437 LAFAYETTE ST - BUILDING INSPECTION ;r
The Cummonwcalth of Massachusetts Town of
Board of Building Regulations and Standards
MassachUSelfs State Building Code, 780 CMR, T"edition imanbow
Building Dept
Budding Permit Application To Construct, Repair. Renovate Or Demolish a ilk
Onr- or Ttro-Funtah Ots effing
� This Section For Oftcial Use Only
QM 1 Building Permit Number: Date Applied:
J Signature: �lI�g I
Budding Comrmnissioner/Inspector o Burldmgs Date
SECTION I: SITE INFORMATION
1.1 Pro rty Address• 1.2 Assessors Map rr< Parcel Numbers
�/3_ G14�g}/�i E 1
I
.I a Is this an acce led street''yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) Frontage(n)
I.S Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.a0.SSa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al❑ On site dis sal s stem ❑
Public❑ Private❑ Check if es❑ P po Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qi9nerl of Record: y37 &4fA\114 ZI,_ S
cu �n on2�
Name(Print) Address far Service:
. q -,7Y5-- 119aa
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alterarion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': d t A/ Z
? L
b 3a it 5 ssv E 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item (Labor
Costs: Official Us*Only
Labor and Materials
1. Building f �OU,' 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard Ciry/Town Application Fee
2 Electrical f ❑Total Project Cost'(Item 6) x multiplier x
) Plumbing S 2. Other Fees: f
4. Mechanical (HVAC) S List:
s Mechanical (Fire S Total All Fees: f
Su ression
Check No. _Check Amount: Cash Amount:
n Total Project Cost S 106 ❑ Paid in Full ❑Outstanding Balance Due:
Ck
SECTION 5: CONSTRUCTION SERVICES
S.ILi/censed Construction Supervisor(CSL) - 6-t_/6//2 2 2
'• I.l� `l �l� L.crnx slumtwr Ev ratio Date
N,4roe of CSL Helder 1 �� List CSL T •s
1._.i1/ Type Ia below)
T I Description
AddMp s U Unrestricted u to 15.000 Cu. Ft.
R Restricted IA2 Family Dwelling
Sisrratnr, M Masonry Only
q�g , f3/-lb RC Residential Roofin Covering
Telephone w'S Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 R stered Home Imp ov meat Contractor(HIC) �G / 7 (�
nY C17"� MOAIf!!Ar?bYLS IP
H IC Co y or HIC Re tstran ame Registrar Number
A 41446 92G i 31 /G /
Eapi anon Date
Sigrande I UTelephone i I
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Data
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
mKZko Zf , 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. !( A) K M�,S AJ Z,t
Print None
Signature of Owntr or Authorized Ag0J Date
(Signed under the gains and penalties of perju!Zl
NOTES:
I. 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 aw have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 1 MRS. respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenVattics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/porches
T�peofcooltngsystem Enclosed Open -
1 "Total Protect Square Footage" may he suh,lituted for 'Total Pro)cct Cost"
-"� CITY OF S.ux., s 1LXSSACHUSETTS
BL•ILDLNG DEPART\IE.NT
1'_O WASHLNGTON STREET, 3ne FLOOR
TEL (978) 745-9595
FAX(978) 74Q9&M
KI-[BERL!rEYY DRISCOl1
DR THOMAs ST.PmRRR
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BL'QDLNG CO.\12MISSIONEI
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electriefons/Plumbers
Aliplicant Information Please Print Legibly
Nalne (Busitt�Or&amzatioo/n,lnJrv,duJ): LOAJrn4&7-CX5
Address* 2. (tJ/4LN11 C � nn q
City/State/Zip: el 1� G � PhoneM:
Are you to employer'Check 1 appropriate box: Type of project(requlreO:
1.(9,71 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.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7. ❑ Remolding
,hip and have no employees These sub-contractors have 11. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) ollieen have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 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' 13.0 Other
comp. insurance required.)
;Any applicant that chocks eon II must aim fin ma the nachos bolow sh"ixj their workm•comp"mi"pulicy infutmallos.
I t.rtwuwttm who substit this aflldsrk indicating they an doing JI work and thm hire outside swnttacrps muss suhmil a new afndsvil indicating suck
!C,,nim"n that chock this box mesa attached an additiuml sheet+)rowing that tmnte of the jndf nttadm and their wurlwu•comp,policy infomution.
I tar an employer that 6 provid/nb workers'compaatadon Insurance for my employees. Below is the Palley otld/eb Sim
informalion.
In,urance Company Name: L(6kcl Y Mo1R1;4 L_ 1A)5
Policy N or Self-ins. Lie. N:rI / d 3A bq(0 a Expiration Date:
lob Site Address: City/State/Zip:
tttack a copy of the workers'compensatto■policy declaration page(showing the policy number and expiration dab).
Failure to secure coverage as required under Section 25A of MGL c. 132 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 S230.00 a day against the violator. lie advissxl that a copy of this statement may be rurwarded to the Office of
Incnttgatiuta ttl'dte DIA for insurance coverage veritication.
/Jo hereby ernes) Ulf of the pains nd Pe
#taldes of perjury that the infarmatlon provided above is truer and correct
Phunc 4:
i01rhiul use only. Do not write in this urea, to be.umpleted by airy or raw•e ofJlciol
City or Tuwn: ___ __ Pcrmit/Llccnse N _
hsuing Aulhuriiy (circle une): - —
I. Iluard u(Ileullh 2. Building Department 3. C'ily/town Clerk 4. Electrical Inspector 5. Plumbing lmpeetor
6. ther
Cuolact Person: _ _ _ __. _.. Phone N•
,S CITY OF SALEM
PUBLIC PROPRERTY
Y' DEPARTMENT
I'dit Hit.) ' NIv '•I I
\1 .,.'14 120 IL\I,:,,V sri4 LrT •1.\I 1'%1. -%f-%".\I
Fit:9711•74 ')i9S • 1:.\s:978-740-)y46
Construction Debris Disposal Affidavit
(required lur all demolition and renovation work)
In accordance with tlw sixth edition of the State Building Code, 780 CN1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
NYWYt �-7�WW2Gi�'�
(name ut'hauler)
The debris will be disposed of in :
p,:uneuf�a�lty) '
1 ddress of lacday)
%ignature St lxnn t a licant
date