245 LAFAYETTE ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Town of
,�� Board of Building Regulations and Standards
-Q Massachusetts State Building Code. 780 CMR. 7'"edition Budding Dept
V N Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tiro-Fairtih Dn elling
This Section For Official Use Only
Budding Permit Number: Date Applied:
Signature:
Budding Commi inner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
I.1 Property Aadr a:� 1.2 Assessors Map& Parcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Disinct Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site dis sal s stem ❑
Public❑ Private❑ Check i( es❑ p y
SECTION 2: PROPERTY OWNERSHIP'
2.1ner'of R ord:
U� 3t�A1 > Y
Name(Print) Address for Service:
-5.6c, - 5d 4' —1 i(319
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alterations) ❑ Addition ❑
Demolition Cl 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
� T),r CC-�t��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building f I. Building Permit Fee: f Indicate how fee is deternined:
❑Standard City/Town Application Fee
1 Electrical f ❑Total Project Cost'(Item 6)x multiplier x
). Plumbing f 2. Other Fees: S
4. Mechanical (HVAC) f List:
5 Mechanical (Fire S Total All Fees: f
Su ression
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S a(g� 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
.. G -
Liceroe Number Ea vau Dire
--v
N.4roc ul'CSL Hylder Lut CSL T
4 �P )h k- h M
Add Type t.�w below)
T Description
,\
�U�i,� �]' U Unrestricted l u amityto o0C'u. Fr)
,��" " R Restricted IAi2 Family Dwelhn
Sig m mre � .M Mawnry Only
RC I Residential Rocifinit Covering
Telephone WS Residential Window and Siding
> SF Residential Solid Fuel BurningA liance Installation
J_1 D Residential Demolition
9.2 R tered H W Improvement Contractor(HIC)
' v
HIC Company Name or HIC e r uant ante Registration Number
Address
Expiration Date -
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. e. 152.§ 2SC(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 Issu cc of the building permit.
Signed Affidavit Attached? Yes.......... d No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, Do�--2„ �— ��� ,as Owner or Authorized Agent hereby declare
that the slattAcrits and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
it � 20 9
Signature of Owner or Authorized Agent Date
(Signed under the Bins and penalties ofperjury)
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 W 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 IO.R6 and I IO.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 ofhaifbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3 "Total Project 54uare Footage"may he.uh,tituted for 'Total Project Cost"
CITY OF SsUX.`I, ,L-less xCHLSETTS
BL'aDNG DUART1lEINT
120 WASHNGTON STREET, Yee FLOOR
TEL (978) 745-959S
FAx(978) 740.9&%
KIJBERI FY DRISCOLL
1YOR THOt1LLS ST.PIERRS
DIRECTOR OF PLBLIC PROPERTY/BV DNG CONOUSSIONER
Workers' Compensation Insurance Afljdavit: Builders/Contractors/Electricians/Plumbers
Applicant Information \ Please Print Leaiblr
NametBusirwss.Orguii:ationlildevtdwJ S): 14 l-t S1Lehe. M�T/a-1, , (kv
Address: `b W :7\ Do ��M
city/Statdzip: Phone M: q13 ILA --73oQ
\re emu to employer?Check the appropriate box: - Type of project(required):
I. I am a employer with `4 4. ❑ 1 am a general contractor and 1
mnployees(full and/or pan-time).• have hired the subcontractors 6. ❑New construcdan
2.❑ 1 am a sole proprietor or parer- listed on the attached sheet. : 7. ❑Remodeling
:hip and have no employees These subcontractors have V. ❑ Demolition
working for me in any capacity. workem,comp.inaualsom 9. ❑building addition
(No worken'comp insurance S. ❑ We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(Na workers*comp. C. 152,91(4),and we have no 12.❑Roof repairs
insurance required.( t employed.(No worker' I3.❑Other
comp. insurance requined.j
•Any uppaeant that ehab box el marl 24u fill rat the slelia below showing their wdxkess'conpanaiun policy infamuduue
I I.vneowmn who substil this aflhkvk indicting they am doing all work atd them him outside con"scle, mar suMnil a new amdavil inditaaing nick
:r,.tra:ton that cheek this bar mud attached an addiliwd sheet showing the name of tits mb conrntebn gad thick wareara'"nap.policy infamaties.
t um an employer that Is providing workers'compenradion Insurance for my employe" se/ow/s rlye policy ated/ab rip
information. �7
In.urance Company Name: ll'L �(,�� "s 1 .S.d1Ah0-P
Policy N or Self•ins. Lie.N: OR U3a2, ' Expiration Date: -2 /e)
Job Site Address: ��u� 4&r -Jt L-Jt`. �� City/Statetzip:�� N M. L NO(gx"
,\ttacb a copy of the workers'compensation pogcy declaration pap(showing tbe policy number and expiration data).
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$230.00 a day against the violator. Ik adviaxl that a copy of this statement may be forwarded to the OIYce of
Invcsugations ol'ihe DIA for insurance coverage vcritication.
/do hereby certify unndder tho pains and penohlu of per/ury that the nrformallon provided above is true annd a arrect
I).W og
Phone 4: �i ,'�� .
iOfficial we anly. Do not Wife in this area, to be eumplered by city or ratvn o/Jkiai
City or Tuwn: eermitik.lccnre
issuing Aulhorily (circle one): -- - —
1. Huard of llvalth 2. Building Department J. City/town Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
l.bnlact Person: _ _. ___ Phone e•
r �
CITY OF SALEM
it X1 PUBLIC PROPRERTY
DEPARTMENT
\I � ,x 1_'0WAMIING:ONSI-ItLET •SAI I'M. I It tiI I"i�ZI')
frl: )1S-14 9i95 . 1::\s:978J40-9846
Construction Debris Disposal Affidavit
(required fur 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 It -._ is issued with the condition that the debris resulting front
this work shall he 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
o fac�ilir+
itty)
(address of facility)
signaturd-W lxrmit applicant
o 0
date
aaln ratl d,i<