76 LAFAYETTE ST - BUILDING INSPECTION (7) -i�- N ► T50 3� P r z �-fL -'F0`
The Commonwealth of Massache l�ussT HAL SERVICE
f Public
Department o ub c Safety
WQ Massachusetts State Building Code(780 CMIJf14 NOY _S.
Building Permit Application for any Building other than a One-or Two-Famrl I"
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official: flu �K
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
-(e m
t No.and Street City/Town Zip Code Name of Building(if applicable)
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❑ Repair 21 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other Specify: o re m v V' me ne 1.
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑ /
Is an Independent Structural Engineering Peer Review required? Yes ❑ No CY
Brief.Description of Proposed Work: %D tCr�'rcv£ ;),e wC d%07
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ACH .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: Factory F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ 1— Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ IU: Utiliy❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA O IM ❑ 111 ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:STTE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information Sewage Disposal: Trench Permit. Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench Disposal Site❑ench will not be P
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❑ 1 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?: S ecial Stipulations:
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tilt TgA-V- On t�ucE
Dt-�-fhkt_ Wku_ 8E REGFUl12ED• '1�,
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
a' (, - LLC' 1-2 �Je �c a S 4- 1,C_ 1--Z
Name(Print) No.and Street City/Town Zip
Pr`o eerty Owner/Contact Information: I t�r1
Title Telephone No.(business) Telephone No. (cell) e-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 budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 N.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
� 1r75e Dlt S. Sa,>�.�i' '7al -2�5- 3UL(
Name(Registrant) Telephone No. e-m✓ ail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor �(J7
�F (•P!/ /� S JaJ (vr I N C .
Company Name
77S�n� SaJ o369Sy - 7a �� V
Name of Person�esponsible for Construction / License No. and Type if Applicable
yd ("I.. I S�• lyecl &,i �J/j
Street Address City/Town State Zip
7zl _ 3`IStP �?LI _�1 _ oaolS \o e01.', M . ifol rom
Telephone N usines Telephone No. cell e-mail address
o. s
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 13 No O
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ o . '?'3..o e Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ o appropriate municipal factor)_$
3.Plumbing $ e
4.Mechanical (HVAC) $ p Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ 4> Enclose check payable to
6.Total Cost I $ D t GI I (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMrr 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 owledge d understanding.
nV� 0ortJ c 4,
Please print and Ugn name Title Telephone No. Date
N S j_ oed �, � p2ISS iI7SI/
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block# and Lot# for locations for which a street address is not
available)
-76 1_ 4 Z L Sy. Ss l�•h ram//�
No.and Street City/Town Zip Name of Building(if applicable)
For the above described property thefollowing action was taken:
Water Shut Off? Yes ❑ No Lei Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No GY/ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas(Natural,Propane,Medical or other
10 Surveyed Site Plan(Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Bu ding Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee
Registered Professional Contact Information
135-7Y3
C Re ' tration Number
Name(Re e-
trant) Telephone No. mail ad •ess /}* -
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State zip
The 'Comonvealth of tlassaelrusetts
Department:of lndu3tYtaZttccldents
offce of Investigaatotxs.,y
1 Congress Street Suite.I00
Boston, MA 02II4-20I7 .
mm.mass.go:v/dia
Workers' Compensation Insurance Affi.vrt Builders/Contractors/Electricians/Plumbers
Applies zt'Information Please Pii— Legibiv
Name (Bmine s§/Orga uzativn/IndiNidual):
Address
`City/State/Zip: e Aw-A Phone.#: S 21:1
Are y anemployer? Check the appropriate box:
Type of protect(required):,
1. . I am a employer.with, $ 4. I am a general contractor"and I' '
employees(full and/or part-time)
r have hired the sub-contractors coushuct on
2.❑ I am a sole proprietor or partner- listed-on the attacked sheet.° 7t Remodeling.
shrp acid have no;employees These sub-contractors have ' g, ;0 Demolition
'employees and have workers' "
working for mein any.capacity. t 9. Building addition
No workers'comp. insurance comp.insurance.
required.] 5. 0 We area corporation and-its 10.0 Electrical repairs or additions
3:❑ I am ahomeowner doing all work -. officers have,execised their 11.❑Plumbing repairs or additions
myself-[No workers' comp. right of exemption;p6rMGL 12.❑ frepairs
e
insurance required.] t - c. 152, §1(4) and we hav6mo' 13.. Other t' (' c l«mployees [No workers
comp,insuranoereguired.]
•Aqy applicant thatichecks box#1 must also fill out the section below ahowing their workers'comperrsatrpa-pol3ay ipfolalatloa:
t Homeowners who submit this'affidavit indicating they are'doing all work and then'hre outsrdexo¢fractora must submit a new affidavit indicating such,
4`Contractors'-diaKchock this box.must attached an additmnal:sheet showing the: ame•of the sub-contractora.and state:whefber or act those entities:have
employees. Iftheaub-cwnfractors have employees,they;must provide their workers'.'aomp policgnumber.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
informations - �t
Insurance CompanyName: /
Policy#or Self-ins Lic. #:. //L2L,QL�6 S-7t) Expiration Date f/ `-a (/S
Job Site Address. -7G La. Ye A/C S - City/State/Zip;
Attach a Copy Of the workers'compensation policy declaration pager,(showing'the poucy n unber 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.ofa STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised thata copy of this statement:+may be forwarded�to[th, Office.of
Investigations of the.DIA for insurance coverage verification.
Ido hereby,ce t ,tin er t e aihs and enal"es.o er'u t/zat the in ormadon provided above is true and correct.
Si nature.. Date:
Phone#' 78l 3 H S 3`7S�
Official.u"se-only. Do not write in this area, to be completed by city or-towmL official.
City or Town: Permit/License #
Issuing Authority (circle one):
1.Board of Health 2."Building Department 3. City/Town Clerk 4. Electrical Inspector 5 Plumbing Inspector
l]
6. Other
Contact Person: Phone#:
Massachuaatts -Department:of PuUlte Safety.
Board At Building:Regulations and!Standards
`Cnnxtr clioo Super,iror -
License:6S.030954
JOSS`ll�SesA.-
04-U4*11'RD
B€SISR :14Bk.0215d
dr. . rr ,r.s•` xpirati0-n
Commissioner 0711?J2Og5• '
' _ �('�rvhwxooaueaar.¢b-pt
Office Of Consumer Affairs&Buss ess0egula'ti�nna Licemeor registration valid for individul=ase.only
E IMPROVE ENT CONTfiAST-QFt`. - before the the expiration date. If found return to:
egistradon:. q3 Two:- Offt e,o€-Comumer Affairs and BusinessRbguiatfon
„piration: .. DBA 10?Eark Plan-Saite 5170
1 JOSEPH S.SAVINP: -p, .. Boston A1AA2116
JOSEPH SAVINI ,Y•F r ' ,�f
40 CANAt ST
p
MEQFORD,MA 02f55
Und'eneemtary ot valid without signature. -
Oct31 1411!50a Joseph S.Savini,Inc, 781-393-4926 p.2
Joseph S.Savini,Inc. Mass Builders License#036954
Contractors Registration#135743
Roofing&Clutter Contractor Phone: (781)395-3954
40 Canal St. Fax: (781)393-4926
Medford,MA 62155
Proposal
Attn.Jim Gagnon 10/31/14
RCG LLC
17 Ivaloo St.
Somerville,MA 02143
Fax:(617)625-8345
Fax:(978)740-0021
Job Address: 76 Lafayette St Salem,Ma.
I- To remove existing metal panels from above exterior windows of building in.designated
areas,42 windows in all,
2. To remove any rotted or defective plywood, insulation,fiaming, from the area behind the
panels that are being Temoved if needed.
3. To repair, or install new,framing,instilarion,plywood,as needed,
4. To cover plywood with new Grace ice and water shield.
5. To install new.040 Bronze Aluminum Panels. Panels will be fashioned to match existing
as closely as possible.
6. To caulk and seal around windows as needed
7. To clean,remove and dispose of all job related debris.
Price Cost per window Including Lift = $719.00
Carpentry work to be done on a time and materials basis=$6&00 per man+Stock
Any required police details will be directly paid for by RCG LLC
Job will carry a ten year warranty against leaks caused by installation defects.
j seph S r?-Ci�
STREET PERMIT
Cttp of *alem
Office of inspector of Ouilbino
DGily}fall ff' / 20
.Permission is fiere6y yven to
to occupy for �L Pur�°oaes
in from of esidle
of S/ ew,QC of slr eel
,`%is permil is lmiiedlo 20 . sa6 ecllo ISe
provisions of16e ordwances andslalales in refalion to cslreels andllie.9nspeclion
andGonslraclion of?3uildinys in l6e Gily of cSalem. A�OUC�� pdL pt2-
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