381 LAFAYETTE ST - BUILDING INSPECTION JqZ'
The Commonwealth of Massachusetts CTTY OF
cis Board of Building Regulations and Standards RECEIVE0
Massachusetts State BuildingCode,780 CM 2NMV
�MSPECTIO!dAL evuedMar2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
QO One-or Two-Family Dwelling ims MAX 32 A 5-, 13
This Section For Official se Only
u l Building Permit Number. Date peed:
1 Building Official(Print Name) - - Signature Date
I11^J SECTION 1:SITE INFORMATION
i �@Pri perry A Tess ' 1.2 Assessors Map&Parcel Numbers d
3 Z t'l*
I.I a is this an a cepted street?yes_ no Map Number Parcel Number
1.3 ZmgInformaaon: 1.4 C�p01DFensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(R)
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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2'-0 a r of Record• n ,( ,(
Name City,State,ZIP ,
( 1-7-AID l
No.and Street Telephone A tmaiLAddress
SECTION 3:DESCRIPTION OF PROPOSED WORK(check.all that apply)
New Constmetion❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg.El I Number of Units Other ❑ Specify:
Brief Description of Proposed Worv:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ Os� 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ D�Q ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ od 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:.$
1 'r/� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ O V ❑Paid in Full ❑Outstanding Balance Due:
M N1 L-GTD (c
�—
SECTION 5: CONSTRUCTION SERVICES
c 1 r ._r_.,,,.r:_....c..,. ..:lso.T.;cens,.rrcT.i G!j.• 1!'L,2 [�ty 5 r 5 �t'�Q
y __ License Number Expiration Date
Name of �Holder
List CSL Type(see below)
5-5
N u. d Street t Type Description
Wi' ad ( U Unrestricted(Buildings up to 35,000 cu.ft.
CityiTown,State,ZIP I V l R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
t J T Insulation
Tel hong�e Email address D Demolition
5PRe 's ed Hame mproypment Contractor(HIC)Cv 9 �t �
1�C. R AiC Registration Nuurn Expiration Date
HIC Co y N to o R t ant a
� 3ass _
�P}nGrtold/ V aEmil address
city/Town,State,ZIP CY �(Y t 7 T Tlevl IhoneJ l
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 o building permit.
Signed Affidavit Attached? Yes .......... No....4......❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOIJ 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 pen t a placation.
Print Ot is Name(" lectronic Signature) Date
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest trader the pains and penalties of petjtuy that all of the information
contained in this appf cation is true and 4cgmte to the best of my knowledge and understanding.
Tr
Print Owner's or Authorized A" in lame(Electronic Signature) 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.eov/oca Information on the Construction Supervisor License can be found at 1Lw.mass.t;ov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.fL) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.fL) 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"maybe substituted for"Total Project Cost"
CITY OF SAIL&N4 A--1SSACHUSE'ITS
BuMDLNG DEPART[EINT
a• 120 WASHIPIGTON STREET,r FLOOR
TEL (978)745-9595
FAX(978)740-9846
KIt[BERIEY DRISCOL
MAYOR THOBIW ST.PiFldltS
DIRECTOR OF PUBLIC PROPERTY/BUILI)MG COXLUISSIONER
Workers' Compensation Insurance Affidavit: Builders!Contractors/Eiectrlcians/Plumbers
Applicant Information I
I Please Print Lei 1
Name IBusine ga ssOrnizationiindividual): ✓4 c)
Address: 77 •• 1 *Z
City/State/Zip: MQ V6( - 1 t -ttM(+O t145 �f�—V'(,6'����
Are yo a employer?Check th appropriate boa: Type of project(required):
LB 1 am a employer with 4, ❑ b am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached shect: 7• &<emodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. q. Building addition
[No workers'comp, insurance S. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LCI 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.❑Other
comp.insurance required.)
Any applicant that checks boa rl must also fill out the section below showing their workui compensation policy mroo atlun
t I Inmeuwntxs who submit this affidavit indicating they arc doing all work and then hire outsidecamr=tM most submit a new affidavit indicating such
:Cummuwn that cheek this box must at tched an additimul sheet showing the wore of the sub cnmteators and their workers,comp•policy information.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and b site
information.
Insurance Company
Policy#or Self-ins.Lie,=comppensadlen
� Expiration Date:
Job Site Address: . City/Statc/Zip:Sit �fE- 2 lq�0Attach a copy of the workers' polity 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 i st the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of•the IA f insurance c verage verification.
l do hereby corer e r the Ins nahle f pery at the hrforamrlan provided above is True and correee
Signature- Date:
Phone#: ��
OfTrial use only, Donor write in this area,to be completed by city or town ojfeciat
City orTuwn: Permit/License#
Issuing Authority(circle one):
1. Board of health 2.Building Department J.Cityffmvn Clerk 4,Electrical Inspector 5.Plumbing Inspector
6.OI her
Contact person: . _ phone#:
1
i
CITY OF S�UENI, UNSSACHUSETI'S
BuMDLNG DEPARTNiENT
` 130 WASHNGTON STREET, 310 FLOOR
T F1- (978) 745-9595
FA.0(978) 740-9846
KI,,IBERLEY DRISCOLIL
,MAYOR THomAs ST.PIERR&
DIRECTOR OF PUBLIC PROPERTY/BU I DNG CONMUSSIONER
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
l 11, S 150A.
T e dehris will be transported by:
Cuc,Q
(nam f uler)
The debris will be disposed of in
q (name of facility)
(address of facility)
L
si atureofp mi licant
date
i�t,.cw�r.ak