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414 LAFAYETTE ST - BPA 16-1187 ROOF a $--7 ( 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 Nj Building Permit Number: Date Applied: ; Building Official(Print Name) Signature _ DaTcR K'a 7. SECTION 1:SITE INFORMATION _ ( 1.1 Propert Address: / 1.2 Assessors Map&Parcel Numbers t`� r C� ylcA` g��l S"/ l.la Is this an accepted street?yes—x— no Map Number Parcel Number ' 1.3 Zoning Information: 1.4 Property Dimensions: : N su Zoning District Proposed Use Lot Area(sq ft) Frontage 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? Check if yes❑ Municipal❑ On site disposal system ❑ ' SECTION 2; PROPERTY OWNERSHIP' 2.1 01vpe ro Name/ ¢cord: I� 7 (Print) !(' b Ci tate,ZIP yty t� ( � 9n No.and Street - elep one Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units 2i I Other ❑ Specify: Brief Description of Proposed Work': S SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials 1.Building $ 0 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees:'$ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ qQ o— ❑Paid in Full ❑Outstanding Balance Due: rf)Ga i SECTION 5: CONSTRUCTION SERVICES i ( 5.1 Construction Supervisor License CSL) J O Aa /)f/yam+//[ AMA&AL Lic nse Numb er Expftion ate t Name of C o er List CSL Type(see below) No.and Street � TYPc Description i ZZ U - Unrestricted(Buildings u to 35,000 cu.ft.) t� R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Maso RC Routing Covering . . WS Window and Siding SF Solid Fuel Burning Appliances a 6 I Insulation _Telephone - Email address D Demolition 5.2 Rfgistered Home Improvement Contractor(HIC) 7/✓ ► INC Registrationr piratio DaHI�om'pn6yN or Registrant Name No.and Stre 1 Email address ,ZIP /�tG�Q/�ib r Ci Town,S t e ZP Telephone SECTION 6L 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...........❑ ;,:,-SECTION7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN x '`"OWNER'S AGENT OR CONTRACTOR APPLIES FOR'BUILDING PERMIT I,as Owner of the subject property,hereby authorize /VUw/}J� /J( to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attes under the pains and penalties of perjury that all of the information contained in this applic ' is t e and curate to the best of my knowledge and understanding. Print Owner's or d 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. ov/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 basementlattics,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" free of Consumer Affairs&Business Regulation .License or registration valid for.individual use only f beore the expiration. 1f found return to: .. OMcIMPROV�AAENTCONTPACTOR � P 'i �;, Office of Consumer Affairs and Business Regulation Registratiqu�'�jg'}g& Type: 10 Park Plaza-Suite 5170 Expire Supplement Card Boston,MA 02116 NATIONAL MANAGE C. - - ' � DANIEL TIMMC`NS r, 2 AUSTIN SQUARE LYNN,MA C1905 Undersecrc•t<wy ;i Not valid without signature I Massachusetts Department of Public Safety - , Board of Building Regulations and Standards License: CS-090308 -Construction Supervisor .� - - DANIELOTIMMONS 70 SUNSET DRIVE#2 _ BELMONT NH 03220 ir. CA— Expiration: Commissioner 0211512018 k , } National Management Team Inc. 'This form satisfies all basic regmireatenm of the states Home Improvement Contractor Lav(MGL chapter 142A),but does not Include standard lunguagemprohcthomeownem Seek legal advice ffneceamry. Any person Massachusetts Commuter Guide ro Home Improvement'before a phk o ny bonne h residence. You should first See co a ropvof•g agreeing raptvock at you ce3-9787 You Wray.brainafire copy by calling Iht Office of Consumer Again and Business Regulaton's Consumer Information Mine at G17-973-8787 or 1.888-283-3757 or on omtvebuce. Homeowner Information Contractor Information Name Company ante — Street (do uotowaPom Office Box address) m�traaoa Solespew voauAaaw 00 Ciry•Tmtu Storm Zip Cade BnWuess Address(aunt kchides wen adnhess)rN 41 Da7enu ne Evening Phom Ci m — "T 971 tmi � — Codee' r MaBmg a W itferrvrt bran above) &niaess Phwe ��Ej�'" v Federal FsoZ O or S.S.NwWer 19 y t�Y v -fi f/ samer�rnmmteevxn..ac awsMwda, namwgapmnmllYwr Impmmuen:._ a e1,4��t�Wf✓ ©2� mm�a.aw,r�m �7Y �3 zli8 ,. H The Contractor agrees to do the following work for the Homeowner; m Mesmbe in daail the node m can let H tP wr.speedymgmre bpe,Mvd;and Bade of umteriakro beuwd,rme odditiwe)aheas ifs,,•) z o a c ?7V lkv4 2c!cl-W - #r✓.rv- -e7vJ'f-4-+.c_ (ez e � � [.PJ�l7,dL JINi�:'t/) w/ i=rL;a�n/I�e l7�l�efif.•d ..,e�f!'tYltc, � Rc1 w itAf/ji.at�(r�r: ✓JY�E(I'/Ti,�Tv�itc. S'c/f r�UGc.s .. �:Ll.-yM � /1cFiif-PlhMNcy R5 Q O Required Permits-The following building permits are required Proposed Start and Completion Schedule•The following schedule will ►a cod will be securul by the contractor as the homrownees agent: be adhered in unless chw.mstances beyond the comtractoes control arise - [n (Owners who secure their own perndts win be 14) so t` excluded from the Guaranty Fund provisions of Dace when rontracror coin b ad m MGL chapter 142A.) egln contacted work. Z '17 Dam when contracted work will be substantially completed. 0 Tom'Confraet Pdce and Payment Schedule Q q The Coutre mar agrees to perform the work,famish die material and labor specified abovx Esr ire meal sumof. 0 min— (h Payments will be made according to the following schedule: Z era N /. QI 8 so upon signing eomtraa(not to aviceed I/3 of the rota)contract price m the cost of special order iumss�ichevm is greater) 8- ?0 0 by!_L—"open completion of 8 by_//or upon completion of _ 8 070 upon completion of the contract (Law forbids demanding full payment until contract is completed On both pWs satis6etiw) The following matedallquipmat mar bespecial t wbepaidfm ordered before the eoatmaed and:begins In order - to met the completion schedme o) t tebepoidthr NOTES:(hincluding all fimnce charges(••)Lawregaims that my deposit wdawnpaym nregnicadby the rometorbeforework begins may . aotetxeed tiro gmwmrof(a)one-Ihird ofdw tang wauaapdce or(b)the actmleonofBay sperielegoipnutmwaommmdeuaterial which must beapecialardemd in advance in men the caupledm wheduk. Fanre W Iv-n wbt ddedb w tre1M N ❑Y (111 (w N the H bedlam wail S bwmmadors Thecroarr ragrewro a solely responsible for complehom of the work described regardless of the serious ofany third Pal cry/aubeontractorutilindby the.wntrnetm. The mmmactor fiuthm agrees inbesoktyresponnblefor allpayseemce mall subcontractors for material d Iab diR muccUMut Contract Acceptance Upon agmng,am docmnent becomes a binding coutract order law. Unless otherwise noted tvitrm this document the contract shall not imply that any lim m othersecmityingrcahas beenphnced ondieresidence. Reaiety the fallowing cautions and notices crucially before signing this matter[. • Don't be pressured into signing the contract Take time to read and fullyunderatand it Askquestiwsifcome t a drmg is unclear,' Make aurc thewntraerorhasa valid H Improve entC ntracto R is= . Thelawreghimmosthom *cove litconuamusmd subcontractonto be cegaered with the Director of Home lmprovemmt Contractor Registration You amf'inquire about contractor registrat(on by writing to the Director at IO Park Prom,Room-5170,Boston MA 02116 or by calling 617-973.8787 or 888-293-3157. • Does rise contractor have insurencel Ask rim Contacuor for his inemmce company information so that You cam confirm coverage,m agk to see a copy ofa"Proof ofdocument.ore document. _. ' • Know your rights Bad msponsdrilifies. Read the hnpormt hifomation on the reverse side of this form and get a copy of tine Consumer ` Guide an the Home impornor at Connector Low. You may cancel this agreement Sit has been signed at a place otherthan the wntracmts normal place of business,provided you ratify tine contractor in writing:at his/her main office or breach office o Posted, y gram seat or by delivery,not later thanodr=ht dithe third business dayfollo by theatyvmdtiof tale wing du signing of this agreement See the attached notice of cemcetlation form for an utopia o 'ght. . DO NOT SIGN THIS CONTRACT H7 THERE AREA BLANK ACES!!! dorm Nemied eopinorne muamlmmbe wupkud omilpiM one wpyshmadpr A'odaevpy E"* Homeowner's Si¢wture ratDaceGare „( A "r Contractor Arbitration The Home improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to,a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both,parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Low. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute ' concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the c me hall be required - __ to submitto such arbitratio as provided In Massachusetts General Laws,c t 142A_ Homeowfterts ture r on toes i stare y NOTICE.The signatures of the parties above apply only to the agree f the parties alternative dispute . resolution initiated by the.contractor.,The homeowner may initiate alternative dispute resolution even where this section is not sepirately signed by the parties. - Homeowner's Rights. A homeowner's rights under the Home improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL.chspter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the w6rk as described,in a ' timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. in addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terns of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Conti-act -The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marketi•.ns void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both pantie :. tmcted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems himtherself to be financially insecure,the contractor may require that the balance of fords not yet due be placed in a joint escrow -- account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: - Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-2833757 or visit the OCABR website at turn)/www.mass.eov/ocabr/ " If you want to verify the registration of a contractoror if you have questions or need additional information specifically about the contractor registration component of the Home improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 - 617-973-8787,888-283-3757 or visit the HIC website at http-//% ww,miass.vov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: bitp,lldb.state.ma.us/ijoineimprovemeni/licenseelist.asy For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727.8400 AND/OR Better-Business Bureau 508.6524800,508-755-2548 or413-734-3114 V"m 2.1-r Ir2L20ta The Commonwealth ofMassachusetts Department of IndustrialAccidents Office of Invesagations 600 Washington Street Boston,MA 02111 www-mass gov/dia Workers° Compensation Insurance Affidavit:$u1'lders/Contractors/Electlicians/Plumbers APolicant Information Please Print Le •b Name(Business/orgenizetion/fpdiviauai �- p� �� ly Address: City/StatelZip: /� 0/ b� Phone#• (' Are you an employer?Check the appropriate box: 6 7 70 1. I am:a employer with /0 4. 0 I am a general contractor and I �e of projectAreguired): employees(full and/or part-thne).4 have hired the sub-contractors 6. 0 New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling slip and have no employees These sub-contractors have ---�- -- 8. t j Demolition - tyor a or me m anv capacity — -, .4 J--------........: . ----- �Fl���-hates-�i�ers ....-� - [No workers'comp.insurance P con .itsurance ---' - required.] ❑ We ❑ 9.❑ 5. are a.corporation and its 10. Electrigal re I am a homeowner doing all work officers have exercised their pairs or additions myself. [No workers'comp. right of exemption per M(L 11.[J Plumbing repairs or additions insurance t ,§ O, 12.@(RRoofr airs required.] . C. 152 14 and we have no � • employees.[No workers' ME]ether comp.insurance required.] Any applicant that checks box 01 must Rho fill out the section below showing their workeas'comp insationpolicyiaformatiom, Homeowners who check affidavitindicatingthey eredojmgellworkeadthenbra;OutsideconlmcEorsmustsubmitanewaffidavitindicatingmch. mPlO Eetera that check tiffs box must attached an additional about showing the mane ofthe sub-co employees. Ifthe subcontractors have employees,they mostpmvidetheir workers'co ah'actoar. state whether ornotthose entities have rap.policynumber. Ian an employer that is providing workers'compensation insurancefor my employees Below Is arepolicy,andjod site information. Insurance.Company Name: > MT�n,® V,006V4 /i! S �_;rtJn Policy#or Self-ins.Lie.#: (n � 62o u 1 e/ S j 7//� EXpirationDate- Job Site Address: W V I-./}��/yi�i F/� ('f +f 11n JY L C'ty/State/Zip: ,C M Attach a copy of the on compensation policy'declaration page(showing the poilcy number and expiration date). fieUFailure to secure coverage as required ' Section 25A of MGI a 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/oi one year onment,as well as civil yienaities in the form of a STOP WORT{ORDER and a find of up to$250.06 a da a amst the vi Y g --- Be advised that a copy ofthis statement may lie forwarded to the Office of Inge gahons o tha CIA_ o_i- __ .. �@...,_ytirage.yercati0 . I do hereby CWO under the pa d Ides ofperjury that the information prorl"above is tr e' a d correct lure 4 Date: O �e 7 a D5TIclal use only. Do not write in this area,to be completed by city or town g0'reiaL City or Town: PermitiLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.ClWown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: '4v CERTIFICATE OF LIABILITY INSURANCE °A'E"'�"°"""YY'' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS 6 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 INURER(S),ABTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the cermicete holder is an ADDITIONAL INURED,tle I,I I ii pes)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and Bonn lieu ofthe policy,certain policies may require an endorsement A statement on this certificate does notconferdghts to the certificate holder to lieu of such endorsements. FROWCPR ACT CircleAgcy, Ina PHONE Business Ins. NA E: 247 Newbury Street 978 777-5619 1 A . f97e1 777-4e98 Danvers, MA. 01923 E° 3' INSURE AFFORDIN'a COVERAGE NAIL9 INsuREo INSURERA:Hartford Underwriters Ins. Co. INSURERB:James River National ManSquare Team Inc. INSURBRC:TOrua National Insurance Co.- 2 Austin Square mstmaaD:Safe Indemnit Insurance Lynn, MA. 01905 NsuRERE:Merrimaak Insurance INSORER F:Travelers Insurance COVERAGES CERTIFICATE NUMBER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POIJCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWRHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDTIONS OFSUCH POLLCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPEOF INSURIWOE S VND Policy NUM1ffiER PML� EF PC OCYY QMTS B GFINERALLiABiLIIY Y Y 00068790-0 1o/1s/15 10/19/16 EACHOCCURRENCE $ 1,000,000 X COMMERCIALGENEPALLIAB0.ITY DAM4GET0 RENTED S 50,000 CLAIMEIVADE a]OOCUR MED E7P ryone emonl t PERSONNUADVINURY r 1.000.000 GENERAL AGGREGATE E 2,000,000 GEN'LAGGREGATELBATAPPLX:SPER PRODUCfS•ODMPpP AGG t 2,000,000 POLICY x- PRO. LOC E D AUTOMo6ILEQA ILiTY Y Y 6233530 5/12/16 5/12/17 E T eaer�mrt' 1 'M t 1 000 000 ANYAUTO BODILYINJURY(PerpemaN S spoff D X SCHEDULED A1n05 BODILYINJURYIPermNdeng r X HIREDAUTOS 7{ NO" MED AUTOS MwacEddeno S f C X OMam07L5i oacuR Y Y 85824I140ALI 2/zs/16 2/26/17 FACH OCCURRENCE $ 5,000,000 E%CL3SLU18 CIAIMS-ALE AGGREGATE $ 5,000,000 OEO RErEPM S S PJORK-5i COMPENSAMON WCSTATU- OT14 AND EMPLOYERS'LULELLIT'( OOrFICEFWEMMaERB .UOM? Y� NIA EL.EACH AGOOEM S IT andah,ry In NH) IT euMer FL DISEASE-EA EMPLOY S DESCRIPTION OF OMPATIONBbeiow EL.OIS EASE-POLICY LIMIT S E rental equipment IMCS-454-711 5/21/16 5/21/i7 limit 100,000 dad 5,000 106102524 5/15/16 5/15/17ded. 2500 100 000 DESCRIPTION ON OFOPERATONS/LOCI1nONS/VEHICLES(AHaeh ACORDiOI,A"Uonai Remadm Schedule,itmomepaeaismgdmd) CERTIFICATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DESCPoBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTH OP2M REFFUNIMTATP/E Janet Nichols ACOR 01988-2010 ACORD CORPORATION.All fights reserved. 25(2010/05) The ACORD name and logo are registered marks of ACORD Phhone:one: Fax: E-Naih