317 LAFAYETTE ST - BUILDING INSPECTION �4 ` G
The Commonwealth of Massachusetts
Department of Public Safety
�'•� J•.✓ ..\la ssach uset to Sla le Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family:Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector.
SECTION 1:LOCATION (Please indicate Block M and Lot k for locations for which a street address is not available)
_1A FA u It 7o
No.and Street Cit) /Tov%n - Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below =
Existing Building Repair ill Alte: I I aln ❑ Addition ❑�,. Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Il Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering er Review.requrr ? Yes ❑ No
Br' f Descripti of Proposed rk:
i
b y
_ I
• a w �.
fY,
SECTION 3:COMPLETE THIS SECTION IF E STING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
m - ExistingUse Gs
Group(s):
P('):
Proposed Use Group(s): t•
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 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1 13H-2❑ H-3 ❑ H-4❑ H-5❑ }_ ••
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3 ❑ R-4❑
S: Storage S-1 ❑ 5-20 U: Utility❑ Special Use❑and please describe below:
Special Use: .
SECTION 6:CONSTRUCTION TYPE(Check as applicable) •.�
IA 18 13 IIA ❑ 1113 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) "
i Water Supply: Flood Zone Information: _ Sewage Disposal: Trench Permit: Debris Removal:
I'ublia'� Check if outside flo,ai Gme❑ Indica tr nwnia pal ❑ �\ trench will not be 1_irrmrd Di.pusal Site❑
'
required O ur trench ur .pccilc:
I'rnale ❑ ur indcntifc Zone:_ nr,rn "le*).tem ❑
Permit i�encln.ed O _
- Railroad right-of-wav: hazards to Air Navigation: \I:\ Iluhmroinmi��i,.n Rosi,,. I'n" ..
N t \ppliC;r1=la ❑ I.�t n,afure�rithur airport apprnadm.i rea' I. their n•)ict) cnmplcted,
„r C.ut�uri i Buil=t. riff 1,,�caj ❑ - ) _ `1 ❑ ur Nl,❑ l c> ❑ V'n ❑
SECTIONS:CON-I-ENT OF CERTIFICATE OF OCCUPANCY
CIt It i,ar ,'I1 ,Ili c'. LIC l)rou p:.l: . it po ufC o n>lrucl ion: l.Vcupant l,,ad per llou r:
17oc.the Sprinkler Sc dem': jpcaal Shpulatiun.:
O �f/I tG!�6 �.ea
SECTION 9: PROPERTY OWNER AUTHORIZATION
and :\d Ifee's, f -Prr:pe�rtt Owpe �� �Aln /��,yr D1, 7
�IOC/17 f���'�i'I!�/`�l"w7Gl� ��' .h /TU'C.� lox
.Name(Print) No.and Street C T vv, c5 y /\f1 Lip
3rd �R �
Irty Owner('ontact Inturmation �� y,r/?
Ihl)C�PP
Title Telephone No. (business) Telephone No. (cell) e-mail address
If t >>liiablr the m�rrhowner hrrebv,ar�thunzes v,�.�
-Name Street Address City/Tow State Zip
to act on the *no perty owner's behalf, in all matters relative to work authorized by this bu ildin g Lerma t a >>l icol ion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It building is less than 350k)cu. it ut enclosed<pace and/or not under Construction Control then check here O and skip Section III.1)
10.1 Registered Professional Responsible for Construction Control
Nome(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town state Zip' Discipline Expiration Date
r
10.2 General Contractor
COQ5-ruC�7?OP 2�LJ4/C
• C`ICJ� N me ` ` S' LJ� / QI
Name of P rs sp msible for Construction License No. and Type if A plicable
�c i f€� 5�1r s r f�eAR��y �a oz?-G
City/ own State Zip
Tele hone No. (business)
Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c.152.§ 2506))
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 fir No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6) _$
1. Building $ 1 Q�� Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
$ Note: Minimum fee=$ (contact municipality)
d. Mechanical (HVAC)
5. Mechanical (Other) Enclose check payable to
6. Total Cost $ 7 OVQ (contact in
and write check number here
5—q SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By enteririlg my name below. I herebv attest under the pains.ind penalties of perjury that all of the information contained in this
app cation is true an iccS r to o✓the best ut my knowledge and understanding.
I'I c not/mid ago n.tnxC� Tide - Telephone rp o.70 U, to
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Ike"t :Addic', Citi 'Tu%cn . to Zip
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Municipal Inspector to till out this section upon application approval:
N{ atc
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
11 r 0 1.\I I \I, \L
II1 'I'S V; 1i•h 1 \r 9'V '4;,".144.
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Construction Debris Disposal .affidavit
(icyuiied lirr all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Coda, 780 CNIR section 1 1 1.5
Dcbris, 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
I l 1. S 150A.
The debris will be lrunsportcd by:
M Z- l edc 6DIsf35Ac
(name of hauler)
I he debris will be disposed of in
3�0 roetg 51 feAgcio y
(name of facility)
PmaDy e)rA
- tuddress ul Iarllityr
67/
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- ,I�nal nut applicant
o� G
date
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
T
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12. W,NI11\,;I%1.\51.41-1,1 • Sntt N• MA%-%' in it I IS-Zi I`/7'�
I I i. •pt-'15.9395 • I�%x 9711-74C 0.446
Workers' Cumpensation Insurance iffOduxit: Builders/Contractors/Electricians/Plumbers
itppiicant Infnrmalion Please Print,Leeihly
Nillne llhnu,,:%ylh;;an-a tlo,%1dl%-dual Y. T Cl
C ' r 1 Y
k
Cily,Starc%ip � y �A o19(,a Thune rl: 511 ! OO` — L�� w ,'
.%re y.,u an employer:'Check the appropriate box: - 'Type of project(required): •''
4 I am a gcncral contractor and 1 6, new construction
1. �1 am a employer with y ❑ ❑
engiloyccs(full and,'ur part-woe).• have hired the sub-cOntracturs
2-❑ 1 om a sole prnprieux or partner-
listed on the :coached sheet. 7• ER Remodeling _
ship and have no employees These subcontractors have S. ❑ Demolition
%torking for Inc in Any capacity. w rk r ' c mP InaUrun
Ge.
9. E3 Building addition
Kn workers'cum . insurance
5. ❑ We area corporation and its
P
I
required.] 10.C] Electrical regain or additions
I uucJ.] otticers have exercised their I
3 ❑
l ;fill ahn uowner doing All walk
1t. ht of excm hon per
MOIL 1 I.
P
lumbing repairsala or additions
•
myself. [No workers' comwe avep. c. 152. �I(4),and have no 12.0 RWl repairs
insurance required.] r - employees. [No workers'
_ comp. insurance requircel.J 13.0 Other
•�u. .,,1phe+ul Ihut checks box nl mucl:dau fill wn the wain 1,cluw showing thea wurkur'cumpenuwiun puli.y inlinnuliom
' I lumuuwncn whu ,,bma this a171davit indi"una-hey im duina.11 work i,td fhcn him ualudc cwurx,un mus,.uhmil i new i1r.davil indiulma u,ch.
4'•,m rwbm that Jmck this hox into#arlxhtd.m;dd,liunal.hcna.ho.iva 111e melte of th+sub-contractarx and their wurlteo'comp.puhcy mfurmanun
/,ups an employer t/rur is pruvidinlir worAers'c•uarpensadoa insaraffcr far ff#y rfnpfuyees. Below is rite pu/icy and fob sire
iu�unnufiuft .
In>uraucl:Cumpiuy Naini:
policy if or Scif-ins.^L�ic. rt: r/!rV !�(.lC ,7�.yUy' �V / . .. __ Enpiralw ;n Dte:
lob lSice Address: 17 '�V�/9 �� ( '�-_. S� - Clty:Slate,Zlp:
.\Bach it copy of flit workers' compensation policy declaralion pale (showing the policy nmuber and expiration date).
failure to%ccurc coterage as required under Sccliun 25A ul'.MGL c. 152 can lead to the imposition oferiminal penalties of a
ren.• ip to 51.5110100 inJlor one-year inpiisuluncnt• is well is cit it pcnulllcs in the form of a STOP WORK ORDER and a fne
of op to S25400 a Jay.Igailut the violator. He advi.<cd that a copy of this >tatcmcni may be furwarJcd to the Office of
In:�fi•{au n1,ul-'J Ic ofA :br io,ui wcc s-e,ilic.lnon.
/du hereby r crriw under a pain% ,t u6ic•%ujperjnry ibuf the in/urfnW/an provided above/is true and correct.
tl fjfriul rue only. Do nor -,rite in this arru, to br cump/rred by aify ur#own qji#iu/.
City or fawn: _._ _ Per mitil.iecn%e is
1%%uinq .ituilim it% (circle one):
rJ .,f IIc.JIh ?. IludJin� Mp:rr....c 1. Cih.'1'uuu Clerk J. L••Icclricdl Inspector i, Plumbing lu%pcctor
6. Other _
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C.-nueI I'c nun: I'hone d:
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Information and Instructions
N I.us.icliusct s Gcncral Laws chapter 1 i2 tcquires all emplo)ers to provide workers' compensation for their cnnployces.
f'arnu.ult to this ,Utu1 e, an empluree is defined as " ei er) pci.ion in the service of anuiher tinder any contract of hire,
e.pre,s or nnphed. oral or ivrnten."
\n ,vnpfu)t•r is defined as "an Individual, partnership, .issoiclatWn,corporation lir tither legal entity,or ally two or inure
Ir the huceolcg engaged it a joint cnicrpnse, and including the legal representatives of a deceased cmplu)er, or the
reccner or trustee of .w Individual, pwti,cnhip, association or other legal cnnty,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein• or the occupant of the
Jivelling lluuse of another who employs persons to do maintenance•construction or repair work on such dwelling house
0,_ o11 rhe grounds or budding appurtenant thereto shall not because of such employment Ix deemed to be in employer."
.%.1GL chapter 152, i25C(6)also stares 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 cummunwculth for any
applicant who has not produced acceptable evidence of cumpllance with the insurance coverage required."
.\ddiuonaily, MGL chapter 15-1, 4, 215C(7)states"Neither the commonwealth nor any of its political subdivisions shall
I� ,anter into any euntract,for the perfumlance of puhlic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
-Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply iub-contractor(s) name(s), address(es) and phone number(s) along.with their certificatc(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
cmpioyces,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
.xccidenls for confirmation of insurance coverage. Also be sure to sites and date the affidavit. The affidavit should
he icnuned 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. Self-insured companies should enter their
self-insurance license number on the appropriate lino.
City or Town Officials
Plense he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of tile affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'I,:asc be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit liconse applications in any given year,need only submit one affidavit indicating current
policy information lif necessary) and under"Job Site Address"the applicant should write "all locations in Icily 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 is proof that a valid affiduvll is on file for future perrnit% or licenses. A new affidavit must be tilled out each
v ear. Where a Koine owner or citizen is obtaining a license or pernir not related to any business or commercial venture
(I.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
licel,I (avettigations wuuld I," to thank )au in advailcc fur your cuoperalion and should you have sly qucstiuni, d i
Illea,e do not hesitate to give us a call.
the D) paruncnl's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Olflce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
d s-'u-tli www.mass.gov/dia
CT.f ui mgegulatfons a�,an ar s
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Construction Su ervisor License
License CS:- 54019
Restriction: 00
'Expiration: 9/17/2009 Tr# 8588
JOHN J NICOSIA OCT 22ZQQjIt..j,'
8 GRANT ST
PEABODY, MA 01960
pdate Address and return card. Mark reason for change
Address - Renewal Lost Card
]PS-CAI 0SOM-0]/0]-PC8490 4
Board of Building Regulat ons and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 108487 _ -
_ - Type; Individual
Expiration: 8/19/2008
J. NICOSIA CONSTRUCTION
JOHN NICOSIA
8 Grant Street ---- — – --- ---- - - ._... .
PEABODY, MA 01960
AF Update Address and return card. Mark reason for change.
Address -i Renewal Employment Lost Card
OPS-CAI C, 50M-05/06-PC8490 --
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Board of Buddhng Rego, ons s d Stands
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License CS ,54019
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