249 LAFAYETTE ST - BUILDING INSPECTION ----------
'File Colillilo Itil'of N1,issaJwsetis-_ _ _
nwea
-It's t4l.tiv ifildin);Cod"(780 LM10
Departiticat of Vublic Safety
Building Permit Application for any Building other than a011e-or�l'wo_Fa III ilybw-el I i fig,
I Ilk st-dioll For Offir I'll Us (1111l')
Huildiol;I'vrout Noilitler Date Applied: ____ Building Official:
T
SECTION 1: LOCA FION(['lease indicate Block Ji Lut N fur loc.ttiuns fur which a street adtiress is nut available)
No And SIrk."t CII1V own III,Code Name of, lltolklijij;
SECHON 2:PROPOSED WORK
F,litionot \IA Slow Code owd — -t Is hert,0 ordivt1t.,11 Ili--
It New Ctilstrut fitio,lit '11.1ilpl) it, the it%o rotes b0m,
Fm'stily 111111dio); 0 14.1mir Alteration a Addition 0 Demolition C3 (114-,ise fill oft,joki
C11,1111;k,III Use a I Change tIfOCLUJIMICY 0 Other 0
Arc building Is en Independent
, la plans :otl/or t t)list rust itil tit w man is"e"19 Sit Pit'"''IS part of III is permit-TPI i(0 lion? )tesO No C3
I t ;
f tit tit ni I Engineering Peer Review req of rcd? Yes 0 No 13
Brief Description ot VrOtIOSCLI Work:___
SECTION 3:CONIIII ' ErE FFIIS SECTION It- txv)IING BUILDING UNDERGOING RENOVAnON,AUDIl"ION,OR
CHANGE IN USE OR OCCUPANCY
CliL-vk hert,if an Existing Building Investigation and Evaluation is enclosed(See 780CMR.14) C3
Existing Use Group(s): Proposed Use Group(s):
SECrION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floms/Storivs(include basenteot levels) It Area Per Floor(sq. ft.)
Fotal Arva(sq. ft.).wti rotai Height(ft.)
SECHON 5: USE GROUP(Check as jeelicable)
A: Assembly \.I 0 A-2 13 Nii;lodob C3 A-3 0 A-4 C3 A-5 13 F_ B: Business 0 F: Educational C3
F: Ficto F-i 0 1:2 0 1 H: High Hazard 11-1 Q H-2 C3 I im3 C3 11-4 C3 11-3 0
1: Institutional 1-1 C3 1-2 0 1.313 1-4 C3 INII: Mercantile a
S: Storage S-1 0 It: Residential 11-10 I(-'_0 R-10 R-40
Special Use 0,111d
special Use
SF(.7HON 6:CONS Hiucr[ON FYPF(Check as Jilplicable)
IA C3 18 C3 IIA 13 Ild a 11111 C3 I V,0�. VA 0 C11 CI
St.( I ION 7: till E INFO RMA I ION(refer to 781)('MR 111.8 for details oil cach item)
Mier Sit ppiy: I lood Lune Information: tiewage Disposal: 1'reitch Permit: I)Qllris Hciniwjl:
Public Cl Chi.,kit of I nuwDisposal Gila C3
I'maiv a Or Ith.,If%
It.hill".1d right-4-way: I LI/ards it,Air.Isav igatioll:
1-1. n"lit to fluild rum It,wd 0 i lr.❑ -r \I,0 0 Lj
I ION S: CON Ess I OF H(111 1('.\11:. OF 0( L:11.\.N( Y
'I'two q ,dv
I,r'I I I I I
Sl:(I ION '1: 1'1(011I IT I OWNP$ AU II IORIZ,\I ION _
L \ ilui ❑Itl \d II't♦9 of Prop HN A,,^"r -\ -- ' � p .� / y P tj
Manx•(I'rinQ _- No, and titrert City/ fawn /Ip
Project • Ocv wr Contact Information:
-_-- ------ e-matt address
Title telephone NO. (business) telephone Nu. (a•II)
It.i ppitable, lilt,properly owner hereby •ulthuri/es
...----Name ..-- -----Street Address .---- — -City/,towli --" State Zip
to art on Ihr property owner's behalf, in•111 nativr.s relative to work aulhoriaed by this building permit application
5HCf1ON 10:CONS'I'ILUCPION CONTROL(Please fill out Appendix 2)
If buildin is Ics+than 3i.U1X1 Cu.it.of enclosed.pace and or not under Constmchon Control then check here O;utd eki l Section 1111
10.1 Registered Prufessional Responsible to Gmstructiun Control
- 1'ele hone No. e-mail address Registration Number--
Name(Registrant) P
titrrct Address City/town Stale Zip Discipline Expiration Dote
10.2 General Contractor
Nance of PetsResponsible for COnsintctio License No. and type if Applicable
Street Address City/Town State Zip
°Fdo r' _ --- --
phone No. business Tcle,hone No. cull e-mail address
SECTION IL•fit, v;f,-r.t::(!_t wuu v.\Ill �' I`•'•t itz.\\I r .\U a 11. M.G.L.c. ISl 25C 6
A Workers'Compensation Insurance Affidavit from the'MA Department Of lntlustrial Accidents must be cta»pleled and
submitted with this application. Failure to provide this affidavit will result in the denial Of the issuance of the building permit.
Is,t signed Affidavit submitted with this a licalion? Yes O No ❑
SECTION 12:CONSI"RUCTION COSTS AND PERMIT FEE
Estiomted Costs: (Labor
Item and total total Construction Cost(from Item b)
I. Building 5 Building Permit Fur-Total Construction Cost S _(Insert here
2, [Irctriral S appropriate municipal Lxhtr) -5
1. I'Iunilnnll b Note: \lininnun fce- 5----(Conlact nuutiCip.IliN')
1. \lechaniial (I lv:\C) 5
17. Nlcchaoicol Other) 5 Inclose dw,k parable to - -
n. f,�I,II G,SI 1.4
•U lr;JIJ (Contact numiiipolily),pad write Chcrk number here _
SECTION J:SIGNATURE OF BUILDING PEl(JIIT AI'PLIC,\NT
Ile entering nn' nm»c below, I hercbv .utcst under tilt,p•IinS and penalties of perpuv that all nt the nfnnuatian Cont,unrd in this
epplic.ihun IS Irto•.ntd aci urme to the la'sl of my knot.Icdp;•and underst.utdiny,.
.- -.. .- Illlr Iok phony \o ILity
I
IN, I,ntn
t.ne /qp
-1 reel \,I,Irrw Ci
\luoiripal Inspector to fill out this section upon appliiatiun appnrcal: .1 - -
I p Ilr
CITY OF SM1 Ell, IN-L-USACHUSETTS
• BUILDING DEPARTMENT
d + 3 + 120 WASHINGTON STREET, 3'a FLOOR
TM (978) 745-9595
FAx(978) 740-9846
R D Kj3tgFRt RY 1SC011
MAYOR THOhUSST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG C01612MISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Avolicant Information Please�Print Le ibt
Name(Busiixss,Orgtnizaiiorulndividual): l � S6 n s--u i Fa7i
Address: acl � nuj^��� (�S� \'
City/State/Zip: _Re try ` Phone#: - L — S — 6 \I
Are ou an employer?Check the appropriate box: Type of project(required):
a employer with 4. 0 1 am a general contractor and 1 6. ❑Now construction
employed(full and/or part-time)." have hired the sub-contractors
2.0 1 am a soft proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors havo S. 0 Demolition
working for me in any capacity. Workers'comp, insurance. 9, [] Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all 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.❑ Roof repairs
insurance required.)t employees.[No workers'
comp,insurance requircri j 13'0 Other
;Any opplica d that chicks box e I must also fill out the section below showing their workers'compensation po8,.yy inf rrnoloo.
r I hmeownen who tuttmit this afndnvit indicating they am doing all wodt and then him outsidecontncters must submit a new,aMdavil indicting such
:Contmcton that cheek this box must attached an additional sheet showing the name of the r jb.comrzctom and their workem'comp,policy infomution.
!um an employer that is providing workers'contpensadon hrsurance foamy employees Below is the policy and Job site
information. �t n _ ,�^_
Insurance Company Name,
(V�s tJ �1
Policy 4 or Srdf--its. Lic, 0: 1 t v`\ 3 10000 C2_i a-J- Fxpiraton Date: - I
lob Site Address: �"l e 1 �l*T��J1,/�City/State/zip: ' _
Attach a copy of the workers'compensation policy declaration page(showing the 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
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm 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 Oflice of
Investigations ul'dte DIA for insurance coverage verification.
/do hereby certify under inns and penoldes of perjury shot the btforntaflon provided ubuv is Prue and correcC
s fildiure:i Date! 8 l l 1
Phone
d• aS"V —�� 5 .
OJjfcful use only. Do not wrire in rids area,to be cunrplered by city or town o111C !
I
Ciryor'rown: ___ PermitR.lcenseft
Issuing Auiltorily(circle one)-
1. Uourd of ileaith 2. Building Departnunl 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: ' - phone B:
fi CITY OF S.XI.EM, iN-LNSSACHUSETrS
BI;IL NG DEPART.M&NT
• 130 WASHNGTON STREET,3° FLOOR
TEL (978) 745-9595
F.qr(978) 740-9846
(u.%(BEAT RY DRISCOLL
MAYOR THo.%w ST.PtERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSIONER
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
�wiiII be transported by:
(ed
1 ° AUj-\- ��Spo-s'�
(name of hauler)
The debris will be disposed of in
kk -,Q y
(name of facility)
(address of facility) -
e of permit applicant
date
a�in;4�tr,l«
F
-+` Massachusetts - Department of Public S,;eret}
7 Board of Buildim_Re,--ulations and Standards -
ConsirllLf:o32 SuA—er Visor License
License: CS 93403
SEAN OCONNOR `
26 CHESTNUT ST
h}�
SALEM, MA 01970
`r-•L !y�� Expiration: 12 IrM3
Cnunii> incr' Tra' 7995
ans gr9a�s+ness eS
ct-1 of rim uT(:o�amer CID OR
FIOMEIMPROVEMENT Type
Registration 123553 DBA
Expiration 3L612013
Preserve Painting'.'
Sean.O'Connor
203 WASHI,0113 f ST ft25� Mnders
ary
SALEM.
MN o1970 = U....
e
ACIORaCERTIFICATE OF LIABILITY INSURANCE °"A"""°°°°"""'
s/22/2012
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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: N the certificate holder is an ADDITIONAL INSURED,the polky(ies)must be endorsed. H SUBROGATION IS WANED,subject to
the terns 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 endorsement(s).
PRODUCER CON Boynton Insurance
Boynton Insurance Agency Pxoxe (781)449-6786 (
FN! 781)449-4269
AR: xo:
72 River Park Street Eo aL
PRODUCER 00004109
Needham MA 02494 1 AFFORDING COVERAGE NAR:s
RISUREO INSURERAN" Specialty
&yron Inc. DISURERB:Bartford Insurance
DBA Preserve Services WSURERC:
203 Washington Street,#256 IxsuRER o:
Salem,MA 01970I INSURER E:
MSURERF:
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 CONTRACT OR 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.
IN—st0 POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE R POLICY NUMBER ISMIDD MRID
GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000
TO RENTED SD,DDD
N. COMMERCIAL GENERAL LIABILITY WSES $
A CLAIMS-MADE FA]OCCUR 013100002122 /23/2012 /23/2013 MERE are E 5,000
PERSONAL S ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE UMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000
X POLICY JEC- LOG E
AUrWOBILE UABIIRy COMBINED SINGLE UMIT $
(EaarJAam)
TINY AUrO BODILYIWURY(Perpe.) If
ALL OWNED AUTOS BODILY INJURY(Peraaidem) $
SCHEDULED AUTOS PROPERTY DAMAGE
HIRED AUTOS (Perectitlent) $
NON WNED AUTOS $
E
UMBRELLA LULB OCCUR EACH OCCURRENCE $
EXCESS LIAR MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION X WC STATLL OER
AND EMPLOYERS'UABILITY
ANY PROPMEPORIPARRIERIEI(ECUTIVE YIN
E.L.EACH ACCIDENT S 100 OOO
OFFICERINEMBER EXCLUDED] NIA O0912 2 SS60UB053N /20/2012 /20/2013
(saaaatory in NH) E.L.DISEASE-EA EWLOYEf E 100,000
DYe&tlesmbe OFF E.L.DISEASE-POLICY LIMIT $ 500.000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1Aw ACORD 141,AddNiomal Ramorlm S Wule,if more apace Is mqulrm!)
CERTIFICATE HOLDER CANCELLATION
( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORQED REPRESENTATNE
William Rohr/WRR �� e
ACORD 25(2009109) A 1980-2009 ACORD CORPORATION. All rights reserved.
INS025(zoo9o9) The ACORD name and logo are registered marks of ACORD