310 LAFAYETTE ST - BUILDING INSPECTION b
The Commonwealth of Massachusetts Town of
U ►� Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a awn&
One- or Tiro-Futnih.Dtre!!in
This Section For-Official Use Only
Building Permit Number,
� / Dat pli d:
Signature:
L/ � - I
Building Commissioner/ Inspec of B dings to
SECTION NFORMATION
1.1 PrIe 9Zy ct�P 51L 1.2 Assessors Map At Parcel Numbers
r Map Number Parcel Number
I.Ia Is this an accepted street'. yes X no
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft) .
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.6.1.C.40,134) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if XesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: `� �-b �
2.27^
Name(Print) Address for Service.
Signature Telephone -7 flz3
7
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work:
,rr I—tiF— _-e S 7,2` Y'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S � � 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical f ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing 5 2. Other Fees: S
4. Mechanical (HVAC) b List:
5. Mechanical (Fire S Total All Fees: 5
Suppression)
��n� Check No. Check Amount: Cash Amount:
6. Total Project Cost: S D v(�' 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Su n isor(CSL)
fiUcw-t,1 0P-% License Number b Expiration Date
w
N,gmc of CSL- Hpld�e/t/, W�� // / /fin
a Py7�� / \ W f'1 cD`'t C( G/� &J,- .f List CSL Type(bec below)
Address / Type Description
U Unrestricted(up to 35,000 Cu. Ft.)
Signature y R Restricted 1&2 FamilyDwelling
ol �^,-� i—t+, (� M Mason Only
'L `ro ?5 7S RC Residential Rooting
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regis erJedfHo a Impr emegt)Contractor(HIC)
C / CI.7 plOGi
HIC / party
N/ a or HIC Ke�gistrafitt�JName Registration Number
VVY�� .17r/Gct
Address �7 1// A2
9 r (Sr2 p
-/�- E vati n Date
Signature 'Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.lf 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 ..........igNo........... ❑
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.
Signature of Owner Date
/ SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
), l�i�(�'/.? ✓/G�C�Df/'$Orn ��P 2�'SCL� / G(S ,�r�,C' as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. �
GZ,1'/ ��G�i i a
Print Name
Signature pf Owner or Authorized Agent Date
(Signed under the pains 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 not 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 110.R6 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Total foors 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 Syuare Footage"may be substituted for"Total Project Cost"
-� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.,\P'. M I 1 'AM .11 1
\I 1"Mt IX LL f e )At l \t, Ms».\1 III III I,507-
17671343'+3 s 1 1.y 9711-174, axle
Workers' Cumpensation insurance \lftlasit: Builders/Contractun/Electriciwns/Plumbers
1 Meant Informalion Please Print Leeihly
p�u ,f� /J
NoinC lllu.nww1�r;;anlr.uiaNlndlu�,lual l:_ \-/+'r ' / S
Ctry,Stare.Zip---���_� l�1 Q Phone ;': ����� 2�2 134'
Are. ou jet employerii Check the appropriate bus: Type It(project (required):
I.❑ 1 .111,a employer with d. ❑ 1 an a general contr ctor and l G. ❑ New construction
cny+loy ces(full an1L'ur part-tune).• pace hired the soh-cuntracturs 7. ❑ RemoJeline
2.0 I adt a sole pmprietilra
or partner- listed on the anichcd sheet.
employees These su ❑ m
b•contrectors have N. Deolition
hip and have p
corking for me in any capacity. workers' comp. insurance. q. ❑ Building addition
I No workers'comp. In+urdnce 5. aWe arc a eot7eortetion and its l0.❑ Eleaarical repairs or additions
I rcyuircJ.] officers have cxciciecd their
light of exem tion r MOL I I.❑ Ptumbing repairs or additions
).❑ 1 :till is homeowner doing all work c 5 152. f§1(4),and we have no
myself. iKo workers' cuntp. l3) 12.❑ Ruul'npairs
in,urance required.] r crnployecs. LKo workers' 13.0 Other
comp. in,urance required.]
•sm .,gshuut that checks box el muss also till W,Zhu.eusron awluw dtuwmy Ihasr wwkeri cumpensaeiws Isuhcy mbursmtiura
'I losswnwawn who cub.nd th.,affidavit indiuuete Itte)use dotny WI work a11d Then ham""side cUt11r%bon must submit a new+a'rdavis indi".ni;vlch.
(..ntnulttn that chuck this box mime auxhed.m uedaiunal..h.ast uhuwiue am uanse of the sub•conlracsun and their wurkan'cnxnp.ptshcy mfilstnadnn
l u++1 tin e+npluyrr thu!is pruridinq rvurkers'rutnpaeeatiun in.mrance jar cry entplgpre•.v. deluev is the policy and jub silo
i+sfar+nater+M1 �n,� 5���
In,arance Company Name' --- -7 - -- - --------
I'olicv Color Sclf-ins. Lic. 0: GlS �yy S 5r•-2 . -__ Expiration Date:
luU Site -\tldre,s:
CI e,_ P S r City.Stu Le/Zip. S%ilp-li '--L ob'7' 70
.\ttach it copy,or the workers' cumpen)atiun policy decla ratiull pahe (shawl iek the policy number and ex plratiun date).
failure to ,ccure co\emge as required under Secuun 25A of.%IGL c. 152 can lead to the imposition of criminal penalties of a
tine op I,),' anlL'ur one-year in,pris.nunent, .,+well a,cis 11 pcnultics in the farm of a STOP WORK ORDER and a fine
of up to 5250.00 a Jay .Igain,l Ilse violator. He advl.+cd that a copy of This malcmenl may be lures aided to the Office of
Ins:,n,u inns ul :hc OIA :or io,w.oxc oncar;c tc1111tahan.
/du herrby t:rtify under the prtiny and putts/Iia•c ufparjnry that the infunnutlon provided above is true and rorrecf.
iulwa
7.r --
Phonedy. /)u roc urine iu Mix urea, ru be cwupleted by t iel,up rotvn gjirial. ]pcclor
: _ Pci init/Liccnse 0
uiiiv (circle onc):
vsltIt !. Iluddiu� ngs.uuncut 1, C its.-luau Clerk J. Electrical lu,pector. 5. Plumbing
Phone h:
1= v
Information and Instructions
Ala>s.�ehusetn U,:ncr.rl Laws chapter I*52 teguires all cmplo)crs to prrn ide workers' compensation for their employees.
Pt.rnum. t to nos .litule, an empluree isJcfincd as" wary pctson in the service of another under .sty contract of hire.
rspress or nnplied, oral ar ,vruten."
ttn ernplmyer is defined as 'an individual, partnership, association, corporation or other legal entity, or any two or more
.'r iCc t„retwir,g engaged 111 a joint enicipnse. and including the fcgal representatives of a deceased emplu)cr, or the
receiver or trustee of .at tttdtvtdual, pattttehhtp, association or other legal ennty, employing employees. Howe\'ef the
owner of a dwelling house having nor more than three apartments and who resides therein. or the occupant of the -
Jw,,umg house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the.-rounds;or building appurtenant thereto shall not because of such employment be Deemed to be an employer."
\IGL chapter 152. p25C(6)also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license tar permit to operate a business or to construct buildings in the commonwealth for any
applicant "too has not produced acceptable evidence of compliance with the insurance coverage required."
\Jditlunally. NIGL chapter 152, 425C(7)crates"Neither the conunoiwealdh nor any of its political subdivisions shall
enter into any contract for the performance ul'puhlic work until accepLlble es idence o(conlpliance 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 iub.conrractor(s) navels), address(cs)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with nu employees uthcr 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 may be submitted to the Department of Industrial
Accidents for contimtation of insurance coverage. Also be sure to sign and date the affidavit. Tle affidavit should
be retilrned to de city or town that the application for the permit or license is being requested, not the Mpartment of
Industrial Accidents. 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. Sc)f-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete rind printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill nut in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennit/license number which will be used :es a reference number. In addition,an applicant
that must submit multiple permitaicetse 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 (ci(y 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 hone owner or citizen is obtaining a license or permit not related to any business or commercial venture
I re, a dug license or permit to burn leaves ate.)said person is NOT required to complete this affidavit.
I he I)I lice 11 Imv"figaliona, would line to thank )l)u in ad%ance fur your cooperation and should you have any questions,
please do Ilol hesitate to give tax a Call
fhe L cp.unncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/din
CITY OF SALEM
PUBLIC PROPRERTY
> ..1. - ;.
DEPART'.MENT
I ANIII\�..• ':1;.tt l r • NA I I V, \L\ i\i Lam. I .•_I't
Construction Debris Disposal Affidavit
(re(luired liir all demolition and renovation work)
In accordance \\itll the sixth edition of the State Building Code, 780 CMR section 1 11.5
Dcbris, and the provisions of NIGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The}}debris will be(trrannsiported by:
1 name oC hauler)
I he debris will be disposed of in
//(name ul lacihty)
I aJdres<ul facllilvl
.I�uatwe of prnmt .Ipphcanl
J�1.
A` CERTIFICATE OF LIABILITY INSURANCE " �`/i 09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Phil Richard 6 Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
491 Maple Street HOLDER. THIS CERTIFICATE DOES- EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite 102
Danvers, MA 01923 - INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:I SCOTTSDALE INSURANCE COMPANY
Pearson Builders, Inc. INsuRERe: Arbella Protection
150R Winona Street INSURER¢ Granite State Ina AIG
Peabody, MA 01960 INSURER
INSURER E:
COVERAGES
THE POLICIESOF 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 WrTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THETERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PANDCLAIMS. -
INSR ADD' .�D�,� � POUCY EFFECRVE POUCY EXPIRATIONINSURANCE DATEIMMIDIVYYM LIMITS
GENERALUABILITY EACH OCCURRENCE $ 1,000,000
A X CCINMERCIALGEPERALLIABILITV CL51445653 11/28/08 11/28/09 DAMAGE TO RENTED
PREMISES ,) $ 100,000
CLAIMS MADEEZ OCCUR MEDE(PIAryompesm) $ 51000
PERSOMLSADVINJURY $ 1,000,000
GENERAL AGGREGATE $ 2.000.000
GENLAGGREGATE LIMIT APPLIES PER PRODUCrs-ODMPIOPAGG $ 2,000,000
X1 POLICY PR0. LOC
AUTOMOBILE LIAMUTY COMBINED SINGLE LIMB
g ANY AUTO 37262400001 7/18/08 7/18/09 -(Eeacdden) $
ALL OWNED AUTOS
BODILY INJURY $ 250,000
X SCHEDULED AUTOS (Perpason)
HIREDAUTOS
NON OWNED AUTOS (Paracddanq
PROPERTY DAMAGE $ 100,000
(Perecddenl)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANYAUTO OTHER THAN EAACC $
AUTO ONLY: ACC $ t
EXCESS I UMBRELLA LABILITY EACH OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RE ENTION
WORKERS COMPENSATION X I WC STATU- OTH-
AND EMPLOYERS'LIABILITY
C ANY PROPRIEIOR/PARTNEREXECUTNE Y7 TBD 3/17/09 3/17/10 EL.EACH ACCIDENT $ 100,000
OFFICER17AEMBER D(CLLDEDT -
(MaMabrylnNH) E.L.DISEASE-EA EMPLOYEE�$ 100,000
I/yea, albeunder
SPECIAL PROVISIONSbdow E.L.DISEASE-POLICY LIMB- 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION '
SHOULD ANY OFTHEABOVE DESCRIBEDPOUCIES BECANCELLED BEFORE THEEXPIRATION
TO WHOM IT MAY CONCERN DATE THEREOF,THE ISSUNG INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2009/01) 01988-2009 ACORD CORPORATION. All rights reserved.
The ACDRD name and logo are registered marks of ACORD