0092-0096 LAFAYETTE STREET - BPA 16-1213 t The Commonwealth of Massachusetts
Department ofPubltNV*fW I A 0 23
Massachusetts State Building Code(780 CMR)
(� Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
j� SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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❑ I Alteration ❑ 1 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 ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed or
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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):
SECTION4: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❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ 1-3❑ 14❑ 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 ❑ HA ❑ 1IB ❑ IIIA ❑ Hill ❑ IV ❑ 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ required❑or trench or specify:
or indentify Zone: or on site system❑ permit is enclosed Cl
Railroad right-of-way: Hazards to Air Navigation: \1A I li io,is I ... m, so K..uae_I
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to BUdd 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:
Dues the building contain an Sprinkler System?: Special Stipulations:
�y fVlptt
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) � No—and Street City/Town Zip !
Property Owner Contact Information:
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 building permit application,
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,000 cu.ft.of enclosed space and/or/ not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control- -
Name(Re istrant) Telephone No. e-mail address Registration Number
l/ 7nles �r �dlyrYtjs � %q/�f!
Street Ad'dress City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'C0&1111:NSA'I ION 1N5URANQ:AFF1DAVIr 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estirnated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ 000 appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
' \ 6.Total Cost $ 3 cr t (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,f 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 edge and understanding.
/ 1 Please print and sign name V Title Telephone No. Dat
Street Address City/Town �) State Zip n
Municipal Inspector to fill out this section upon application approval:
Name Date
DISPLAY PERMIT IN A CONSPICUOUS PLACE ON THE PREMISES
1
Commonwealth of Massachusetts
{ ! City of Salem, Fire Prevention Bureau
I
'VI
q 29 Fort Ave, Salem, MA 01970(978) 745-7777
SPRINKLER SYSTEM PERMIT
For: Sprinkler System
City of Salem
Date: 10/6/2016
Permit Number(if applicable): SS-16-14 ❑ ��
In accordance with the provisions of M.G.L. Chapter 148, as provided in 10A this permit is granted
to Lynco Fire Protection, Inc
(Full name of Person,Firm or Corporation) \ ,
for: Modify existing sprinkler system r �
lJ J
at 92-96 LAFAYETTE STREET, SALEM, MA.
(Street and#or Describe Location for Adequate Identification
Restrictions: •--- -
Fee Paid $50.00 This Permit will expire on 2/6/2018
Signature of Official Granting Permit Title
Call (978) 745-7777 For Inspection I