45 LAFAYETTE ST - BUILDING INSPECTION (2) 12S it � 5 ..
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The Commonwealth of Massac CONAL SERVICES
DWlding
Department of Public Safety
Massachusetts State Building Code(780 CMIN Permit Application for any Building other than a One-or1 rl 'all
(This Section For Official Use Only)
r— Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
' n No.and Street City/Town Zip Code Name of Building(if applicable)
U ' SECTION 2:PROPOSED WORK '
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building 0" Repair❑ Aiterationd I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes JY No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No,8'
Brief Description of Pro osed Work: —6 "I o —s v
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR -
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): 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.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A'5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ IL Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I11❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IITB ❑ 1 IV ❑ I VA ❑ VB ❑
SECTION.7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
- Public)2r Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
ate, CP�L-(� 1-1 (z
SECTION 9: PROPERTY OWNER AUTHORIZATION -�
Name and Addre�/ss of I-'reger xer LP_ S S ee—l
Ar Ert Z6, 0 `E Ib 13q5;5?oQtd L Ne W eSSfOA
Name(Print) No.and Street 1 City/Town Zip
Property Owner Contact Information:�1's4mn SVVI'+k fVr /ZCG .
RrG . l_ LG 61 G_ � 1 181118 00_� l'�c1nr' cG-LLG.cn
Title I Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
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 10:.CONSTRUCTION CONTROL(Please fill out Appendix 2)
(ff building ie less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O 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 Contractor �mnsf/'uo1� 6µ: CG '
Lo.�rr)�efe �yts'F'/'ucTtbN ��"yIGG'
CompaAy Name
i)~-fk t La CIS-0 1 L/Z6
ITampe of Pers n Resp ible for ConstructionLicense No. and Type if Applicable
ja8A 4oVlaA f- (Z1 Uri
Street Address City/Town State Zip
-75'1 �K)Zq -yy? pqq b - Iaferri ere FLerl�zgot,kke- -
Tele hone No.(business) Telephone No.(cell) a-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 ranee of the building permit.'
Is a signed Affidavit submitted with this application? Yes Er No 0
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=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 15,0100 o (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 in kr wledge and understanding.
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Please print annd me Title Telephone No. Da
L M co(yi
Street Address City/Town `l State Zip
IJ
Municipal Inspector to fill out this section upon application approval•
'w Name Date
\Uxpiration:ff]1016a0l_�
ffice of Consumer Affairs&Business Regulation
OME IMPROVEMENTCONTRACTOR
egtstretion ,a114610 Type:
5 DBA
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LaFERRIERE CONS'fjP2� ION SfFRVICES - .{
TIMOTHY LaFERRIER� ,r , Ty
138 WESTON RD
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LINCOLN,MA 01773 Undersecretary
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-051426
TIMOTHY J
682 Conant Road'
Lincoln MA 01713
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-� 06IJ712016
Commissioner
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The Commonwealth of MassachusettsPnnt
Department of Industrial Accidents
f Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017 -
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: L a fee.ccIere Gns44-vsot,on .Pl��v1Ce
Address: (0 9 i4 Co ac%n4 12`0
City/State/Zip: L. (n cD I In ✓ ",^ Phone#: O Lf R O
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.PL I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g• Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers'comp.insurance required]* 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp.insurance req.] I 12.❑Other
'Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#I.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic.# Expiration Date:
Attach 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$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi ,under the pains and penalties of perjury thatR,the information
on provided above is true and correct.
Si afore: vAA L4 rrt&u9ate: A 12c H Z 3 j I
Phone#• S -:�Tj 6 L(go
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written." _
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states 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 commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate 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 employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned 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 line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please 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/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
www.mass.gov/dia
Fomt Revised 7/2010 -
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C,�y ofSakm,, assaMusetts 8-c? c,,
- Fire Department Z •
David Cody 4W.Lafayette,Street
Chief ,Salem, ;wfarsrcfrttsetts 02970-3695 29 :Fort Ave.
978-744-6990 tirc tPrevewion
2e!.97&-744-Ir35
dcody@sa(em cons '13urcau
-Tax 978-745-4646 976-745-7777
FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR A BUILDING GPPERMI'f
IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE
AND THE SALEM FIRE CODE, APPLICATION IS HEREBY MADE FOR THE APPROVAL OF PLANS
AND THE ISSUANCE OF A CERTIFICATE OF APPROVAL FOR A BUILDING PERMIT BY THE
SALEM FIRE DEPARTMENT. ( Ref. Section 113.3 of the Mass. Bldg. Code)
JOB LOCATION: `7 s L c( �c�y {e}-�� 5 f---
OWNER/OCCUPANT: .�jhe Cvl2P e. S/FI'a� Pefie(" CAdi ceJ-r—I-
ELECTRICAL CONTRACTOR: c v l= e C r C:
FIRE SUPPRESSION CONTRACTOR: T a-`� ti e pp"" �qp
SIGNATURE OF �/ '�-g( '7` l l 6 L/C?O
APPLICANT: _ Q Ff PHONE 8:
ADDRESS'NP 2
APPLICANT: L t'✓1 CO 1 K /� dC3' TOWTN:OT GIN CB (y
APPROVAL DATE:
Certificate of approval is hereby granted, on approved plans or submittal of
Project details, by the SALEM FIRE DEPARTMENT. All plans are approved solely
for identification of type and location of fire protection devices and equipment
All plans are subject to approval of any other authority having jurisdiction.
Upon completion, the applicant or installer(s) shall request an inspection and/or
test of the fire protection devices and equipment. (ADDITTIONAL REQUIREMENTS,
SEE REVERSE SIDE **+)
C� NEW CONSTRUCTION.
PROPERTY LOCATION HAS NO COMPLIANCE WITH THE PROVISIONS OP
CHAPTER 148, SECTION 26 C/E, M.G.L., RELATIVE TO THE INSTALA•-
TION OF APPROVED FIRE ALARM DEVICES. THE OWNER OF THIS PRO-
PERTY IS REQUIRED TO OBTAIN COR11LIANCL AS A CONDITION OF
OBTAINING A BUILDING PERMIT,
PROPERTY LOCATION IS Ii1' CO?•:PLIACNE WITH IRE PROVISION OF CHAPTER
148, SECTION 26 C/F; M,G-L.
EXPiRAl'ION DATE:
J ;iC lili i.. Ui+))131:. 7 SUO SfoO i'T. U; '•+.J �': �1`t
30.00
;t ?!Fit+2R•' $50.00
CHECK#
In compliance with the provision of Section 113. 5 of the Massachusetts
State Building Code, ;and under guidelines agreed upon by the Salem Bldg.
Inspector and the Salem Fire Chief, the applicant for a building permit
shall obtain the Certificate of approval (see reverse side) and stamped
plan approval. from the alem Fire Prevention Bureau.
Said application and approval is required before a building permit may be
issued. The Massachusetts State Building Code requires compliance
approval of the Salem Fire Department, with reference to provisions of
Articles 4 and 12 of the Building Code, the Salem Fire Code, Massachusetts
General Laws, and 527 Code of Massachusetts Regulations.
The applicant shall submit this application with three (3) sets of plans,
drawn in sufficient clarity, to obtain stamped approval of the Salem Fire
Department. This applies for all new construction, substantial
alterations, change of use and/or occupancy, and any other approvals
required by the Massachusetts General Laws, and the Salem Fire Code.
Exception: Plans will not be required for structural work when the
proposed work to be performed under the building permit tiil-L
.qpj:, in the opinion of the Building Inspector, require a
plan to show the nature and character of the work to be
performed.
Notice: Plans are normally required for fire suppression systems,
fire alarm systems, tank installations, and Fire Code
requirements.
Under the provisions of Article 22 of the Massachusetts State Building
Code, certain proposed project& may not require submission of plans or
complete compliance with new construction requirements. In these
cases, provisions of Article 22, Appendix T, and Tables applicable
shall apply. This section shall not, however, supersede the
provisions outlined in the Salem Fire Prevention Regulations, Chapter
148, MGL, or 527 Code of Massachusetts Regulations. All permits for
fire code use and/or occupancy shall apply for the entire structure;
fire alarm and/or smoke detector installation shall apply to the
entire structure based upon current requirements as per Laws and/or
Codes, but the existing structure may comply with regulations
applicable for existing structures.
Notice: Sub-contractors may also be required to file individual
applications for a Fire Department Certificate of Approval
for the area of their work. Such sub-contractors shall file
an Application to Install with the Fire prevention Bureau
prior to commencing any work for those areas applicable.