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332 LAFAYETTE ST - BUILDING INSPECTION (2) 1A u zZ�� The Commonwealth of Massachusetts gA, Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only. Building Permit Number: Date tPlied: /k ly Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers '5 1 L 6F .X\e. `fir l.la 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: kale K2\ltnacw's SONkm,Yc�A 01q�0 Name(Print) City,State,ZIP 5-51 Loki(,W, S� 1�e� 54l b9g� KylekelbrwV� r� gmu�\ gum No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building I� Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work':A2Cur\��c,��tP. NOCANWWm My 6, ni"Uiy_. SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials 1.Building $ 31 U.00 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 1t�0 ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier ' x - 3.Plumbing $ y000 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount:- Cash Amount: 6.Total Project Cost: $ 5\,50 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) lobo3s C6/a`6401h GImanni NArde\\q License Number Expiation Date Name of CSL Holder A� U Cr l C S} List CSL Type(see below) No.and Street Type Description Somew l\e fY�A Ua\ U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City frown,State,ZIP M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances lK1-b98-9$4K QIuI�WhijP.{lo%iZCA�"fi�tuG�tW1,Gu`M I Insulation Telephone - Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) wuUnt\t �or&mC> 110970 G HIC Registration Number xpiration ate HIC Company Name or HIC Registrant Name 1 CfG tP PG/♦1 sCy oJ�B CohSkNL�iun COM No.and Strelft Email address City/Town,State,ZIP Telephone 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 ..........A 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 Cj10V0,n^I\t to act on my behalf,in all matters relative to work authorized by this building permit application. Ky �� & �,l� 0&�s -Z, Pr - mt O ne's Name(EI tr me Siggature Date SECTION 7b: OWNER 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. Cvigj1ly —w\Nr&\10, aNl�iau Print Owner's or Authorized Agent's Name(Electronic Signature) f 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.mass.ttov/oca Information on the Construction Supervisor License can be found at www.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 Cost" CITY OF Sri XNX I, IMASSACHUSETTS • Bt:BDLNG DEPART%WNT \ 120 WASHIINGTON STREET,3'o FLOOR TEL (978)745-9595 FAX(978) 740-9846 KINBERLHY DRISCOLL MAYOR T HomAS ST.PIERRS DIRECTOR OF PLBLIC PROPERTY/BunMING CO\MBSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information __ 1 Please Print Legibly Name(Business:Organization/Individual): 11k Uys"' CUY14�^Cs1C�wy1 / 17��n1(lY�`t�� 1VGkbiax\A Address: 'A- City/State/Zip: 5oW&,F\JA\J-- ,MN 0�,1�A3 Phone#: 7 I !W-%-q`6Wi6 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with _ 4. ❑ 1 am a general contractor and i E] employees(full and/or part-time).* have hired the subcontractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ?• ❑Remodeling ship and have no employees These subcontractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. 9• ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its !0.❑Electrical repairs or additions required.) Officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I C]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' 13.0Other comp. insurance required.] •Any applicttn thus checka box#1 must also fill out the section below showing their worker•compensation policy infuomatiun. '1 btmeuwnen who submit this affidavit indicating they am doing all work and then hire outside contractor most submit a new,affidavit indicting such. �Contrmtnun that check this box must attached an additional slmet showing the name or the sub-contractors and their workers'comp:policy information. l am as employer that is providing workers'compensation insurance for my employees. Below is the polley and Job site information. \ ' Insurance Company Name: A•�, 1,NV�\J�v Q� Policy#urSelf-ins.Lie.#: NWC- `A00--I 0M)Ac6-W, A Expiration Date;--4[lpl Aol9 Job Site Address: 5,3d, City/State/Zip:fja4mi,MA 61q ]0 Attach a copy of the workers'compensation 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 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 Office of Investigations of the DIA for insurance coverage verification. i do hereby certify under the pains and penalties of perJury that the information provided above is true and correct 51>;tinhtr-e' Awozl�t Date ab�1 4� q ``� G 1 Phone#: -7q 1- lyq 0 -q�t '7 , " OJTcial'use only. Do not write in this area,to be completed by city or town oJJtciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Ileallh 2.Building Department 3.City/rows Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other,_ Contact Person: Phone#: 3 a, LooSaa e, ke Sk ToEA\ aceG'w �.5�k. _ y 1n5\oUed. 'Flee}otmf\ .may or muy nok:be c¢gv cea A�\._net a\Q,ckt�ca\ ._ko be 1�5ko\�eA�+,� _ e\� �u5ku11 svbQore.\ ��. `oaszrr.e,�l:Cx�tc,_' A\I _aGsebW.ca_�c�m ko be, ��SkuUc� wha,rs, _ —nog a� ee Of, RO�Y5\\"O- x . _ Plumb&n5_ will be, %5\0A6 -For New ca,knun. - "��,. ' Owner_ko_..p�re)nu .-_Cmb)nu�,Cou� es avQ wal w CITY OF S.Cuz I, tiL1SSACHUSETTS ©I:ILONG DEPAR-M&NT ; - ` 130 WASHLNGTON STREET, 3''0 FLOOR TEL (978) 745-9595 F.Aax (978) 7.10-9845 K11ffiE1tL.HY D[�lSCOLL rti{AYOx THOSNS ST.PIERR$ DIRECTOR OF PUBLIC PROPERTY/8CILDLNr,CONNISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5 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 iviGL c 111, S 150A. The debris will be transported by: y y �n�s��s V�leJra\5 (name ot'hauler) The debris will be disposed of in (name of facility) LD S-�• SomexvAe,lmA- Oa\`-A -3 (address of thcility) i signature ofpermit applicant t Il' i