258 LAFAYETTE ST - BUILDING INSPECTION }
CP
The Commonwealth of Massa L;tAL SERVICES
r— L (firs
p `�` ;ip Department of Public Safety
\§y( r Massachusetts State Building Code(780 . )
-"-�` Building Permit Application for any Building other than a(S on2-liamp Ekv()2hg
(This Section For Official Oise Only).,
Building PermitN umber: Date Applied: Budding Official
SECTIO 1:LOCATION (Please indicate Block a`and Lot 4 for locations for which a streetaddress is not available)
0 M`lYe�Wla(Aof
No.and Stre t City/Town Zip Code Name otnuilding(ifapplicable)
SECTION 2::PROPOSED WORK
Edition ofMA State Code used If New Construction check here❑ or check all that apply in the two rows below
16� Existing Building ❑ Repair Alteration 0 Addition❑ Demolition ❑ (Please 511 out and submit Appendix 1)
Change of Use ❑ Change ofOocupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part ofthis permit application? Yes ❑ No ❑
Is an Independent Structural Eng ineering,�eer Review required? _ Yes ❑ No ❑
Brief Description of Prpp�ppsed Work: c•'� r QAd
i v-1. W 1!h '1104. 7 0a . 1t L1 .
rj Gi14d. ilail (14ta C1
SECTION 3:COMPLETE THIS SECTION IF E)aSTING BUILDING UNDERGOING RENO VAT ION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Buin Investigation and Evaluation is enclosed(See 780 CMR 34) D
Existing Use Group(.): Proposed Use Group(s):
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.)
SECTIONS:USE GROUP(Check as applicable) -
A: Assembly A-10 A-2D Nightclub D A-3 D A4D A-513 B: Business D E: Educational ❑
F: Factory F-1 D F2 D H: High Hazard H-1 D H-2 D H-3 U H-4 D H-5 D
L Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3 If R4 Cl
S: Storage S-1 ❑ S-2❑ I U: Utility❑ Special Use❑ and please describe below:
Special Use:
SECTION.6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA D IIB ❑ INA. D IIIB D IV VA 0 VB ❑
SECTION 7:SITE INFORMATION(refer to 780CMR 111.0 for details on each item)
Water Supply Flood Zone Information Sewage Disposal:
Trench Permit: Debris Removal:
Public A trench will not be Licensed Disp alor Site p
Check if outside Flood Zone❑ Indicate municipal tit i��d
required trench or specify`x
Private❑ or indentify Zone: or on site system ❑ permit is enclosed ❑ \'(�ytS'Tc ['
Railroad right-of-way/ Hazardsto Air Navigation: MA Historic Commission Review Process:
Not Applicable W Is Structure within airport approach are Is their review comple ?
or Consent to Build enclosed ❑ Yes D orNo--Q� Yes❑ 1
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Typeof Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?:Spectal Stipulations:
t
SECTION 9: PROPERTY OWNER AUTHORIZATION
am and Ad res ofpro arty Owne
Name Print) L No.and qtreeti City/Town Zip
Property Owner Contact Infoy�ahon:
�vr ✓t� 76) _6 1- 3eerMaNGc¢m%Pd
Title Telephone No.(busine s) Telephone No. (cell) -mail add r sn.
I licablp,the roperty owner hereby auth izes �j t
Name Street Address City/Town State Zip
to act on the property owner's behalf;in all matters relative to work authorized by this building permit application.
SECTION IO:CON STRUCTION CON TROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.R.of enclosed space and/or not under Construction Control then check here D and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Coontracto
(.k..t4t
Com ny Name
6�51_ - CC? 42G26 0P,
Name of Pe on Responsibl nstr ction ' Li'ce-nse No. and Type if Applicable
1 ILCV '.+ll�iff� .IP'lY t
6194 —
�
Street Address City/To State Zip
Telephone No.(business) Telephone No.(cell) l address
SECTION 11:WORKERS,'COnIPENSATION 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 ofthe issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes Q No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
a d Materials) Total Construction Cost(from Item 6)=$
L Building S Building Permit Fee=Total Construction Costx (Insert here
2.Electrical S appropriatemunicipal factor)=$
3.Plumbing $
4.Mechanical IN VAC) $ Note:Minimum fee-$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (9tP (contact municipality)and write check number here
SEC ON 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,Iher b attest on r the pains and penalties of perjury that all of the information contained in this
ap kation is t ue and accurate t th be o kn and understanding. (;-;,/2'?!(
� (o�l
Please print sign nam .A �`_r ,,/ Title `A A Telephone N Date
Street Address City/Town State Zip
Municipal Inspectorto fill out this section upon application approval: "LGz-v f a
Name Ll Date.
,< CITY OF SMX.N4 .NL L1sSACHL'SETTS
BI;UMNG DEPARTNWUNT
�y/
• ' A• 130 WASHINGTON STREET,Sao FLOOR
TEL (978)745-9595
SAI{(978) 740-9846
Kl!jBEgy.EY DRISCOLL
T
MAYOR tto;<tAs S7.Pt>rRRE
DIRECTOR OF PUBLIC PROPERTY/BCB:DCvG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4 t licant Information Please Print Legibly
Naine(Busuic organizationilndividual);
Address: ``rr �i� 1 �
CitylState/Zip: r 1l .li- Ael6a t'MI 01, 4Y
Are
you tm employer'Cheek appropriate boa: Type of project(required)-
i.hJ 1 am a employer with 4. [1 1 am a general contractor and 1
employees(full and/or -time).• have hired the sub-contractors 6. ❑No onstruc[ion
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 1. emodeiing
ship and have no employees These sub-contactors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑Building addition
INo workers'comp. insurance 5. ElWe am a corporation and its
required.) officers have exercised their
10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L[]Plumbing repairs or additions
myself.INo workers'comp. C. 152,¢1(4),and we have no 12.❑Roof repairs
insurance required.]t erriployeus. [No workers' 13.❑Other
comp.insurance required.]
'My appli am that dials boa 91 mast also fill out the seal®below showing their warless'compensation policy inromtation.
'I rumcnwretc who sahmit this afildavit indicating they arc doing 21F work and thin hire oulsidocmnractms mum mhmit a row afF,davit indicating such.
:Cont maoo that cheek This bort must attached an amitiooal sheet slowing the name of he sub-wntractors and their woden•comp,policy inf xmatimo
I am an emplayer that is providing workers'compensation hisurancejor my employees Below is
_
rh
inrncn e poDcy andfb star
Insurance Company Name,. 01
Policy 9 or Self-ins.Lic,0: (!2 j5 Expiration Date�� (L���� q''7 '
Job Site Addrtss: (i� CitylState/Zip:'$9 L '11--9 ,0, 1 C a
Attacb a copy of the workers'co pens tion poBry declaration page(showing the policy number and expiradon date).
Failure to secure coverage as required under Section 25A of MGL a 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 penaltiesin the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. 13e advised that copy of this statement may beforwarded to the Office of
Investiganom of them
he for insurance coverage verification.
I do hereby real mrd r pa'n au allies ojperjury Char the irrjormadar provided above is true and correea
Si gn;t hre• Date: 21'I C57
P one d: _....
Ofr7riai use only. Do nor write in this area,to be cattapieted by city or town og-tciai
City or Town: Permit/l.Icense k
Issuing Authority(circle one):
1.hoard of health 2.Building Department 3.Cilyffown Clerk 4.Electrical Inspector S.
Plumbing laspector
6.Other
Contact Person• Phone#:
Lesley
Management
December 21, 2015
Re: Greystone Manor Condominium Trust
256-260 Lafayette Street/]3 Linden Street
Salem, MA 01970
To Whom it May Concern,
Please allow this letter to confirm that the Greystone Manor Condominium Trust has
hired Paul Haggett& Co.to revitalize the rear deck and stairs at 258 Lafayette Street,
Unit #4, Salem, Massachusetts.
Sincerely,
KGvn.I 1)1 Lard,
Kimberly Lord
Property Manager
P.O. Box 946 Marblehead, Massachusetts 01945
Telephone (781)639-0534 Facsimile (978)374-4852
Lesleymanagement@comcast.net