259 LAFAYETTE ST - BUILDING INSPECTION CITY OI" S_\I,F, N[
° 1 > > > .:
,•, �?� ,,y, 1 L'131.IC 1. RO1 I .Il l'l
APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT l
:ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS J
IMPORTAN'I':Applicants must complete all items on this page
SITE INFORMATI ( M00-
Location Name F Building j
Property Address_
Map#
Located in: Conservation Area Y!N Historic distri
Use Groups
(check one)
Residential(3 or more Units) R2 x
Type of improvement Residential (hotel/motel Rl _
(check one) Assembly(churches) A] _
New Building_ Assembly(nightclubs etc) A2_
Addition Assembly(restaurants,recreation) A3_
Alteration Business B_
Repair/Replacement_ Educational E
Demolition_ Factory(moderate hazard) FI
Move/Relocate Factory (low hazard) F2_ jOY•./
Foundation Only_ High Hazard 11_ V
Accessory Building_ Institutional (residential care) 11 =
Other(descri be) Institutional (incapacitated) 12
Institutional(restrained) 13
Mercantile :M_
Storage(moderate hazard) S 1 _
Storage(low hazard) S2
OW NERSIIIP INFORMATION(Please type or Print Clearly)
OWNER Name
Address
Telephone
DESCRIPTION OF WORK TO BE PERFORMED
ES'TL\1A"TIED CONSTRUCTION COST
L
CONTRACTOR INFORMATION �
Name
Address
Telephone - —
Construction Supervisor's Lic # d
Home Improvement Contractor#
ARCHITECTIENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $I1/$1,000 + $5.00=
COMMENTS
The undersigned does hereby attest that all information stated above is trae to the best
of my knowledge under the penalties of perjury
Signed
Date 6 Q
� r
e _ 203 WASHINGTON ST.#256
PRESERVE SALEM, MA 01970 =r i
SERVICES carpentryf painting;roofing I gutters PHONE:978.745 8745 r
r-Ax:978.745 �
3476
MM
SALESC�RRESERVESERVICES COM $ _4aa n !
Lafayette Court Condo.
08
259 Lafayette St Date Bid: :Sean 'C
y Estimator:Sean O'Connor
Salem MA,
(976) 766-8042
ROOFING ESTIMATE
COMMENTS Replace the upper slopping roof on the main building. Exclude the flat roof roof and all
other roofs on the building, outbuildings, and garage.
PRIOR PREPARATION
PERMITTING: All permits will be obtained in accordance with the law as required.
DISPOSAL: A dumpster will be placed in a area designated by the homeowner.
ROOFING PREPARATION
COVERING: Tarp the exterior of the house so as not to damage the siding.
SHINGLE REMOVAL: Remove all layer(s) of old shingles
NAILING: Re-nail roof decking as necessary.
UNDERLAYMENT
FELT: Install 15 lb felt on all areas not covered by ice and water shield.
ICE AND WATER SHIELD: Install 3 feet of ice and water shield on eves and valleys. Install as
necessary on other areas.
FLASHING
DRIP EDGE: Install drip edge on all perimeters.
VENT PIPES: Install new boot or flange around vent pipes.
CHIMNEY(S): Install new flashing around all chimney(s).
VENTILATION
LOW PROFILE: Install low profile vents.
Rn,PFING MA] ERt ALS
O
:.;4SPHAULT SHINGLES: Install 3 tab shingle year. to match
PRICE $ 4400 including Labor & Material
Payment Tenns: 20% deposit (day of start); 30% progress; 50% end ofjob Me/Vi-sa Amex
Sean O'Connor Customer Signature _
ADDITIONAL TO ABOVE ESTIMATE: `J
BILL 1: Replace the breezeway roof between the 2 buildings using the same system as above.
Price $ 1625 Including Labor and Material
*Above price includes all discount and coupons discussed prior to estimate.
*Warranty: Craftmanship: Kyron Inc. DBA Preserve Services guarantees all work perfonned for
a period of I year. If any problems occur we will cover the cost of labor and materials. For the warranty
to be valid the invoice presented at the time of completion must be paid in full. Materials: Are
warranteed by the manufacture and the duration of the warranty is specified in the materials section
above.
a Board of Building Regulations and Staudar6s
7 t HOME IMPROVEMENT CONTRACTOR -
<v
Registration: 123553
Expiration: 3t6/2009 Tr# 128093
Type: DBA
Preserve Painting
Sean O'Connor - -
203 WASHINGTON ST.#256
-.SALEM.AMA 01970 '
Adminisira:or :'
BOARD OF BUILDING REGULATIms
License: CONSTRUCTION SUPERVISOR
W Number: CS 093403-
- y Birthdata :213'1l1969
` .Expires 31/2009 Tr.n0:- 93403
- Restricted: tz'�
SEAN OCONNOR
26 CHESTNUT ST; - -
SALEM, MA 01970
Commissioner. z -
00/10/1c000 14:OC /014474L07 DUYNSILNT 1POT M=f`RiY VR%= 0D/O4
JA�QBt , CERTIFICATE OF LIABILITY INSURANCE a6/,I
PRO ,(78040-6786 FAX (783)449-4269 IM CERTIFICATE 13 ISSLISD AS A MATTER OF INFORMATION
BDYNTON INSURANCE AGENCY ONLY Alm CONFERS NO RIGHTS UPON THE CERTIFICATE
72 RIM PARK STREET HOLDER.THIS CERTIFICATE DOES NOT AAANIM,EXTEND OR
ALTER THE COVERAGE AFFOROM BY THE POLIC ES BELOW.
NEWHAR, NA 02494
INSURERS AFFORDS40 COVERAGE NAICO
oRnm Kyron Inc INaaffRK MMX Specialty
DBA Preserve Services INSURERS; KaFiftrd Insurance
203 Washington Street,t256 INeuRSAa
Salem.NA 01970 WSURERD:
SIINiRER @
CO
THE POLICIES OF INSURANCE LISTED 86.43W HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTI ATHSTANDING
ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VWTH RESPECT TO WHIGR THIS CERTIFICATE MAY SE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES OESCRBEO HEREIN B SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POUCIEB.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INMI TTPEOFMI9UINM POLICY WINNER! LIMITS
4SKEAIILIJMMM NA)033100099� OS/23 8 05/23/I rt
sm t 1000
.004
X CmawmUALGEf1ERALLUABIIlTY TM f SO
C-mam m �OCCLm Pw,an) S 5
A PERSONAL 8 1 000.000
SATE t 2 DOD,000
G®YLAGCREGATE LRW APPLIES PER: PIOP ROG t 2,000,004)
X PDUCY LoD
AutaRDxaE UTA1M.ln ( )csmm UAIT
ANYAUM s
All OWNEV AUTOS BODILY INJURY
BCHWXLEDAUTOS (PwPn) f
Mw
NMEDAUfOB SCORY INJURY
NOWINNTEOAUIOB /PArAc/emD _
Pr rr DAMAGE( s
..+s.6E LYIMUTY AUTOONLY-MACCIOENT f
Atwmm OTKERTNN FAACC I
A"GN.Y: AM f
e1RSSINIMRELLA MASIUYY eACHOCgMiENCE f
OCCUR CJAINSMADE AGGREGATE f
t
DEDUCTIBLE f
REfBRmR t f
TtuNINiscONPENSATImMAND 0143R39I OS /2008 OS/20/2009 X
EYrRDYERS IJAB6UY
B . E.L EACH ACCIDENT S 100.
Ifpw,dmAeu �� E.1-DUAEE-EA EMPLOYER S 200.001
SPECIAL AEA. EL DISEASE-POLICY UNIT t 500
OTIRTI
Ufa ATIOIMIIneATmRSIYBtCIMJERCLLMmRGADDSO LnomORS61®IY fSPBTAL PRDASRNIs
1 T7y Injury aIw /Or Property Damom Deductible
R INURNATIONAL PURPOSES ONLY. IF ADDITIONAL 1NFORNATION 15 NEEDED PLEASE CONTACT THE AGENT.
cHOLDER
SN =AAF OPINE ABOW ODD POLICIES BE CANCELLED SEPORE7M
RJIMATION DATE THISNEOF,THE M9mND INSURER YELL EIIAIIOR TO MAL
iD *Avg"arm M"=TOTM C731fACATe mumm MARTED To THE LOT.
SDTPASIIRE IIAM1 INIEH NOTICE tNALL R00@NDaaUGATNN ORUReDJTT
MANY TLIE A
TO M10N Xr NAY CONCERN
ACORD 2S(2ODTBB) CA601W CORPORATION 196E
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
+ors •.,
71 -J 3
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t
construction Debris Disposal Affidavit
(rcwluired lilr all demolition and rcnow ation work)
I
In accordance pith the sixth edition ofthe State Building Code, 780 CNIR section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting froth
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:
Inamc of haultr) -
he debris will be disposed of in
(namr ut faullly) .
I,IdJre.� ul rawlhtvl -
or Im ma .giphc jilt
V
Jle
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
i
'.1 . i, 1 I.. \\ .II:\ .. •..1:lIIt � \11I V, \i\ U .. 1 . • . I' -
III 'I'S.'J i-9 '4 11,
construction Debris Disposal .affidavit
(lvyuited lilr all denloliti\m iuld rcno\'ation \cork)
In accordance \\I(II the sixtll edition of the State Building Code, 780 CbIR section I 1 1.5
Debtis, and the provisions of MGL e 40, S 54:
Building Permit it _ is issued will, the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal I'acility as defined by MGL c
111, S 150A.
The debris will be transported by:
022tCll
I nine ut Innitf)
Ile debris will be disposed ofin
t nslnr ur taellrty)
I adJrca. ut I�clhn'1
�of p:nnll ./ppirc/nt
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
vl s 2�^W,%lt tl.\(:I(i.S n s urr • SAL I s4,M.%l1A(.I nl it l I S, 07-
1i-.1, 978-76-9595 • f.%x. 9714-74C.'N46
Workers' Cum ensation Insurance :%ffidw it: Builders/Contractors/Electricians/Plumbers
-till1 )licant Inform- lion Please Print I eCihly
Name 1tuvuosi t)r�anv:uinrylndtvuluull:
Address:
ctly,Slare,7ip' Phone i-r:
Arc %you an employer? Check the appropriate box: "Type of project(required):.
1.0 1 ant a employer with 4. ❑ I :un a general contractor and 1 6. ❑ New construction
e nyaloyccs(full and,'ur part-tame).• have hired the sub-contractors
listed on the attached sheet. 7- ❑ Remodeling
2.❑ I ;tin a sole proprietor or partner- -
silip and have no employcos These sub-contractors have K. ❑ Demolition
Corking tier me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'cuinp. insurance 5. ❑ We are it corporation and its
officers have exercised then! 10.❑ Electrical repairs or additions
required.]3.❑ I an,a homeowner doing all work nigh[of exemption per MCiL I I.❑ Plumbin g b repairs or additions
myself. LNo workers' ctnnp. c. 152, j 1(4),and we have no 12.❑ Ruof repairs
insurance required.) r cirployces. [No Corkers' 13.❑ Other
comp. insurance required.]
•4uy .yphcant Ibot checks box rt1 must also rill out the wcuon Wuw sbuwing their wurkui cumpensutiun policy infurmuLium
' I lomuuwnen mho submil this affidavir indiauing They sue doing'It cult vW Ihcn hire uul%lde cwurnemm must autmtit a new affidavit indiuning such.
-Comm�lun dial check this box must attschtrl.In additional altcel.hawing the mine of thu sub-conlractors and their workers'c(vnp.policy mfurm:alun,
lain an employer that is pruriditttf workers'c•untpensruinn insurance fur my eutpluyees. Belnty is dte policy and job site
i of✓nnuti✓m
Imurance Company Vame: —.-_ ... ..__...._..._--.__------
I'olicv 4 or Self-ins. Lie. n: . .. Expiration Date:
Job Site Address: CLty,StaL&Zip:
Altach it copy of the workers' compensation policy declaration page (showing; the policy number and expiration date).
Pailwe Lo secure coverage as required under Section 25A ul'>IGL c. 152 eau lead to the imposition of criminal penalties of a.
Line up to 51.500.00 and/or one-year imprisonlncnt, as %yell as civil penaltics in the furor of a STOP WORK ORDER and a fine
ofup to)250.00 a Jay against lilt violator. tic advised that a copy of this,mtcancnt may be forwarded to the Office of
Invc,n,amuns ul Lhe DI,% for insocar.ce covcngc %cfilicat:on.
l do hereby c c rtifv under the p✓iru'and penalties of perjury that the infunnution provided above is vise and correct.
Date. --
tJfficiul ase only. Do not write in this area, to be completed by city or fmvn official.
Citv or town: _-_ Permit/I.icenxc'0_
Issuing .\uthurily (circle one):
I. ISoard of Ile:dlh 2. lluildiug Department !. <:ilyr fuau Clerk 4. L•'leclrical Inspector 5. Plumbing Inspector
6. Other -. -
Contael Penun; ..- _ Phone 77:
Information and Instructions
.\Ia�sacltnsetts Gcncral Laws chapter 152 requires all auployers to provide workers' compensation for their employees.
Pursu:mt w this statute, an empluree is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written." l
An employer a defined as"an individual,partnership,associanou,corporation or other legal entity, or any two or more
or the t0r"oing engaged in a Joint enterprise, and including the legal representatives of a deceased employer, or the
fecei%er or trustee of dui individual, pattlier]iltp,association or Other legal entity, employing employees. However the -
owner of a dwelling house having not more than three apartments and 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 oil the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.%IGL chapter 152, §25C(6) also states that"every state or local licensing agency shall 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, :NIGL chapter 152, §25C(7) stales"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfornwnce ul'puhlic wurk 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 number(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 maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
Lie rctumed to the city or town that the application for the permit or license is being requested, not the Department of
Industrial ACCidenls- Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Picric 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must Submit multiple permiUlicerse applications in any given year, need only submit one affidavit 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 is on 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
Iha of i1cc of luvestigatiuns would like to thank you in advance fur your cooperation and should you have ;my questions,
pease du not hcsiwre to give us a call
The Dcparuncrit's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Otflee of Investigations
600 Washington Street
Boston, MA 02111
Tel. tl 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSA7 4HUSE S 01970
(978)745-9595 EXT. 311 FAX (978)
CERTiPICATF OF NON-APPLICABILITY
it is hereby certified that the Salem Ilistoricsl Commission has determined that the proposed:
❑ Moving
❑ , Construction ❑ Alteration
Reconstruction ❑ Painting
❑ Demolition ❑ Other Work
❑ Signage e or
as described below does lot forth Ininvolve 1ll extile Historic District's Act(M.G.I involves
chitectural 1eatuT Ch140C) and the Salem Historic
exemptions or limitations
Ordinance.
District La a ette Street
Address of Property:
Name of Record Owner: Flwi Can llys�i 1 nrstetdl
Description of Work Proposed:
e existing (CertainTeed XT3Q Black). No changes in color,
Replacement of black asphalt roof to replicat
material, design or outward appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: November 12 2008 SALEM O L COMMISSION
By:
The homeowner has the option not to commence the wort: (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.