225 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7"edition Building peps
t\ Building Permit Application To Ca�n truct, Repair, Renovate Or Demolish a #
One- /ivo- a nily Dwelling
T i ect' n For Official Use Only 1 '
Building Permit Number Date Applied: /
Signature:
Buildin ommissi er/Ins r Buildings Date
ECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.la Is this an accepted street?yeses 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:
Public❑ Private❑ Zone: — Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1_Owner]of Recor ,
Name(Prin, — Address for Service:
7�/-77I — r�7aQ
ig ture Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check 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': tc .Py/..SLitr r—�nrf�f[gTi�;jG�27 %=/riL`.Qcx>9R
♦
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:
❑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 $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: 7771�9 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
5�y03'7
e4 el-461r, Cf —X7� License Number Expiration Date
Norge of CSL- Helder /��.
List CSL Type(sec below) ec
Type Description
Addres
U Unrestricted(u to 35,000 Cu. Ft.)
t R Restricted 1&2 FamilX Dwelling
Sig - ure Masonry Only
q77-160 i9/}?l Residential Roofing Covering
Telephone S) Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
' HIC Company Name or HIC Registrant Name�� .�' Regist ZK trrati n Number
/>
Address Expiration Date '
Signature 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 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
1, �� .Y7 f s�/ as Owner of the subject property hereby
authorize �0,�y��i3,Q s;'.�C to act on my behalf,in all matters
relative to work horized��t 's building permit application.
Si nature of Owner Date
SEE/CTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, tTrlrHetrs ('yr riFs^�.t �.t,2lJ ( A- ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Nam
Signat o Owner eor Authorized gent Date
(Signed under the pains and penalties of perjury
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below.
Total Floors 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
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 SALEM
PUBLIC PROPRERTY
" J DEPARTMENT
I tl: 978-74599;45 ♦ P. \: 'i78..74 9/ 41,
Construction Debris Disposal Affidavit
(required l"or all dcmulition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 Cb1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
111. 5 150A.
The debris will be transported by:
(namC of hauler)
The debris will
be disposed of in 77`ceilo-1-1
(name of facility)
-
(address of facility)
Ignalure of permit applicant
:late
.lol,i i.,ei da.
CITY OF SALEM
lrli PUBLIC PROPRERTY
Eve
DEPARTMENT
FIst L';-aflil'UNI5CUL1.
Si Avua 12C WASHIN612,NSMEL-T• SALEM,MASSA0It:sl:I IsG1970
TL,1:978-745-9595 0 FAX.978-74C-7846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
-kpplicant Information Please Print Leeibiv
Name(Buswc%s/OreaniratiONlndividual):
Address: /o'a' �.� �st � X�F!
City'Stalcr%ip:
:ire you an Dyer? Check the appropriate box: Type of project(required):
1. am a employer with 4. ❑ I am a general contractor and[ 6. ❑ new construction
employees(full antb'or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner-
listed oil the attached sheet. Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
INo workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per rvIGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12. ' Roof repa pirs/y� n
insurance required.) t cinployces. LNo workers' 13.0 Other. ^4466 r Roc-4.
comp. insurance required.]
-.Any upphcaul thus checks box ill must also fill out the suction Wow slowing lheir w'urker eumpensution policy inlivmutiori.
'l lumcuwm;n who submit this affidavit indicating they are doing all work and then him outside contmcton must submit a new of.davit indicating%rich.
�C'ontmctun shut chuck this box molt attached a n additional chest showing Uw name of the sub-contractors and their corkers'comp.policy information.
l our can employer that is providing nvorkers'compen.cntion insurance fur any employees. Beloty is the pulicy and job site
iufurmution. / /J
Insurance Company Name: �iiuNG'_....
Poliov k or Self-ins. Lie. #: &0"',90gir y.... ..-_ ..._-._.___ Expiration Date: rj
Job Site Address: a aa—_ ZA S�� City'Statelzip: O 4 a-r�-s-
Attach it copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to sccurc coverage as required under Section 25A ui'}IGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 Lill to S230.00 a day against [Ile violator. 13c advised that a copy of this statement may be 1-orwarded to the Office of
Ineesti.atiuns ul the DIA for insurance coverage %crilieation.
l do hereby certify under the pi . x'wnd penultics of perjury that the information provided above is true and correct.
d
siunilt IIe, A c Date'-47
official use only. Do rot a•rire in this area, to be completed by city or town of CiuL
City or fown:___-- _ Permit/License
Issuing Aulhurily(circle one):
I. Board of Ilcalth 2. Building Department 3. Cilyfforvn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Diller .___. .._
Contact Person: -__. Phone p:
.Information and Instructions
Afassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as-...every person in the service of another Under any contract of hire,
express or implied, oral or written."
a
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,parmership,association or other legal entity,employing employees. However the -
owner of a dwelling house having not more than three apartments ind who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152. §25C(6) also states that"every state or local licensing agency shaft withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, ivIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants „.
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone nwnber(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does'have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial.
Accidents for confirmation of insurance coverage. Also be sure to sign and date.the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at tire number listed below.- Self-insured companies should enter their -
self-insurance license number on the appropriate line.
City or Town Offlclals
Please he sure that the affidavit is complete and printed legibly: The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permiulicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennidlicense applications in any given year,need only submit one'af6davit indicating current
policy information(if necessary) and under"Job Site Address" the applicant should write "all locations in - (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit ison file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
l'hc Otficu or Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. i1617-727-4900 ext 406 or 1-877-NIASSAFE
Fax # 617-727-7749
R:vised 5-26-05 www.mass.gov/dia
�7cr. ?_ 03 De:,Cup c. .-...,decor 978?44-D5`.7 p.1
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BONN CONSTRUCTION COMPANY, INC.10i16tug
- ROOFING SPECIALIST-
100 FERNCROFT RRUNIT 204 DANVERS MASS.0192.5
OFFICE-978-750-8881-FAX4978-53I-9202- Et_1 4978-490-0281
PROPOSAL
Submitted to: Ed Seialdoni Phone 4 781-7'71-9729
10 Lafayette Place Fax.4
Salem Ma.01970 Cell x
ATTN: 5d ---- _-- ---- — --
Re:tun sites: 225 ,afayette St. Salem
Des;Sir,OR WAQN1 IT AiAY CONCER-N,
e hereby propose to furnish material and labor-complete in accordance with specifications
Bvlcw for the followiug sctr.,;
>IrstalltralfineL insulation over cxfsrine Too.'deck.(uanO rnofwilt stay).
>Scm.dawn pith dues inch emoted screra on each board 15 pa 4x8 shar.
>Apply 061)G:nflor,rab'xr v%cr ocw insutaiion by means of fully adhered system. Flash acist:ng 3kyUght.
>Immll throe inch aluminum feu:metal anu.•td all lice edged and flash-this also terminates the rubber from movmg srtd shrinking.
>Inslall new alaminnet meal cap every inch wile ova-existing stake(outer caps).
ReMOVe all slate and run xcw rahber up aml behind roinLlall slate replete as it bralu t
>Flasb all pipes and ttrAls etc-add wood as needed.Caulk all edged and under the vri,frg wood post on front side...
>CLEAN'ALL DE3RIS FROM GRuijNDS?NTO ON L RS
SITE DMMTE .
>A�.L O'MER ROOFS AKE NU';!NCL{mI-D Alain roofmly
>P1.L WOFLk IS PERFOW—FL)Ir,• IH SAFETY I LUWESSES AND RO?ZS.4ND CAI;MON TAYt.
>ALL.WORK I`; GUAR?::TEED ON LEAKS .AND BLOW-OFFS !�DR 10 Y1 ARS.
ALL PERMITS"A 11A.BE PULLED IRY Bonn Construction Composy Inc.
CY COST OF PROJECT IF !3CCEPTED> flat roof area ........................$3,995.00
•1' >COST FOR two val!evx Milton existing old slate install new copper ata'.slate_...........-........ ,.,_ ,...$3,8?3.09
>Coet for quick fix,replace brukan slate apply rubber to curtain sections,metal"bibs to all less slates,
A..L PAY P�.TTS=7l3 DEPOsfr,REST t�PJPI SATIS['ACTION ANDCON.PLF.T[ONOF"LiJ R . .
OJECT.
THANK YOU '7�'•7�3-
JAMES L CURRIER]OWNER
F.L'.D.1004-3336347-MASS,KEG.LI(.TNCF,#W52fi-CONS7RLIC;'ION SUPERVISORS LtcndCE it 99357
Our workers are fully coveted by Workmen's Cmepensmion Inmmnee and Iiabildy Ines attcc.
Catifioetes of last x are a.ai!uble noon request. y
'""/Owner/president ✓I cd
Borsa Roofing,Co.Inc ,xieidrraiBuilding Ownu,-Satan Ma t hncnoainc I9ULv,:c�huu naer
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ACOR_D_ CERTIFICATE OF LIABILITY INSURANCE OPID a
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Seven Federal Street _ ALTER THE COVERAGE AffOROEn BY THE POLICIES BELOW.
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TRAVELERS J� One Tower Square, Hartford, Connecticut 06183
BUSINESSOWNERS COVERAGE PART DECLARATIONS
CONTRACTORS PAC POLICY NO.: I-Gao-830.W1213-COF-08
ISSUE DATE: 07-02-08
INSURING COMPANY :
THE CHARTER OAK FIRE INSURANCE COMPANY
POLICY PERIOD:
From 07-11 -08 to 07-11 -09 12 :01 A .M. Standard Time at your mailing address .
FORM OF BUSINESS : CORPORATION
COVERAGES AND LIMITS OF INSURANCE : Insurance applies only to an item for which a
"limit" or the word "included" is shown.
COMMERCIAL GENERAL LIABILITY COVERAGE
OCCURRENCE FORM LIMITS OF INSURANCE
General Aggregate (except Products-Completed Operations Limit ) $ 2 ,000,000
Products-Completed Operations Aggregate Limit $ 2,000,000
Personal and Advertising Injury Limit $ 1 .000,000
Each Occurrence Limit $ 1 ,000,000
Damage to Premises Rented to You $ 300,000
Medical Payments Limit (any one person) $ 5 ,000
BUSINESSOWNERS PROPERTY COVERAGE
�— DEDUCTIBLE AMOUNT: Businessowners Property Coverage: $ 250 per occurrence.
Building Glass : $ 250 per occurrence.
BUSINESS INCOME/EXTRA EXPENSE LIMIT: Actual loss for 12 consecutive months
Period of Restoration-Time Period: Immediately
ADDITIONAL COVERAGE :
Fine Arts : $ 25.000
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read the policy.
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SPECIAL PROVISIONS:
COMMERCIAL GENERAL LIABILITY COVERAGE
IS SUBJECT TO A GENERAL AGGREGATE LIMIT
MP TO 01 02 05 (Page 1 of 03)
017331
p
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DAMES CURRIER
f SSS 66E 20 KROCHMPLO 4
PEABODY,MA
.�_ _ 1D11IA11
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR _
Reglstrationt 140520
E1cplratigo; -10/23/2005
Type ,Privafe Corporation
BONN CONSTRUCTION_CO INC:. ,� '
JAMES_CURRIER --,
100 FORNCROFT ROAD ..
DANVERS.MA 01923 Administrator
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