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310 LAFAYETTE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts +� Board of Building Regulations and Standards CITY OF G)V Massachusetts State Building Code, 780 CMR SALEM _ r Revised Mar 1011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Datc Appli d: Building Official(Print Name) igna ure SECTION 1:SITE INFORMATION 1.1 Property A Cress: S 1.2 Assessors Map&r Parcel Numbers I.la Is this an accepte treet?yes no Map Number Parcel Number 99 1.3 Zoning Information: IA Property Dimensions: c m Zoning District Proposed Use Lot Area(sq ft) Frontage(R) �_ 1.5 Building Setbacks(ft) _ Z Front Yard Side Yards Rear Yard '� r Required Provided Required Provided Required Pro4?u rn 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: O ' / Zone: _ Outside Flood"Lone? CD Public 19' Private❑ Check iFoo Municipal 8—n site disposal system O I] SECTION 2: PROPERTY OWNERSHIP' 2.1C:10 Recof-d: Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Constnrction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg. ❑ NUmberof Units Other ❑ Specify: Brief 'tY-�'tl [� C t ,L jl�-1d')t.�h I ✓h t S C. n t�A t Y_t SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ ' Q co I. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ 0 ❑Standard City/town Application Fee ❑Total Project Costa([rem 6)x multiplier x 3. Plumbing $ / ZOOO 2. Other Fees: $ 4. Mechanical (IIVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash.Amount 6.Total Project Cost: $r53 606 ❑ Paid in Full ❑Outstanding Balance Due: !v ll C( \LL- I L.mc�m -F02 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) p mLicense Number Expiration ate Name of CSL Holder 1 A\ List CSL Type(see below) U1 No.and Street Type Description y�� , 9 O Q ) U Unrestricted(Buildings u to 35,000 cu.ft.) L �/'' -� R Restricted 1&2 Family Dwelling Citya w� M Masonry RC Roofing Covering WS Window and Siding Solid Fuel Burning Appliances SF I Insulation Telephone Email address f D Demolition 5.2 Registered n Home Improvement Contractor("IC) /60 Y3 'A—�11hr� HIC Registration Number Expiration Date IIC CompanyName1�0 �rJ ' h�SS�lca NN and Emai address -�. � Glsb ! >8i 353��6 T CitylTown,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) �` Work6rs 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. ix. Sign Affidavit Attached? Yes .......... ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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(Electr ignature) Date SECTION 7b: OWNEW OR AUTHORIZED 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. Print Owner's or Authorized A nt' ?lectronic Signatur Date NOTES: 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.ntass.gov/oca Information on the Construction Supervisor License can be found atwww.mass.gov/dps 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 Cosf' C23*11:affil CITY OF SALEM, NLASSACHUSETTS BL'ILDNG DEr.+Hr\t&sir � 120 W."HLNGTON STREET, 3'"FLOOR TEL (978) 745-9595 F.ur(978) 740-9846 KI\il3ERLEY DRISCOLL L1YOR THONLXS ST.PIEERRH DIRECTOR OF PUBLIC PROPERTY/BCQDING CO\L\IISSIONER Workers' Clnnpensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers Aplilicant Information Please Print Le ibt Name (Business Organization,'Individual): Lc, '1/C Address: �Q b City/State/Zip: Is one Are you on employer!Check the appropriate bo;i' Type of project(required): I.❑ I am a employer with 4. am a general contractor and 1 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ I at i a solc proprietor or partner- listed on the attached sheet.) 7• ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity, workers'comp. insurance. 9. ❑ Building addition (No workers*camp. insurance 5. ❑ We are a corporation mid its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. (No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) r employees. [No workers' comp. insurancercquired.j 13.❑ Other •Any applicaan dwt check,bon sf must alw fill out the,ectiun below showing their workeri cumpenamiun policy inlurmatiun. t IN'"`"wm"ahu suhmit this amcinvir indicating they are doing all work and then hire outside contractors most suhmit a new afndavil indicating such. :('ontrwturs that check this box must enwhod on addidural,hrwl showing Ihu n;unv of the rubevntncton and their wnrkon'comp.policy infurmmion, I ant un eurpluyer ilia!is providing)vorkers'compensation in.turance for my eatployees. lie/owls the polley and fob site iu/ormation. Insurance Company Name: .....__..__ Policy g or Self-itts. Lie. @: -_--.,_ Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensatlon policy declaration page(showing the policy number and expiration date). 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to SM.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations oldie DIA for insurance coverage verifical ion. /do hereby certify under ft afns and peuukiex of perfury that the infurrnatlau provided ubuve is True and correct Data: O//idol use wJy. Do not write in this area,to be completed by city or to Ion official City ar Town: Issuing Authority(circle one): I. Board of llealth Z. Building DeparUncut J.Ci1ylruwn Clerk d. Electrical Inspector 5. plumbing fnspeetur 6. Other Contact Verson:_.__. Phone ;i: IIf -AS _ � I 4 4- 1 -7 -- �� , I I I f � I 1 i 1I I ! I I f t4 ` I I i I , I , II - } {- i._ I , I i I , I 4y x i I ' V , �r « . � 4• i + , +, + « . w...i.. r f � � � M-r- .m, r — wr —j a +{ 1 it l �� i + 1 ♦. ; T. El IF } 4 - 7E) 6 _ - J f pu Massachusetts -Oepartnent O 3aard of Suiidarg Qeg,>iafier;s d 5zandards CS-032197 LELANDMHUSSO 490-500 W ASEU fGTON ST _ LYNN MA O �..t•..- 10/16/2015 Nor " �e ' p 'JI `f'�nuarr>u4tn� rJC"l/e rrr�.>.,!/a ` L0se4f,cop°q:44.f,�6�: !!e&8u;ineea Beg6lstiou TIy1PR+lIfAFNCt7NTRAGTiSR, ,� " i4t�ttittpnt�a i0bA3 4d r `-0"z -».i', :EET fah- 8f?H�814 � {pgA} N.M.1HUSSEY R. AY-15 CONTHAC7O L@6aod_Hogj . ,° 490-5D0 WASHlN6TON ST . _ . - --..�_ ::may ` CITY OF S•1LE,m, LY4-1SSA CH L S ETTS ,4. t /� BL'ILONG OEPAWMENT h` 120 TISHLNGTON STREET, 3w FLOOR RT TEL (973) 745-9595 KIMSERE EY DRLISCOLL F.LX(973) TW-9845 r��L9Y0;'L T2-1O.%LU ST.PIE.RRS DIRECTOR OF pL'©LIC PROPERTY/aL:=LNG COJLMISSIONER Construction Debris Disposal AtHdavit (required for all demolition and renovation work) In accordance with the sixdl edition of the State Building Coda, 730 CD,fR section 111.5 Debris, and die provisions of tNfGL c 40, S j4; Building permit t# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facili l 11, S I50A. ty a9 do6ncd by b9GL c The debris will be transported by: y ' (n�mc ut'ha ler) _ The dchris will fie disposed ut'in : (name of r'acdrty��--� to 1'1'19 (.t dress of rite lily) I future u(prrmif.tpp(ic.t n.