85 LAFAYETTE ST - BUILDING INSPECTION (3) � ..
_ J SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street CitY/Town Zip
Property O%cner Contact Information:
,Ca....c. .Sbw.ta o - 04 ,oEiin 978- *2.- 993
Tifle Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the propertc owner hereby authorizes
IN60ROC./L /y5 C�,QOT ST $f�
Name Street Address City/Town State Zip
to act on the property owner's behalf, in.ill matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed s ace and/or nut under Construction Control then check here❑and skip Section ]U.I)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address. Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
,73t 0 C;/ . 23c/�h.o E/25
Company Name:
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Name of Person Responsible for Construction License No. and Type if Applicable
/yS Gs OOT ST T3—VG`A'LLy /WA O/O/.�
Street Address City/ToTwn State Zip
g�2Z- S/.,79 Gil -903 - 7967 ./nv L&5 VX� ci4.eiz o, . ,✓67-
Tele hone No. (business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the i seance of the building permit.
Is a signed Affidavit submitted with this a lication? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6) _$ SOO
1. Building $ 35 00 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $' /p pp appropriate municipal factor)=$
�( 3. Plumbing $
/ 4. Mechanical (HVAC) $ _ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ - Enclose check payable to
6.Total Cost $ y,5 n p _ (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.
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XPlease print and sign name Title Telephon No. D e
Street :Addles Cih'/ own State Z p
Municipal Inspector to fill out this section upon application approval:
Name Date
(';yy The Commonwealth of Massachusetts
Department of Public Safety
! .
.\tass,uhusetts State Building Code(780 CMR)Seventh Edition -
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Onlv) t
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block B and Lot M for locations for which a street address is not available)
8S G/tf A��Tr£ 5T M A O/9 70 e-4-VVISAIY COo J 3A ✓K
:Nu. and Street City /Town 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❑ Alteration Addition ❑ Demolition Cl (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: r`
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 ❑
Brief Description of Proposed Work: 44—i,:®✓zc A 3<n' moor A10A1 LOA .O L✓.A LL
Z7ELLST6 GLEG >•2rG.+L t /Z E�pA�2 SUS,OtNOtO C�/LING
X
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) Cl
Existing Use Group(s): a Proposed Use Group(s): L3 t•
Existing Hazard Index 780 CMR 34: Z Proposed Hazard Index 780 CMR 34: Z.
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 ❑' H-2 ❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4 ❑ 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 ❑ IIt6X I IV ❑ 1 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:
A trench will not be Licensed Disposal Site[�
Public Er Check if outside Flood Zone C� Indicate municipal 0� renc �/ '
required L7or trench ur.pecifv:
I'rira to ❑ or indentifv Zone: or on site.Nxtem ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: %1A I li,tori,C.n...m,,nn Rc,,, Pn,,—:
Not Applicable 1" In Strudure within airport appnrach area? Is their le%ierc completed.'
err C onsent to Build enclosed ❑ Ye, ❑ or No 2" Yes ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: L+e Group(s): Tcpe of Construction: Occupant Load per Hour
Does the building contain an Sprinkler System?: Y sS Special Stipulations:
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
II I '1'9 'li.•1;'y . 1 \C: 'i.'Y 'J}•).iJb
Construction Debris Disposal Affidavit
(reiluired li)r all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CA9R section I 1 1.5
Debris, and the provisions of MGL e 40, S 54;
Building Permit It 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
l l 1. S 150A.
The debris will be transported by:
FRIG Z 1-)15)00 L
(1mme of hauler)
The debris will be disposed of•in
GoU.AA/TA A,VtEAC+ y
(name of facility)
aZH7 GOMME2G�A �— S r Z_ MA U/905
(address of facility)
H 411ah1i'C O 1)if 111t.1 n) (Cant
B•z? -/o
date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.rsm:W1 Y:)RI9Ct'I.1.
�I Yt)a 12C WAiHLNO a1N S CaEba' • SAL EM,MAVSA i It:.c'I I S 0197.^,
978-.'45-9595 is 1'.,x:978-74N1846
Workers' Compensation Insurance :affidavit: Builders/Contracturs/Electricians/Plumbers
tli� tot Infunnalion Plcrse Print-Leeibly
1.4aMe tnusiixas/OrsaniratioNlndrvidual): �f-SRC - 3VZI_014eG CONS r/LTAN7-5
Address: 5 C-A007' Ss,
City,Statei%Ip: 4 Me, 01915' Phone ii: 6/7 -6703 - 7867
;%re you an employer! Check the appropriat�e b x: Type of project(required):
4. L'✓I t inn a general contractor and 1 (s. New construction
I.❑ I am a employer with ❑
employees(lull and/or part-time).' have hired the sub-contractors 7. [V]Reinodeling
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet. :
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. [] Building addition
No workers'cum insurance 5. ❑ We are a corporation and its
1 P officers have exercised their 10.❑ Electrical repairs or additions
required.) 1 I. Plumbing repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL ❑ b P'
myself. LNo workers' ctanp. c. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. LNo workers' 13.[3 Other
comp. insurance required.]
•,any;Ipplicaut that checks box nl must alsO Jill Out the V:01011 IN:ow showing their workers'compensation pulicy rohirnutiun.
'I tumeuwtwrs whu utbmir this affidavit indicating they ore Joins all work and then him outside cuntraetom must submit a new atrdavit indicating.such.
-C'onmaeul that check this box mtwt coached,m additional.durot showing the nanta of the sub-contractors and their workans'comp.policy infornraduir.
i a)n un employer that is providing)vorkers'c•onpensation insurtince fa-mry employees. Below is the policy utld job site
infortuation.
Insurance Company Name: .__ ..._. ...-...------------
Policy 4 or Sclr-ins. Lic.tl: .. ..---_ Expiration Date:
lob Site Address: City;State/Zip:
.kttach at copy of llte workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverdge as required under Section 25A or.MGL e. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprismunent,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it day against flit violator. Be advised that a copy orthis statement may be forwarded to the Office of
Iovnngau�nu o(thc DIA ror insurance coverage Ycrific-ition.
i do hereby terrify under the pains and penuhics ofperjury that the Infor)nadon provided above is true and correct.
Ih G1 -7 8a3— '7t9fi .
Official use only. Do not Ivrite in this area,to be completed by city or town official.
I
City or'l'own: _ Permit/Liccnse 9_____ _
Issuing Authority (circle one): .
I. Board of llvalth 2- liuildiul Mpartnlcut 3. Cityi foi%u Clerk 4. Electrical loipecfor 5. Plumbing Inspector
6. Other
C'nmt at:l Person: _ . .---. Phone 7:
Information and Instructions '
.Massachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this%tatWe, an empluree 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. Nowevcr 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."
.SIGL 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, hIGL 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 ofcunipliance w ith 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 sub-contractor(s) namc(s),address(es)and phone nuniber(s)along with their certificate(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
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 dale 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(lie 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.
!'lease be Sure to till in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple penmidliceise applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address" the applicant should write "all locations in (city 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 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 burn leaves etc.)said person is NOT required to complete this affidavit.
lbc 011 ace 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 Dcp:rtinciWs address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OtHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Kcvised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
Bedrock Building Consultants
145 Cabot Street
Beverly, MA 01915
Tel 978-922-5479
Cell 617-803-7867
Fax 978-922-2590
E Mail iaylevy2verizon.net
8/26/10
RE: Remodeling at: 85 Lafayette Street in Salem:
The following subcontractors have liability and workers compensation insurance:
Todd Main& Co.
G. J. Electrical Contractors
Paul Ritchie Flooring
Jay Levy
Bedrock Building Consultants