422 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
R Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR,70 edition Ois SALEM
Revised January
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1,2008
One-or Two-Family Dwelling
^v1 This Section For Official Use Only
Building Permit N r: Date Applied: 7-e1A1C Z O z Q
Signature: �7 JuNc 2 2 2 O/U
- Building Commission Inspector of Buildings Date
SECTI N 1:SITE INFORMATION
1.1 Pr per[y Ad Ness: / 1.2 Assessors Map& Parcel Numbers
1.1 a Is thisjanan accepted t?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 Owners of Record:- -- - '
rzu� L/Z2y La f,g�Frr� sr
e(Pn Address for-Service:
978 Zio :7
Si Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 00 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:- C4 Mr7[!r-- QCD RCb/�AtIC /Y!/fTE.P/�G. /Fi(/Q
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ S Od l) oc 1. Building Permit Fee:$ indicate how fee is determined:
2.Electrical $ r ❑Standard City/Town Application Fee
❑Total Project Cos[ (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
6.Total Project Cost: $ S ODO Check No. Check Amount: Cash Amount:
0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licens C70ileo
ction Supervisor(CSL)
7License Numbers Expiration Date
Name of L-Hold r List CSL Type(see below)
Address any Type Description
U Unrestricted(up to 35,000 Cu.Ft.)
v' v R Restricted 1&2 Family Dwelling
Signature— �/.�. M Mason Only
/`�' RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Re t,71 HurMe j pr v�y+ment Contractor(HIC)
ff''��1�rJJ t'L Registrationtra Number
MC o--(;. H Rego ant e / ' �N
Adds s
Q 'nA7VCIv��t�7Cj (i3�f 1 Expiration Date
Signa el hone
SECTION 6:W RS'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, J--,4r—w 4 Aw/€ as Owner of the subject property hereby
authorize 1310& to act on my behalf,in all matters
relative to work auth by this building permit application.
/23 -Fa -6
Si a Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 MC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"maybe substituted for"Total Project Cost"
CITY OF S.U.Em. N'L-1SSACHUSETTS
• BUHMLNG DEPART%MNT
130 WASHNGTON STREET, 3'FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR
TZ l016CAS ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNaSSIO,iER
-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
111, S 150A.
The debris will be transported by:
ame of hauler)
The debris willbe disposed of in
/ /.Pi/lD
(name of facility)
aa_1W7Da)1J
(address of facility)
signature of permit plicani
& a -to
date
Jcbriwfl:Jce
CITY OF SMEN1, 2NIASSACHUSE=
BUILDING DEPARTM&NT
a
120 WASHINGTON STREET,Sao FLOOR
TM (978)745-9595
FAX(978)740-9846
KINBERLEY DRISCOLL
MAYOR11tOMAS ST.PIERRS
DiiitwrOR OP PCBLIC PROPERTY/BUILDING,COW IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n Please Print LepJblv
Name (Busitwss:Organizationlindividuaq:
Address: 9 1A(.I�ccJ
City/State/Zip:—�(iO4h-/-, MA-01?7i Phone #: nE' JFP S
Are ou an employer?Check t f-
e appropriate box: Type of project(require
I. I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).' have hired the sub-camtactors
2.❑ I am a sole proprietor or painter- listed on the attached shccL t 7. ❑Remodeling
ship and have no employees These subcontractors have S. ❑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 thew 10 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL It.❑P bing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12•['�f repairs
insurance required.]t employees.[No workers' 13.0 Other
comp. insurance required.]
Any applicant that checks 1101101 most also rill out the section below Showing their woskets'comPrn wim,policy iMotmadoo.
Ifomeownaa who submit this affidavit indicating they anc doing all work and dum hire oWideconttactora most submit a tmw affidavit indicating such.
:Comminms that cheek this box must anached an additional ihxt showing the nuns,or am subconoarom and their wotkens•comp policy infamanion.
fain an employer that it providing workers'compensadon insurancejor my employees. Below is the poBey and Job site
information.
Insurance Company Name-
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
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 S 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 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.
l do hereby cerrljy under der pains annjd ppenaltl ojpe►Juty that information provide/dam above Is true and correct
Date:
Phone
Official use only. Do not write in this area,to be completed by city or town oJJiciaL
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
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