90 LAFAYETTE STREET - BUILDING INSPECTION (2) CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
1 ERLEY DRISCOLL
MAYOR 120 WASHINGTON STREET♦SALEM,MASSACHU=S 01970
TEL:978-745-9595♦FAX978-740-9846
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APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT:Applicants must trim tete all items on this page
SITE INFORMATION
Location Name 6W-AlS IYWWi Building,
rogerty
Address
! O 1,AfQA_,Tre
Located in: CoAsery ation Area Y/N /� nHisistoric district
APPLICATION DATE —I ' G CJ o I
Use Groups
(check one)
Group Homes R3_R4_
Residential(3 or more Units) R2_
Type of improvement - Residential(hotel/motel) RI_
(check one) Assembly(Theaters) Al_
New Building_ Assembly(restaurants&clubs) A2r_A2nc_
Addition Assembly(churches) At_
AlterationBusiness B_
Repair/Replacement Educational E_
Demolition_ Factory(moderate hazard) F1_
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional(residential care) I1_
Institutional(incapacitated) I2_
Institutional(restrained) I3_ ,
Mercantile M_
Storage SI_Moderate Hazard
Storage S2_Low Hazard
OWNERSHIP INFORMATION(Please type or Print Clearly)
OWNER Nam eRGfr 00 GFj G6/D ,7C6
Address RtlG LLL /7 j n �d/Y</ii%¢< \I�
Telephone
Signature N
DESCRIPTION OF WORK TO BE PERFORMED
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ESTIMATED CONSTRUCTION COST D 06 .00
P6 PDX 36
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
K HXLEYDRISCOLL
MAYOR
12O WASHINGTON STREET*SALEM,MASSACHUSETTS 01970
TEL:978-745-9595♦FAX:978-740-9846
CONTRACTOR INFORMATION
Name tAKApHS GLL rfdfhy MATODP
Address � �I�-r�f Al wffia ,y A - oZ
Telephone 719/,Y �tij}$
Construction Supervisor's Lic# C-S
Home Improvement Contractor# /_3/ ` 6
ARCHITECT/ENGINEER INFORMA ION
Name 6A p ry(je
Address ✓ /l,p 7y�
Telephone
Mass. Reaistration # gm 8
PERMIT FEE CALCULATION
Estimated Cost x $11/$1,000+$5.00= �
COMMENTS
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the penalties of perjury
(owner) (agent)
APPROVED BY:
DATE APPROVED: �U .Q
F111/11712/2H08 07:31 15086561499 PAGE 01/01
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ARCHITECTURE
PRELIMINAR ECLARATION FOR PROJECTS SUBJECT TO CONSTRUCTION CONTROL
(780)CM dition Section 116.0)
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Name of Project Aleris Dental Center Inc. -Dr. Borris DDS
Location of Project 90 Lafayette, Street—Salem, MA
Pursuant to 780 CMR 6h Edition Section 116.0 REGISTERED ARCHITECTURAL AND PROFESSIONAL
ENGINEERING SERVICES—CONSTRUCTION CONTROL, I state the following relative to the above
mentioned project:
1. I am duly licensed under the applicable laws of the State of Massachusetts as a professional Architect/
Engineer, licensed as specializing as an Architect
2. The plans and specifications for the above project have been prepared by me, by employees of my office
under my supervision,or by registered professional consultants engaged by my office.To the extent that
such plans and specifications are not complete as of the date hereof,they will be completed in accordance
with the forgoing sentence.
3. 1 will carry out or supervise the review of all the drawings and other contractor's submittals,for compliance
with the design concept.
4. 1 will carry out or supervise any special professional inspection of critical construction components required
by code or normal standards of good professional practice.
5. Plans and specifications prepared by me or under my supervision conform to all applicable codes of the
Commonwealth of Massachusetts, and all materials specified therein or selected by me in accordance
therewith are,or will be, in accordance with said Massachusetts codes. .
6. 1 will make regular and periodic site visits to determine generally that the construction work is proceeding in
accordance with the plans and specifications and submit monthly reports to the Salem Building Department
relative to said visits and inspections with regard to materials, progress,testing as may be required, and
change orders with accompanying approvals and or corrections ordered by me.
7. 1 will submit as a part of my monthly report any approvals or rejections of field alterations to shop built
components, including but not limited to any flame cutting of steel components.
8. At the completion of construction, before the project is permitted to be occupied, I will submit a report as to
the satisfactory completion and readiness of the project for occupancy. I will list any outstanding items which
do not endanger said occupancy but remain to be completed as part of the approved plans.All requirements
of the Architectural Access Board will be met prior to an Occupancy Permit being issued. I will list all pertinent
eviations from the approved plans, multi unit sites sha -tie complete with respect to site access for the entire
roject d proportional site accommodations, pa ' and landscaping for each unit to be occupied.
I, a and rsign have read the above and will pr a the services as outlined. I further underst t these items
ar mi I um uirement and any other requ i ents under Law are not waived or modifi
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A ril27 2009 AM.
Origin seal an signature Date ''' `
James ilmour
JGAA itecture ?HOFs
360 Woodland Street Holliston, MA 01746
t. 508.429.9667 f. 508.429.9657 email. jgainc@verizon.net