99 LAWRENCE ST - BUILDING INSPECTION / The Commonwealth of Massachusetts
Huard of Building Regulations and Slautdards CI'IN OF
st Massachusetts State Building Code. 780 CNIR SALGM
Building Permit Application To Construct, Repair, Renovate Or Demolish a
(Are-or Tno-Fumilr Du adliag
This Section For 013icial Use 0n1
Building Permit Number: Date Applied:
i
DuilJing Oliiciul(Print Nu •; ) ZZ l7-
Sigt �� Date
SECTION I:SITE INFORMATION
1.1 Property Address,92 / 1.2 Assessors flap& Purce Numbers
7 7_La/�cJ(7�l�� _
I.la Is this an acre led street?yes ✓ no \Imp Number Purcc1 Number
1.3 Zoning Information: 1.4 Property Dimensions:
Tuning District Proposed tJse Lot Area Isy 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§Sy) 1.7 Flood Zone Informatlon: 1.8 Sewa a Disposal System:
Public Private❑ Zane: _ Outside Flood Zone?
Check it' cs❑ Municipal On site disposul s)siem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
N;unc(Print)N9nA P_ - I rH rbe I �•q �j) �Jllcl�,ly�j-'n�/ iYJff
Print) �'T-' ('iq•,Stmr,l.IP
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units-_a,_ Other ❑ Spccity:
Brief Description of Proposed Work': ^Kt fiCM{n/ 9-
4eNP�a
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
ILabor and\latrriais) Official Use Only
1, Building S f)SK 1. Building Permit Fee: f Indicate how fee is determined:
'_. Electrical S ❑Standard City'Tosvn Application Fee
❑Total Project Cost'(Item 6).x multiplier x 7 I'lumhing S 2. p -
_. Other Fees: S
4-Mechanical ill\',W) S List:
S Vechanicul IFirc —
Su++ression) S Totul .mi Fccs: -
('heck No. ('heck Amount: C,ish \mount:
I,. Total Project Cust: S 9 j, '90 a ❑p;:id in Full ❑0tnstanding 13ah ce Due:
MILD DL✓r47t-U, 4 cl:�
SECTION S: CONS'FRItcrION SFRVIC'FS
5.1 Construction Supcn isor License(CSL) LDY668_-'
I icoisrc-Number I v) ration Dme
N;unc of l'SI. IolJer
a/ � I ist l'SI. I)pe he¢
---.------ I)pe Description
No. and Street
ke,tricte(cd(Ilui Win�s a l0 15,0110 cu. It.)
It ItedriaeJ I8Ianti) Dwellin
Cib(('owr.State.%IP M \lason
RC Itmilln C'ovcrin
K'S Windaw;md Siding
/ SF Solid Fuel 13urning Appliances
978 ��- � I Insulation
Tcic hone Ifntail:iddreS.' D Denurlilion
5.2 Registered Home Improvement Contractor(HIC) 17G {
IIIC Rcgistnaion Nronhcr vpt uuun Uulc
I(t4' ,I in) Nam•or I IIC I?istram ante
-cc )f �t r� 5 " SylSrvlo�� 1Y��
W.
N tdd /'�1Z'J limuil address
r R�7 �9x
City/Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. I52. 1 2SC(6))
Workers Compensation Insurance affldavit must be completed and submitted with this application. Failure to provide
this atiidavit 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
I,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.
Print owner's Naaue(ElecWnlc Signature) Dale
SECTION 7b:OWNERI 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 Owncr's or:\Whorircd Agen1's Name I lilcclnnlic Sign;aurc) Data
NOTES:
I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Pragrami.will 1 have access to the arbitration
program or guaranty fund under\I.G.L.c. hq'A. Other important information on the HIC Program can be Ilnrnd at
woa man, AA Information on the Construction Supervisor License can be found at ni.n+ dil,
2. \Then substantial swrk is planned,provide the information below:
rota) flour area I sy. R.) . ____.._I including garage, finished basement attics,decks or porch)
Gross livingarealsq. that __ Habilabhe room count
\(1n1110OfIircplaces _. . . .- - \'umberol'bedroonls
iNumherafhathrooms . . \umberof'halfh:uhs
1)lie of heating Sy deal Number of decks, porches
i
11pe, IcoulingSysleln I`nclascd Open
1, 11u.d Troia Square Fwtago ma) he suhSlilutcd firr"rolal Project Cost"
.i
crry OF siuEm. AkSSACHL'SETTS
BUILDING DEP.4RTNl&\T
120 TASHLIIGTON STREET, 3o'FLOOR
TEL (978) 745-9595
Ect(978) 7.W846
vj.%f3FR! FY DB.ISCOLL
�L�YO.i 7Ho%w ST.PIEARH
DIRECTOR OF PUBLIC PROPERTY/BUMD(NG CO.NNISSIONER
Workers' Cmnpensation insurance Affidavit: Guilders/Contractorv/Electricians/Piumbers
knolicant information M Please Print Legibly
Nainc (Iloiitx2r(Jrgtninlinn:Indiv\i^du;J)�: S-P2,a� �' 1 s t an z L
Address:_ _V ;�y�y�` C44 l'- 5�
City/Statc/L.: ZhRUe(�S O GL- Phone N 9 Z8 �S7` �;aSQ
Are you an employer?Cheek the appropriate qo I 'type of project(required):
1.❑ I am a employer with 4. W I;can a general contractor and 1 5. ❑ w construction
employees(full and/or part-time).* have hired the sub-contrac(on
2.❑ I am a sole proprietor or partner- listed on the attachcd.nccct, : 7• Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'camp, insurance. 0. Building addition
(No workers',comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their ME] Electrical repairs or additions
).❑ 1 am a homeuwnur doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.(No workers'comp, c. 152, §1(4),and we have no 12.Q Roof it-pairs
insurance required.) t employees. [No workers' IS,�Other
Gump. insurance required.]
;Any applicant n chucks w but,I must aim rill out the u.,Iiw below showing chair work,n'cumpensarten polity,neumaeon.
'I hvnuuwn'se who wilmil this a111davil indicating they am doing all wart and then him",side contra',,,rasa,suhtnll a new allidavil indiming ruck
:6,ntm oon,ihal,heck this box must aaach'd can additional shrel showing the rattle of the rub.unlmtom and Iheir workers'wrap,policy inl,matloo.
loin can eurpluyer shut ii pros/ding rvorkers'cumprusodun insurance for my unp/uyeex Below is tlu pulley and job site
insurance Company Name: 0 rn ` 0_QO V �` , I ll.�e C.
^l Q
Polity 4 car Self-ins. Lic. H: 000_ IODr� _ — Expiration Date: I Or �✓
29 �a ufrqKuce s4-
-- JubSiteAddress: CirylState/Zip:
Attach a copy u(the workers'compor tlon pulley deciaralton page(showing the policy number and explrarlon data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine op to 51,500.00 und/ur one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and',tine
of tip to S250.00 a day against the violator. [It advised that a copy of this statement may bu turwurded to the Oflice of
Inarstigmiuns oldie DIA for Insurance coverage vcrWcaticn.
!du'lrrrrby renijy r der the ulns mrJ nut!es ury,that the infurnrodon provided�abuuv,i.r true and carrece
I'Fo ,t• s�—bag"JCX l
iO//iciul rise uuly. na our write in this area, ru be cotirplefed by city or town njjiciaL
jl City or Town:
PcrmittlAcense d
Issuing Awhorily (circle one):
1. hoard of llralth '. lluildimg Deparhnenl I.Cilyi ruivn Clerk 4. F.leetrlod Inspector 5. Plum7111.1pector
6.Oilier
l Cunlu<11'cnno _._ __... -- Phone rl:
i_ __ —
i
r . y
Information and Instructions
\lassachuscus 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 apartments 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, g25C(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(7)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-contractors)nume(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)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. Aiso be sure to sign and data 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. Sclf-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
or the affidavit for you to rill out in the event the Office of investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that most submit multiple permittlicense 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 permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e, a dog license or permit to bum leaves eteJ said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
l'he Department's address, telephone and fiax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Iavestigadons
600 Washington Street
Boston, MA 021 I l
Tel. 4 617-727-4900 ext 406 or 1-877-NIASSAFE
;deci;cd 5-26-05 Fax 9 617-727-7749
www.mass.gov/dia
1Q.
CITY OF SALENf, `tiLISS:kCHC'SETTS
9L DLYG OEP.1ATtL\T
1_0 W.UHLVGTON STAE$T, Jw F,OOR
rEL (973) 743.959!
K1ICBERLfiY DRLSCOLL FVc(973) 744.9&m
.tifAYOlt THO&W ST.PMMA
DfAECTOA OP PLBLiC PROPIATY/8CQ•OL%jG C0.%0jjssj0.%Eft
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.
Debris, and the provisions of MCL c 40, S 54; 3
Building Permit At isissued with the condition that the debris resulting from
this work snail be disposed of in a
111, S I SOA. properly licensed waste disposal racility as defined by VIOL c
The debris will be transported by:
The debris will berdisposed Orin :
name of favably) �—
t�ddn„ or rjcu jy)
41,
e of permit �pplican/���
171� �a
Office,7f1t%jfqpXM41,3
— HOMEIMPROVEM� EENTCONTRACTOR _ {Registration: 170886
z Expiration 1/6/2014 Type:
Individual
� --P EN P.MANZI
STEPHEN MANZ
-36 PURCHASE ST
DANVERS,MA 01923
Undersecretary
Bria111 rN Dye:gtm�nt o Puhl
444���111 gulldm"Rcluf,lh S Ititr
Construction Supervlsorls Ind 4t Inrl a tlr.
License:: CS License
g 04669 : : ,:•>;
STEPHEN MAN'
36 Zj
PURCHASE ST ayy
DANVERS, MA 01923 : !
(...on....ioo„� .
Expiration: 7/2@014,
.- Tr#: 104668.