411 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
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 Applied: '
1
Building Official(Print Name) t Tignafore Dial
SECTION 1: SITE INFO MATION
1.1 Propetty Add�re 1.2 Assessors Map&Parcel Numbers
�•If�� („p
1.1 a 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 Own r of Bee
C i1u brr��� E�170-. ,/A G15'70
Name(Print) / City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Desert ton of Proposed Work': '2�.n o.r L�7t�c_ Ltct a
1Y SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1 000 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑ Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (BVAC) $ List:
5. Mechanical (Fire $ /
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ .1 5 ppQ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL H61der
List CSL Type(see below)
/O �.9✓�/z r� Sl
No.an treet Type Description
Al-6.ed/kL Od U Unrestricted(Buildings u to 35,000 cu.ft.
J 7 R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1119�y p 1
///�12G�//1� �/972/�i4�'� HIC Regissttration Number Expiration Date
HIC Company Name or HIC
X2;r�`66 gb;Zt Nar!!p,e/<,,C
No.and Site 46S G 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 .......... ❑ 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 author-i is building permit application.
�r
P ' caner' . ame(Electronic Signature) 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 Agent's Name(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.gov/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"maybe substituted for"Total Project Cost"
CITY OF S�UF2N4 NvLASSACHUSETTS
BUILDING DEP.kRTNC&NT
p• 120 WASHINGTON STREET, 3a°FLOOR
TM (979) 745-9595
FAx(978) 740-9846
KlmBERLEY DRISCOLL
I�iobtAS ST.P[ERRfi
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BL'ILDL\G CO%0,ilSSICNFR
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n Please Print Leeibly
Name tBusitxss:Organizationttndividual): 8 9 l�/- R0 R-1 Titi)C
ni
Address: R n x I Ig to
City/State/Zip: Pem/5a0J4E- 10234 Phone #: 9819a6a5Z0
Are you an employer?Check the appropriate box:
Type of project(required):
I.117 I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
]No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
10.0 Electrical repairs or additions
3.❑ t am a homeowner doing all work right of exemption per MOL 1 I.[] Plumbing repairs or additions
myself. [No workers' camp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp. insurance required.]
•Anv appli=1 that checks box dl must also�11 out the section below showing their workers'wmpeosatiun put icy infumtation.
'Ilom¢owntrs who sulmtit this affidavit indicating they arc doing all work and then hire onside contractors most submit a new affidavit indicating such
:C:unirxron that check this box must attached an addiuomd sheet showing the name of the sub-contractors and their workers'comp.policy infumution.
I um an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
irrfolnruJion. _
Insurance Company Name: ft ✓C--C.e 2S _
Policy#or Self-ins. Lic. #: '� PJ O 6 — mil Sq 10 3 — 3— �
11 Expiration Date::
Job Site Address: �Il 6%51 yz_ )'t City/State/Zip:Jf)/en') /r/n- 019 -)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 ot'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 penaldes ofperjary that the informatlon provided above is true and correct.
Sienatare (Jute•
Phone�: 7- I a� t� J 00
Official use only. Do not write in this area,to be completed by city or town offrciat
City or Town: Permit/License
Issuing,%uthorily(circle one):
1. Board of Health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ ___ Phone#:
RightFax C3-2 6/29/2011 4 : 51 : 36 AM PAGE 2/002 Fax Server
ACORD. CERTIFICATE OF LIABILITY INSURANCE 06/29/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SL AUTHORIZED REPRESENTATIVE
OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:R the certificate holder is an ADDITIONAL INSURED,the policyQes)must be endorsed. If SUBROGATION IS WAIVED,subjectto the
teens and conditions of the policy,certain policies they require and endorsement. A statement on this certificate does not center rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
PHONE FAX
ALBERT J TONRY&CO INC (A/C,No,Ed): FAX
(AIC,No):
300 CONGRESS STREET E-MAIL
ADDRESS:
PRODUCER
QUINCY,MA 02169 CUSTOMER 10 It
2873Y INSURERS)AFFORDING COVERAGE NAIC#
INSURED INSURER A: TRAVELERS DIRECT ASSIGNMENT
INSURER B:
E R CARRARA INC INSURER C:
INSURER D:
PO BOX 1146 INSURER E:
PEMBROKF,MA 02359 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTES INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W HICH THIS CERTIFICATE MAY BE ISSUED
OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.
UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDLSUBR POLICY EFF DATE POLICY EXP DATE
TYPE OF INSURANCE POLICY NUMBER (M%CmYYYY) (MROMYYYY) LIMITS
LTR INSR WVO
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
CLAIMS MADE OCCUR. PREMISES(Ea occurrence)
MED EXP(Any one person) $
PERSONAL A8 ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY PROJECT LOC PRODUCTS COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT E.accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
(Per accident)
NON OWNED AUTOS PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR EACHOCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WC STATUTORY LIMITS OTHER
WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY YIN UB-4159PS3311 03/10/2011 03/102012 E.L.EACH ACCIDENT $ 100,000
ANY PROPERITORIPARTNEWEXECUUVE Y E.L.DISEASE-EA EMPLOYEE $ 100,000
OFITCER/MEMBER EXCLUDED?
(Mandataryln NH) E.L.DISEASE-POLICY LIMIT $ 500,000
It yes,describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONSNEHIC LES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
PROTECT:K E LY AICLAUGHLIN
LOCATION:31 SURREY DRIVE.PLYMOITITL MA 923W
CERTIFICATE HOLDER CANCELLATION _
TOWN OF PLYUMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE
11 LINCOLN ST WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
PLYMOUTH,MA 02360 Charles J Clark
ACORD 25(2009/09) 1988.2009 ACORD CORPORATION. All rights reserved.
CITY OFSALENfi AkssACHUSETI'S
OLtLOLVG DEp.1RT.%LLNT
110 W-kj'4LNGTON STREIrr, Ji FtOOIt
TIM (978) 745-9595
KBEBERF Y ORLSCOLL FAUX(978) 740.9846
MAYOR TNO.+w ST.PMXAX
DIRECTOR OP PLaLic PROPERTY/9LQ,pC-4G CO-%NISSIONER
Construction Debris Disposal At'tldavit
(required for all demolition and renovation work)
In accordance with the sixth edition orthe State Building Code, 780 CMR section 1 l I.S
Debris, and the provisions ofMOL c 40, S 54;
Building Permit X
1 is issued with the condition that the debris resulting from
1 11, S i SOA.work shall be disposed of in a properly licensed waste disposal facility as defined by MOL c
I
The debris will be transported by:
CAgcLL,4-
(nume of houler)
The debris will be disposed of in
(name of facility)
01dress or C,cduy)
+ yn+nrre ofpermrt�pp6unt
,:ate
C
M:Issachusetts- Department of Public Safch Board of Building Re mlations and Standards -Construction Supervisor License
License: Cs 60145
MARGARET R CARRARA
PO BOX 1146' m
PEMBROKE, MA 02359'"
Expiration: 1/24/2013
Gemmisaioner 4'
Tr#: 8572
T ..:W .w.aii iYG�KNRtPYi;iertai'+s-s.al+w-. ,»aW..sr,ery ._c .u:.
A 07k
tea.-\ Office of Consumer Affairs&B sioess Regulation
HOME IMPROVEMENT CONTRACTOR. -
Registratlon �1 11044 Type: '
Expiration 219/2013 Individual
��
- WMAGARET
R cA RRRA ?(t
MARGARET CAR,ARA�. i
r3/
P.O.BOX 1146@108ARK -
PEMBROKE,MA 02359 '
t - Undersecretary