255 LAFAYETTE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
R Board of Building Regulations and Standards CITY OF
\V�!/� Massachusetts State Building Code, 780 CMR SALEM
"���'�' Revised Mar 2011
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a
1 One or Two-Family Dwelling
This-Section For Official Use Only
Building Permit Number Date pplied: § g
Buildmg Official(Print Name) :Signature ate -
-
SECTION 1: SITE INFORMATIO
1.1 Property Address: 3) 1.2 Assessors Map&Parcel Numbers
— Ss Ca�Yn S`tvti �oh,�
1.1 a Is this an accepted street?yes_ 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�1 Private❑ Zone: _ Outside Floody�°ne? Municipal Won site disposal system ❑
Check if yes❑
SECTION 2 PROPERTY OWNERSHIP'.
2.1 Owncr'of R5gprd-
chi stilt iSock\tq 5,ebA--t j'M:rs a970
Name(Print) City, State,ZIP
zss /au4 '7&( 75N s,9z 17n
No.and Streck Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all thatapply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) �$ Alteration(s) ❑ Addition El
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : Rtwove 1Lu -%� Walls imeell me SlncwI Ualue- awely
c-er( oa a ffYe, Olwm . kt C41,m , i6wcll "ItLIWILOI1 .1 QPOIV r21w
v L End t c l( .v Lnc.l�7 u tlnt d✓a�� 12
SECTION 4.ESTIMATED CONSTRUCTION COSTS �r
Estimated Costs: "t
Item OFficial'Use Only s
Labor and Materials
1. Building $ 3 T7a, ov 1. Building Permit Fee $ -Indicate how fee is determined:-
❑ Standard City/Town Application Fee I
2.Electrical $ $ao. w " '
❑ Total Project Cost (Item 6)xmultiplier:. x'
3.Plumbing $ 6ou, oca 2 Other Fees
4. Mechanical (HVAC) $ List.
5. Mechanical (Fire $ 'Total All'Fees $ r '
Suppression)
Check No Check Ainouiit $'Cash Amount
6. Total Project Cost: $ t"f S`�a 0, oo ❑ Paid in: El Outstanding Balance Due:
6 ��
SECTION 5i CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
:7-Aow6! 6ewkc., License Number Expiration Date
Name of CSL Holder
e List CSL Type(see below)
No. and Street Type
1 � Descn'. x �;„:. r '`; �. p Lion
�...
Unrestricted(Buildings up to 35,000 cu.ft.
(/!-P✓� L'4 !� R Restricted 1&2 Family Dwelling
City/Town, ate,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
�7Q— gsZ> 3Sr/ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
i t?P� r�.,G �, ice` . 6 �r Iz�z,L h-o-a ->3
HIC Company Name or HIC Registr Name HIC Registration Number Expiration Date
15.
No.and Street {tt�ss Email address
�i,�wl,� elQl� S'�k �r�.- 3��i
Ci /Town, late,ZIP Telephone
s
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 of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...... ❑
SECTION 7a: OWNER AU HORIZATION TO BE COMPLETED WHEN "s',
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'.,OR'AUT110... D 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 application is true and accurate to the best of my knowledge and understanding.
�OiMaS (xn./F�i L(U /$ 2vrL
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
��`-NOTES•`' � � 'w .�,�.
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
www.mass. oe v/oca Information on the Construction Supervisor License can be found at www.mass.eo4^dns
2. When substantial work is planned,provide the information below:
Total floor 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"
i! CITY OF SM ENI, AXSSACHLSETTS
BUILDING DEPhRTRIE-NT
.• - t I?• 120 WASHINGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAx(978) 740-9844
KINfBFRt AY DRISCOLL
�uYOR T Hews ST.PiFm
DIRECTOR OF PUBLIC PROPERTY/BUM-DING COMMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aunilcant Information Please Print Legibly
Name(Businx-ss.Organizatiorvindividual):
Address: �S �/�'/✓/�77� /ir ter (7 C, _
City/State/Zip e8 Phone M ? 7l 2-
Are you an employer?Check the appropriate box:. Type of project(required):
1.❑ I am a employer with 4,,® I am a general contractor and 1
6. ❑New construction
employed(tLll and/or part-time).* have hind the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• Q Remodeling
ship and have no employees These sub-contractors have V. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9• Building addition
(No workers'comp.insurance 5. 1 We are a corporation and its
required.) ` officers have exercised their i0,0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself. (No workers'comp, c. 152, §1(4),and we have no 12.C] Roof repairs
insurance required.)t employees.LNo workers' 13.C]Odaec
comp.insurance required.)
-Any applicant char ducks box r I mutt also fill out the uctim below showing than workers'componsadun potiuy infurmmlom
t Ihwmowm"who tutmoit this affidavit indicating they am doing all work and then him outside-contractors must submit a new affidavit indicating such.
�Conaacnors ihul chsck this box moat attached an additional sheet showing the name of tho subcontractors and thak workers'comp.policy infenwtion,
lam an employer that is providing nvorkers'compensation hisurance for my employees. Below is the pof4y and Jab site
injorrnutian. ) /, _
Insurance Company Name: [ G-W)-1 �I t.t./4tit( ./�iL�Lf/Fn,t7✓
Policy 4 or Self-ins. Lic. tl: Expiration Date:
Job Site Address: City/State/Zip:
%ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section25A 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 29 civil penalties in the form of a STOP WORK ORDER and a fine
of up to S25O.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigutions ofthe DIA for insurance coverage verification.
i do hereby certify under the pains and penuldes ojper/ury that the Information providodd aab fir a and correca
Sienalttre: Zlt6_ Date, [%+-Pe &
Phoned;
Euse only. Do oar write in this urea,to be complUed by city urtown o/Jirial
n:lhorily(circle one):
llcalih 2.Building Department 3.Citylfown Clerk 4. Electrical inspector 5. Plumbing inspector
_rsmt: __ Phone d:
b CITY OF SALEM, NlixsSACHUSETTS
BUILDING DEPARTMENT
+ 130 W.+sHLNGTON STREET, 3° FLOOR
a� TEL (978) 745-9595
FAx(978) 740-9846
lClNtgFRi FY DRISCOLL
;RLEYOR THo.%w ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BUMDDJG CONWISSIONER
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:
(nam$of hauler)
The debris will be disposed of in
t /
(n a of facility)
cue.' /tGF_. C11ew
O (address of facility)
signature of permit applicant
�rJCv37' /- ' ZG�2
date
a.�d5�ir,i,x