76 LAFAYETTE ST - BUILDING INSPECTION (12) .A ' The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts Stale Building Code(780 C\IR)Serenth 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 I .pector: pp!
SECTION I: LOCATION(Please`indicate Blocc'k N and
d-rLot
q# for to ati for hich a street address is not available)
-e#(ey '102 fC--1 e,r _ /,/if-1_2d
No. and Street Cite /To%%n Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK _:�d
If New Construction cheek here❑or check all that apply in the two rows below '
Existing Building❑ Repair❑ Alteration ❑ Addition❑ , Demolition WIPlease fill out and submit Appendix 1)
ChangeufUse' ❑ Change ofOccupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering P Review required? Yes ❑ No 2'
Brief Description of Proposed Work: Gr 7,�_ / c- ,`
a'Z b 7 j n Vs
(� 12 �1
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING NDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): r
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 ❑ 172❑ _� H: Hilth Hazard H-1 ❑ H-2❑ H-3 ❑ - H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 Cl1-4❑ M: Mercantile❑ R: Residential R-10 , R-2❑ R-3❑ R-4❑
S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA Cl fill Cl IIIA ❑ IIIB ❑ IV I VA ❑ VB ❑
M
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl : Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Oil"' ('heck if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site
Prieate❑ or mdentifc Zunr: or un site sestem ❑ rermit is
❑or trench ur.pecify:
}'remit is enclosed ❑
Railroad right-of-way: Haza rds to Air Navigation: MA Illsh,rir(,�mmis+i, n Hoc w, 1'r„rr..:
.\nt Applicable tam. Is titructiu'e%rnhm air`+urt app/roach arr.t.' I.their rene•%c completed.'
,n Cq).cut'hrl4udd enclosed'❑ ; N'es❑ nr\o 9 1'es a,\o 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
('Moon ul C odc: L',e Crnu plsl: iepe of Consl«ii Uun: Occupant Lund per PIuuC
1111s the t'uddmt;contain an Sprinkler S(stem.': Special Stipulations:
4:::';" & 7osD - 1-7q — 57?a
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nameand Addressol Fropert) ZnZ6
n��o, ,tuc -/��v�/� C� jovl yvf ,
Name(Print) Nu.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) a-mad address
If a ,,ClicaG ZLC ,ble,the property mvner herebv authorizes �� (/ems` A� ®`q�O
J y GJ�e�,G� J G� [
Name Street Address City/Town State Zip
to act on the pro+erly owners behalf, in all matters relative to work authorized by this building permit a, lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclo d s ace and/or not under Construction Conwl then check here D and slup Section 10.1)
10.1 Registered Professional Responsible for Construction Control
6,.17 B /0 & 0 6
Name(Re gistnn Tel ne No. e- ul address Registration Numbe
Street Address City/Town State Zip ' Disc Aline Expiration Date
10.2 General Contractor
Company Name:
Na of Arson Respun' ble f itCun trow t n ^ ° �Cicense Nu' and T pe tf Applicable �
Street Asicir = .a /� ty/Town �y,/L State'
Telephone No.(business) Telephone No.(cell)F,72--z 3 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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ I Building Permit Fee=Total Construction Cost x—(Insert here
2. Electrical .$ "Od ,c.,D appropriate municipal factor)_$
3. Plumbing $ floo,ad
Note:Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 6jcio,00 (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.
I'I ,.r-xnt dn name n Utleeleph��9,� / Dale
Street Address Cityi Totcn State Zip �•�.
Municipal Inspector to fill out this section upon application approval:
Name Pate
CITY OF SM EM. NL-sS.xcHusEM
BLuaINNG DEPJ1a-mENT
1_G W.,smmTON STurr. )ov Moot
7YL (9711)745-9595
F.%x(971n 7449S"
KMBE)tLEY ORMCOLL TAoaue ST-FMMAI
UAYOt
DlttliC•foa o1 PLet.0 paoiRaTr/at:11DLNG CoacMSloNElt
Workers' Compensation Insurance AQldaviC Ouilderi/ContractonlElectriclansiPlumben
%il"llca"I Infarmallon Plesse
Vaine 1eY7uacaOrgarrrartOM1IIMbYrdYYII:
Address: 0S' 141ah RQAQ
CityislatriZip: U �'lfoneN 97a- aa9- �Nz7�
Are Joe as rmpleyel'Check the appropriate beat Type of praises(rsgadrea
1.❑ 1 am a cmploye with a• ❑ 1 an a terral coneacass and 1
cmployces(fWl aatVe part-liar).
• Well
ed the s aa ukeaestace E Q New cenanuctiw
1.up I am a sole propriete or partner- listed of the AKWA d sheet d y. ®Remodeling
:hip mud have no cmpleyen These sub-corxneaaa hew S. ❑Demolition
working for me in say capacity, worsen'comp.inquin ace. 9. Q Iluilding addition
I No worsen'comp. insurance S. ❑ Wo an a corporation and is I O.Q Elsusical repairs a additionsr gairerLl odkers have exercised their
S.❑ 1 am a homeowner doing all work right of exernprias post MOL 11.Q Plumbing repairs or additions
myselL(No workers'comp. C. 132.f 1(41 and we haw no 12.Q Roof repairs
insurance required.I► empleyen.(No wartow 1).Q Othe
consµ insurance requim/.J
.
Any 4ppUC20 this cestaa but et mare 24e 41•rr roe aeries saw rkswiry astir woraw' , poq iaaresatlah
't hutwownw who sub"ads sA`vb inrlodq itrs an doing rn was ad duo hire am*eaaootrs oar dove a new andbril inaiswisq sr-►
<'.wuawa slid chwh this sea nrYf aaahra r adrariwwl.Aov Juwing rti ryas elrhe er►sartatae W rlrk+araw'ma p p iky ta6musiee.
/der roe rwpbyp that b pwvldArg wwAers'crwpenndre AusrsraJir ray ray/eyses sibw 6 rAe pnlfq roe//a1 odor
in�atatrrlaa
Insurance Company Name: aT 7 8 - q 0�L - G 2 3,3
Policy ear self-ins.Lie.# C P S t o 3,q3>v A^ �ry �ap�,tian dote G !o 00
Job Sire Adtlrose: 76 L�rA X12 `�Sl �/�. /"/T CitylgiaWZip:
.%crack a copy of the workers'compose idso policy dwbnlbs pep(sbewing the poiley somber,and aspired"date)6
Failure to scrum coverage a regtrired undo 4actioa 2SA of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to S 1.500.00 and/or one-year imprisonment,as won as civil penalli"in the form of a STOP WORK ORDER and a floe
of up to S2J0.00 a day against the violate. Ile adviw:d that a copy of this sialemam maybe rurwarded to the Office of
Iuvcstr gations of dove nIA for insurance coverage vvitkatiom
Id*hereby terrify under thin�pains undpitmolder
,,%oorrluoy that IAr infrrwer/w provided above is true and cw►rA
P•.rmea: 970 'I a. ,,.�''"'CCCC�a����7(l
L(Q7/flCiVJUI9IInIY6 only. Ornitwrier in this arrestwn: ecraiM.Icense l_hurily(circle line):
Ilealtb 1. Rudding tlepartmcnr 1. Chi,/town Clerk 1. flecirical linptctor S. Plumbing Ingpeelo►
non: Phone 0•
CITY OF SALEM
PUBLIC PROPRERTY
�N ,
* �• DEPARTMENT
\I .1.'N I:C \•I IIT1...��151N&I'T •5•%11%1.\t.%Nvu 111 .4
1f1:'1.'/.71.47i4S �l°\!t:%7�•i 1,}'IIM
Construction Debris Disposal Aiildavit
(required fur all demolition and renovatiun work)
In •accunl:utce with the sixth edition of the State Building Cole, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building I'errnit q 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
111. S 150A.
The debris will be tr,•rnnsportcd/by:
t nama of hauler)
The debris will be disposed Grin :
(n:une o17'ac11n�—
1:1,lan.N t1t rudfilyi
vrnalure ol•lurmit,lpplicant
11a e
.NOEL ;Massachusetts- Department of Public Safet.
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 43546
Restric[ d to: 00
ROBERT A LINDENFELZER
305 HIGH RD
NEWBURY, MA 01951
--L �le< Expiration: 8124/2011
fonnnbsioner Tr#: IM