414 LAFAYETTE ST - BPA 16-608 INSULATION 'ILI The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR S
Revised MdMar
ar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Seetlon For Of lci ,:Use only
O Building Permit Number:. Dat pplied:
( Building Official(Print None) . . Sviahre , Dat�
SECTION 1:SITE INFORMATION t Ate'
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers r-<
l(mil 1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: F"
rn
I o rJao � t
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 pply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Pub]
Private❑ Zone: Outside Flood Zone? Municipal On site disposal system ❑
Check if yesQ-�
SECTION 2: PROPERTYOWNERSHIP"
2-1I1 ( >KR¢Rn2a �Ipn.,,m1� n1
Name [ Ci State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRI I PTIqX OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Z Other ❑ Specify:
Brief Description of Proposed Worl2:� i 'ti- t°G l' 'fr,
In Lyn i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ qppd•00 1. Building permit Ace:$ Indicate how fee is determined;
❑Standard City/Town Application Fee
2.Electrical $ -
®V` O ❑Total Project Cost?(Item 6)x multiplier x
3.Plumbing $2$-00, 00 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Cheek No. Cheek Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
111Qt1.�-U TO 1'� •C� . �� 13
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /i S _��-29sCy d]- Z 6
SO/1 h Y I K�Jfi� License Number 1 Expiration Date
Name of CSL Holder j
List CSL Type(see below)
No.and Street Type DescFiption,.
��+ U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted l&2 Family Dwelling
r a Cityfro4,State,ZIP M Maso
t e J RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
ffzyilfi 9� tT rl0000&YAffa .Q�j� I Insulation
el hone Email address D Demolition
' 5.2,Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
Me eumpany Name or HIC Registrant Name
rr
No.and Street Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFMIAVIT(M.G:I,. c.152.§25C(6))
Workers Compensation Insurance affidavit must b completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Iss of the building permit.
Signed Affidavit Attached? . Yes .......... Q1 No........... ❑
SECTION 7a:OWN:ER AUTHORIZATION TO BE COMPLETER WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR RVILDING PERNHT
I,as Owner of the subject property,hereby authorizeJB h'7 \ U ham.
to act on my behalf,in all matters relative to work authorized by this building permit application.
Lane
Print Owner's Name(Electronic Signature) D e
SECTION 7It: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.
Print Owner's or Authorized Agent's Name(Electronic Signature) I 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
wlvw.mass.eov.%oc l Information on the Construction Supervisor License can be found at www.mass.eov/dns
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"
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor.
License: CS-07-074567
JOHNPKEANE
212 HUMPHBEYST
SWAMPSCOTT MA
a
. J..L.� � �.)no Expiration
Commissioner 08/02/2016
i
OTY OF SALEM MASSACHUSETIPS
Buz=Yt;DEPAm2emr
120 WAsMx,7r NSnW,3RDRDM
U 978)745-9595.
FAx(978)744984b
%II�ERLEYDRISQ7IL
MAYOR DiOWAsSTAEM
DBMCJVR OFPURUCFXCFMY/BUMD1WCCMMCNM
Construction Debris D1sposa/Aff1dav1t
(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 coo, S 54; Building Permit if is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed "
waste deposit facility as defined by MGL c 111,S 150A.
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
(name of facility)
VOrA fear, i2g ; OH
018E
(address o cility)
Signature of applicant
,91q /6
Date
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street'Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / Please Print bl
Name(Business/Orgamzetion/Individual): /, i.,
Address:
City/State/Zip: Sa q Phone#: is 17-
UV
Art you ao employer?Check the appropriate box:
I.n l alit a employer with Type of project(required):
rW=a,'r/ eawkyees(full eod/orpan-time).* JE
7. Ne construction
2. am a sok proprietor or partnership end have no employees working form
any capacity-[No workers'comp,insurance required.) 8• odeling
3.0 Iran a homeowner doing all work myself.[No workers' 9. ❑Demolition
comp.imurance re
4.01 am a homeowner and will be hiring contractors to conduct all work on my l 10 Q Building addition
ensure that all contractors either have workers'compensation msuramos or a11.0 Electrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5.01 am a general contractor and I have hired the subconhacmrs listed on the at
These subcontractors have employees and have workers'comp,imuuance.t13.Q Roof repairs
6.❑We area corporation and its officers have casmiud dwjrright of exemption 14.Q Odrer15Z§1(4).and we have no employees.[No workers' instance
c°'op. requtre
'Any applicant that checks box#1 must also fill out the section below showing their workers'compm pion policy information.
t Homeowners who submit this affidavit indleating they are doing all work and than him outside contractors must submit a new affidavit lodiWting such.
tCotractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees Ifthe subconrracors have employees,they must provide their work=*comp policy samba.
lam an employer,that is providing workers'compensation insurancefor my employees Below is thepo/icy and job site
information.
insurance Company Name:
Policy#or Self-ins.Lic.M Expiration Date:
Job Site Address: �h/S �p_
Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a tine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby eern under fhepauia and penalties ofperjury,that the mforarahon provided above is true and correct.
Si ature: P_C P-li�: 6
Ph a#:
Ofciat use only. Do not write in this area,to be completed by city or town of/rciaL
City or Town: Permit/License#
J[6.
ssuing Authority(circle one):
.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Otherontact Person' Phone#'
:i
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written." -
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartrnents and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C( )states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited liability Companies(IJ.C)or Limited Liability Partnerships(LLP)with no employees other 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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department 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. Self-insured companies should enter their
self-insurance license number on the appropriate line. _
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple perrrit/license 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 (city 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 pertmts or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or pemrit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suits 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia