117 LAFAYETTE ST - BUILDING INSPECTION The`C6M`M' onW'e'a' 1th'o' i MSgsach-
Department of Public Safety
%lassachusetts State Building Code(780 CMR)Seventh Edition
n
City of Salem,
Building Permit Application for any Building other than a I-or 2-Family Dwelling
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: - I Building Inspect
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which A street addr0s ie%t available)
117 Z*64ye-Tre- �r- 6�lm Aw
A
No.and Street City /Town Zip Code Name of B1.111c[ing(if applicable)
SECTION 2: PROPOSED WORK
If New CL)nstr cf10m&eck'4ra' 0,or checkall that',il5ply in thetwb^rows below
'u
Existing Building 0 RepairO I Alteratign 0 molitiori P (please fill out and submit Appendix 1),
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No AL
Is an Independent Structural Engineering Peer Review required? Yes 0 No III
Brief Description of Proposed Work:
PEm VVF- e4441-iAJ10JbCWS Akfls 1i0J574LL- AzAj?y 6052�45�-T
44<-r-- al all �=
- e7w-&
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION, OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) 0
Existing Use Group(s): Proposed Use Group(s):
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2r 0 A-2nc 0 A-3 0 A-4 0 A-5 0 1 B: Business 0 E: Educational 0
F; Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
1: Institutional 1-1.0 1-2 0 1-3 11 1-4 0 M-. Mercantile 0 TR.- Residential R-10 R-2 0 R-3 0 R-4 0
S; Storage S-1 0 S-20 U: utility a Special Use 0 and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
JA 0 IB 0 IIA 0 IIB El I IIIA 0 IIIB 0 1 IV [3 FVA 0 VB 0
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage D Debris Removal:
Disposal: Trench Permit; Ft
O's
L s
isp
_beL Licensed
it, Ci
0 1 , El h ni, alo A trench will not be n dDi,,posal Site 13
Public 0 Check ifoutside Flood Zone 0 Indicate micip
i � if b required 0 or trench 'pec,IV:
Private te 0 )r indentifv Zone: or on site ss stem
permit is enclosed EJ
Railroad right-of-way: Hazards to Air Navigation: NIA i Ji,t,,n, ........ [Ir... Is:
�'j , I c "t",c
\,,t -\pp1ic,i1b1v 0 I\ Is then ie%ie%\ completed?
"'t to, B I le I "10 Ye
m Imsent to Build enclosed 0 Yes 0 or No)0 Yes 0 \,I) 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
171fithIn of ('OdC:- Use GIOUP(S): - Tc peof ConstrUCtion:- Occup ant Load per Floor:
Does the building containan Sprinkler Sc stem?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
CA2rM'S CCr4Mv; Tr9s /so wood Ab DA4f4T,erEO /214 oL/07
Name(Print) No.and Street City/Town Zip
1' �,Owner Contact Information:
`Tom NEE - IA &La 6&A441 Wi0.41
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to act on the property ow'ner's behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(,Please fill out Appendix 2)
(If building is less than 35,000 cu. ft.of enclosed s pace and/or not under Construction Control then check here❑and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
uss�-_}tea (PITSSAa Iof dl.l ayao l l 37 R"Cp l
Name(Re�istrant �'ele�hone—No. e-mail address Registration Number
30 +� � <�'� ma 02uz7 I-M-7.L/I
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
A/P�✓ ,y/� �/ �✓tr�e r - sus ✓V'
/./,� /� ,
Compa
big-Nny 440 7tgCX/.c c- log {wag-
Name
ame of Person Responsible for Construct' n License No. and Type if Applicable '
�
.'a. N
Street Address City/Town State Zip
Telephone No. (business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes IN No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contac mu icipali
5. Mechanical (Other) $ Enclose check payable to r
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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.
Srt��seR �03L4
o z ��
Plei�e kkr int ane ,ign name Tide Telephone No. Date
Stlee Lf Cita/Town State Zip
unicip �nspe c o f' ut this section upon application approval: � '�✓"'"'
l Name Date
V"� e�
B I mg egula onsan an ar s
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Registration: 137861
Type: Private Corporation
Expiration: 1/13/2011 TAF 278814
NEW ENGLAND WINDOW SYSTEMS, INC..
RUSSELL HADAYA -
30 H. STREET
BOSTON, MA 02127
- Update Address and return card.Mark reason for change.
CAI SOM-0]i0]-PC8490
Address Ej Renewal Employment Lost Card
is i -- - .
I
CITY OF SALEM
;j PUBLIC PROPRERTY
DEPARTMENT
1:.;II r0 \\II \I, \I\..\i I • .I'I
I 1 1 'J'S '4; 'lia: 11 \\ 'i-,V '4_ 'Ii4,.
Cotistruction Debris Disposal Affidavit
(reyuiicd l'or all demolition and renovation work)
In accordance wk ith the sixth edition of the State Building Code, 780 C'NlR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit K 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
I 11. S 150A.
The debris wvilI be transported by:
(name uthaaler)
The debris will be disposed of in
(name W Iacdily)
laddress ur facility)
.I�nalmc I Ile 1 .yIlcanl
�, •— 2-Z --O�
dale
CITY OF S.1LEM, ,1LvLxSS.ICHL'SETTS
BUILDING DEPARTMENT
1220 WASHINGTON STREET, 3wa FLOOR
TEL (9711) 745-9595
FAX(9711) 7440846
1CINfBEtIEY DRISCOLL
,MAYOR TrIOD(AS ST.PMRRtlt
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\MaSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information •l_ Please Print Legibly
Nattle (Busimx Orp nizatiory Individual):A� F- M,126"�:&*r� -7 G
Address: --30 # t-57?n5E7—
City/State/Zip: -507STOW A OZW Phone H:
Are you an employer?Check the appropriate box: Type of project(required):
1.Q 1 am a employer with 4. Q I am a general contractor and I
employees(full and/or part-time).• have hired the sub-contractors6. C]New construction
2.Q 1 am a sole proprietor or partner- listed on the attached sheet : 7. Q Remodeling
,hip and have no employees These subcontractors have S. Q Demolition
working for me in any capacity. workers'comp.insurance. 9, Q Building addition
[No workers'comp. insurance S. Q We are a corporation and its 10 Q Electrical repairs or additions
officers have exercised their
3.Q 1 am a homeowner doing all work right of exemption per MGL 1 I.Q Plumbing repairs or additions
myself. (No workers'comp. C. 152,§I(4),and we have no 12.Q Roof repairs
insurance required.]r employees. INo workers' 13.0 Other.
COMP. insurance required.)
•Any applicara that checks box at mum also fill out the section below slowing their worktn'compensation policy informasion.
'I h meowrwn who submit this affidavit indicting they are doing all work and then hue outside eanown.must suhtnit a now,affidavit indicting such.
4%,mra.•taa that cheek this box mint anached an ctrl nunal sheer showing the home of Itre suAtontrocbn and their workers•mmp.put icy mrooruoom,
I ane an employer that Isproviding workers'compensadon lnsatrasice for my employers, Below Is the pulley and fob site
informmion. //
Insurance Company Name: !,l L ,ke1 6C�LGfW —t.A.t-� �WV P
Policy M or Self-ins. Lia #:1A)",44-31
A)",4 S-3/x,16-3c),07 _ Expiration Date:
Job Site 9"i4 f�Tr�Address: �j7 (t4T City/StatWZip: 6k-A-9,A 61 /`7J
Attack 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 5250.00 d day against the violator. He advised that a copy of this statement may be forwarded to the Office of
Invcsngatiuns ol'tha DIA for insurance coverage verification.
I do hereby cerci e e pains and para s of pe,Jary that rhe infbrmadon provided above is true and rurrem
SL t Ire Date: 6'20-0`/
Phone d: to! — ZZI 63f 7
OJfcial use anly. Donor write in this area, to be cunrpleted by city or town offrciaL
City or ruwn: __. __ Pcrmit/Llccme p
Issuing Authority (circle une)t -- -�- ---I. Board of Health 2. Building Department 3.City/town Clerk J. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _. .. . . -- --- Phone a:
11-25-2008 12:55PM FRWINIGHT RUDD AND C +6175426734 T-782 P.002/002 F-337
acom CERTIFICATE OF' LIABILITY INSURANCE op NLW DM °°SIN
NEID I)m 11125/OS
PRODUCER ! THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
George Peters Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Nanci Peters HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
170 Milk Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Boston MA 02109
Phone: 617-542-4448 Fax:617-542-8501 INSURERS AFFORDING COVERAGE NAIC0
INSURED i INSURERA safety Inaurance C
New M
NSUNER a. Liber Mutual Ins Group
l� Had Wi;adow Systems :CriC
RlfaSel�- Haaaya INSURER C: N°amae.Fa xn°°c�nw DarPnny
30-32 H Strebt DIBURER D.
South Boston MA 02127
INSURER E'
COVERAGES
THE POLICIES OFINSURANCE USTEDBELOW HAVE BEEN ISSUED TC,THE INSURED NAMEDABOW FOR THE POLICY PERIOD INDICATED.NOTWITHSTANOING
ANY REQUIREMENT.TERM OR WNOI110N OF ANY CONTRACTOR OI HER DOCUMENT MH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
NAY PERTAIN.THE INSURANCEAFFORDED BY THE POLICIES DFSCF•.BED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BF PAIOCLAIMS.
RISK
LTR NS TYPE OF INSURANCE POUC(NUMBER ORTE MUCY
UTE MMIO ULTfT$
OENERALLNBIUTY EPLYI OCCURRENCE $1000000
C X CDMMERT7AL CENER°v.�MaLrrY HGIS2394308 02/01/08 02/01/09 PREMISES EF tsarerwa $100000
CINMSMADE i]❑OCCUR MED EXP HY11'°ne magm $1000
PERSONALAADVINJURY $1000000
GENERALACGREGATE $3000000
GENL AGGREGATELIMITAPPLIES PER: PRODUCTS-COMPIOPAGG $3000000
POLICY JECT Ux
AUTOMOIIRE LIABILITY COMBINED SINGLE UMIT $1000000
A ANYAUTO 0163898 04/20/08 04/20/09 (EB°sw°PI)
ALL OWNED AUTOS I BODILY INJURY
X SCHE13ULEDAUTOS (Por FSA) b
X MIRED ALTOS EDGILY INJURY
X NONLOMEO AUTOS $
PROS DAMAGE
( 1
GARAGE UABLNY AUTO ONLY-EA ACCIDENT S
ANYANO O11wiR THAN EA ACC 1
AUTO ONLY. FGG S
EXGESSNMBREUA LIABILITY EACH OCCURRENCE 55000000
OCCUR F7 CLAIM SMADE HOP5388d308 02/01/08 02/01/09 AGGREGATE $5000000
s
DEDUCTIBLE $
X RETENTION :10000 a
YYOANFAS COMPENSATNNI AND XTORY UMIT6 ER
B FOUR'LIAR WC231S3:1.72630407 11/03/08 11/03/09 EL EACHACCIDENT S500000
OFFIC EM EXCLUDED? E.L.DISEASE-FA EMPLOYE 1500000
Ryr"mAR"NS°°` I ELDSFJISE-POUCYUMIT 5500000
SPECNL PROM W., DFIIAv
OTHER
errpPTNw os nPEPnnoN51 LOCAT10161 VEHIO{.ES J EXCLUSIONS ADDED BY ENDORSEMENT IS PFtl)IIISNkJS
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELUEO BEFORE THE E URIRATION
DATETMEREOF,THE ISSURIB INSURER VFILL ENDEAVOR TO MAL 30 UYSVIMITMN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL
IMPOSE NO OBLIGATION OR UABILITY OFANY MIND UPON THE MUREA ITS AGENTS OR
REPRTXENTATNES,
AITINONTEO REPRESENTATIVE
Nauci Peters
ACORD 26(2001108) OACORD CORPORATION 1988
I