233 LAFAYETTE STREET - AFFIDAVIT Final Construction Control Document
To be submitted at completion of construction by a
Registered Design Professional
for work per the 9th edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title233 Lafayette Street Renovation Date:July 13,2021 Permit No.
Property Address 233 Lafayette Street,Salem,MA 01970
Project: Check(x)one or both as applicable: x New construction x Existing Construction
Project description:Renovation of a 26-unit building after a fire.
I Derek Rubinoff MA Registration Number:20071 Expiration date: 8/31/2021 ,am a registered design professional,
and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning:
X Architectural Structural Mechanical
Fire Protection Electrical Other:Describe
for the above named project. I,or my designee,have performed the necessary professional services and was present at the
construction site on a regular and periodic basis.To the best of my knowledge,information,and belief the work
proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building
permit and that I or my designee:
1. Have reviewed,for conformance to this code and the design concept, shop drawings,samples and other submittals
by the contractor in accordance with the requirements of the construction documents.
2. Have performed the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine if the work was performed in a manner consistent with the
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
Enter in the space to the right a"wet"or `�N D A/?,
electronic signature and seal: ��� �A. RUB�y
c� o No.20071 in
WEST ROXBURY,
o MA
q� OF tUA
Phone number:(617)504-2599 Email: dubinoff@derekrubinoff.com
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013