work is planned,provide the infonuation below:
Total floors area(Sq.Ft.) (including garage.finished basement/attics.decks or porch)
Gross living area(Sq.Ft.) Habitable nxuu count
Number of fireplaces Number of bedroorus
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Opeu
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
I — 600 Washington Street
Boston, AM 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Narne iBusmess�or_eanizati�orv?ndivid //ual): 0 �� l.i6`4 (-"�� .
Address: a� \l�a I i
Citv,iState,,'ZiP:__ 'S-1 -
Phone:
Are yo an employer'. Check the appropriate box: i Type of project(required):
r 4. ❑ 1 am a general contractor and [ 6. New conswcdon
1. I am a employer with ❑
employees(full and/or pan-timel.' have hired the sub-contractors
r-� listed on the attached sheet . ❑ Remodeling
2, iJ 1 art. a sole proprietor or partner- i
ship and have no employees These sub-contractors have I S. Q Demolition
working for me in any o workers capacity workers' comp. insurance. 9. Q Building addition
' comp. insurance ❑ We are a corporation and its
10,7 Electrical repairs or additionsre
required.] officers have exercised their
❑ I am a homeowner doing all work right of exemption per NIGL 11 ❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152. 31(4)- and we have no 12.❑ Roof repairs
insurance required.] ` employees. [No workers' 13.0 Other
comp insurance required.] _
`.kny applicant that checks box 01 must also fill out the action below showing their workers'compensation policy inforrtwtioa
't{pmeownC,s who submit this afrids.^it indicating they sm doing all work and then hire outside wntracHns must su}mdt a new dirt nit mdicatmg such
Contractors that check this box must artached an additional sheet showing the nerve of the subc:ontmcttrrs and their workers'comp.policy info tion.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. // I
Insurance Companv Name:
Policy x or Self-ins. Lic. #: U w� oO / Expuauon Date: �
Job Site_address: City/Stateizip: t J f1l P 01✓J6
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
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 S1.500.00 and/or one-year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification-
1 do hereby certify under the pains and pe I s of perjury that the information provided above is true and correct
Signature: / Date
Phone 4: rl— 7 U
F)Ith
only. Do not write in this area,to be completed by city or town ofj`iciaL
n: Permit/License#
hority (circle onel':
Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son: Phone #:
++a3vGArUvy,c sa�ttGiW,r I vnc.r earvvbVlVPL'R:9i°iV KIVITIiY UI'T,DI@-Il1C VbK11FITiJile
2 South Kimball St. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
PO Box 5248 ALTF-RTJWC(WjEgAggAU9MF,2AYTHF._ W.
Bradford, NA 01835 wuRERS AFFORDING COVERAGE NAIC 0
INSURED Bea arpentry , INSURELA: AZN! Insbranee Co. 33758
27 Jasper Street INSURERS:
Saugus, MA 01WG INSLIF"0;
.. INSURER D:
INSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE WEN ISSUED TO THE INSURED NAM 0 ABOVE FOR THE POLICY PERIOD INDICATED.NOTWIIHSTAHOR
ANY ReAUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOMA4ENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE W*SUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TOM,EXCLUSIONS AND CONDITIONS OF SUCI
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEIIN REDUCED BY PAID CLAIMS.
TVPC OP INSURANCE {NII.ILW NUI183EhMUM MKy' H LON"
OENSRAL LIABRRY EACH OCCURRENCE I
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OCCUR ®CLAIMS IMDE AGGREGATE 6
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W*RXERSCOMPERSAMONAND YYPC6002469012009 04 9/2008 /19 010
EMPLOYERS'LAMU7Y - EA-EACH ACCIDPNY S 200 DO
A a M �' EL OLAEAME-W EMPLOYEE S 100,00
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SHOULD ANY OF THB ABOVE DESORL®ED POLICIEB BE CANFALLED SEPORa TNa
I MRA@ON OATS TNMWP,THE*=NO INSURER WILL RNMAVOR TO 4"
DAYS wmrT6N NOTICE TO THI1 8&RTP�ATi!HOLITFR HaLeEO TO THC LIFT,
.. - BUT PAR.LIRS TO AWL SUCH N07ME MALL RIPCM NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THS INSURER ITS AGENTS OR RWAS PINTATIVES,
AUTNORLM RCPREMINTATiVE
William Costello'
ACORD 25(2001m) FAX* (781)233-9144 GACORD CORPORATION 19
05-31-2009 12:36 BEAL CARPENTRY 7612339144 PAGE1
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