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101 LAFAYETTE ST - BUILDING INSPECTION " t q -`1 ctc ( 61� o rn The Commonwealth of Massachusetts Department of Public Safety yd - Mass chusetts State Building Code(780 CMR) Building Permit Application for any Building other than-a One-or Two-Family Dwelling ,(This Section For Official UseOnl ) Building Permit Number: Date Applied: Builduug Official: SECTION 1:LOCATION(['lease indicate Block-k and Lot#for locations for-wfiich a d ila ) 10 i L N�`O' S� SALem PW1'2 No.and Street.} d. City/Town! Zip Code '+Name of Building pplicable) - .SECTION 2:PROPOSED.WORK Edi turn of MA Suite:Chyle used—y If New Construction check here❑or check allthat apply in the two rows below Existing Building%?-- Repairer- Alteration ❑ 1 Addition❑ 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,+�:,. lsan independent Structural Enginee_`iing PeerRevie u fired?7-1 p Yes ❑ No - dBriet Description of proposed.4Yik:l'��'.IJJ � I� T' l�flh 1�►7� � - + ' QGC - 4J to IZ.'/i2S / 'o ra "C r1 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR. J CHANGE IN USE OR OCCUPANCY Check he,-ea ar,`- " ;sling Building investigation and Evaluation is enclosed(See 780 CNIR 34) ❑ Existing Use Group(s): Proposed Use Group(s): ✓) SECTION 4:BUILDING HEIGHT AND AREA y�.. Q - - Existing Proposed t,f 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-f❑ AS❑ B: Business(Z--- E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ , H-5❑ 1: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ NL• Mercantile❑ It: Residential R-10 R-2❑ R-3❑ P4❑ ' S: Storage S-1❑ S-2❑ U: Utility Cl Special Use❑and please describe below: Special Use. _ SECTION 6:CONSTRUCTION TYPE(Check as applicable) IN ❑ - IB ❑ IIA ❑ IIB ❑ IIIA ❑ Hill ❑ IV ❑ VA.❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) ~ - Trench Permit: Debris Remuval: Water Supply: Flood Zone Information: Sewage Disposal: Publii'f— Check if outside Flood Zone Indicate municipal A trench will not be Licensed Disposal Sitel�. requiredVL.rrtrench or specify: Private O or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: \{_\I.h tr i i i m)nn v n It o,ji.,y 1 uxcs: Ngt,r\pplicalilc' ---- {° Is Struchve within airport approach area? Is their review completed? _ -. or.Consent to Build enclosed❑ Yes.❑ or NrriK--- - Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition oECode: - Use Group(s):.. Type of Construction: - Occupant Load per Floor: r: Does the building contain an Sprinkler System?: Special Stipulations: Qv1 P�IL:ED 4�ZS TO A SECTION 9: 1'IIOPER'IY OWNER AUTFIORIZATION Name and,Address of Prop•rty Owner - Name(Print No.and Streu City/Town Zip Property Owner Contact Information: o __qq� Title Telephone No.(business) Telephone No. (cell) e-mail address rIf applicable,the-ptoperty gFyner hereby authorizes :. 5 - " mA O am-e 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). 1 If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then cheek here O and skip Section 10.1 ` '10.1 Re istere Professional Responsible for Construction Control - - Name(¢egis mt) rTelephone No. a-mail address Registration Numbe Street Address Ci /Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Pe .on esponsible for Construction License No. and Type if Applicable £ - s�- l�f l d/S` .4-74- 0/ Street Address City/ cnvn State Zip - J Telephone No.(business) Telephone No. cell e-mail address SECTION 11:\V01,,KERS'C0M11 N''iA IION INSURANCti A]FIDAM'I 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 Estimated Costs:(Labor I�Q(JD O O and Materials) Total Construction Cost(from Item 6)_$ Z 1. Building $ -2 DOO .o'p Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 1. Mechanical (FWAC) $ Note:Minimum fee=$ (contact mn//unnicipality^) 5. Mechanical Other $^ ^ (contact Enclose check payable to 91 22 6.Total Cost S IOD6© municipality)and write check number here SECTION 13:SIGNATURE Or,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. �S► `E dv� <,kkAos ©wngx V/_535 lease pr nt and sign name► Title Telephone Dat Cain tvl S l CSr�t✓1 Street Address Crity/Tovn State Zip Municipal Inspector to fill out this section upon application approval: Name Date s CIn of S:1LE1,t, -1SSACHUSETTS t 13L:IL 12NC;DEPART\ZNT } ` 120 7`1SHLYGTOW STREET 3.v , FLOOR,k>„.. " ' T EL (978) 745-9595 F.ux(978) 740-9845 KIN ffiF_RL.EY DRlSCOLL NLAYO;t Trgo.%txs ST.PIERaa DIRECCOR OF PGBLic PROPERTY/8j:anLNG CO\L\I15SI0NER Construction Debris Disposal Aff"Idavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CM section 111.5 Debris, and the provisions of NIGL c 40, S 54; Building Permit # 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 rtvlGL c I 11, S 150A. The dchris will be transported by: y (name of!tauter) 'fhe debris will be disposed of in (name0(raeility) rL_)Cn� S 1 LEA I (address of facility) I sig re o[permit applicant ,late — r !� e CITY OF SAI.EM, ANSSACHLSETTS I?tL'IL.DING DEPART>IEINT 120 WASHLNGTON STREET, 3`o FLOOR TEL (978) 745-9595 FAx(978) 730-9W wNBFRt F.Y DRISCOLLTti ontnsST.Pt>✓ex& VY 1YOR DIRECTOR OF PUBLIC PROPERTY/H1:11.DiNG COMMISSIONER Workers' Compensation Insurance ABdavit: Builders/Contractors/Electricians/Plumbers Applicant Information ////'���' %"// r� 1 Please Print Legibly VIIInL' 113usinessOrganiratiorvindi victual): �a�At tt' � /1A�7�C- L/�h.9 Address: Ee170ere City/State/Zip: VQ��Lt Y)1/} . 0/4G6 ph N: Are you on employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2-I -` 2.[L4-Lmn a sole proprietor or partner- listed on the attached sheet.t ? Rs�Remodeling ship and have no employees - These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition [\'o workers'comp. insurance 5. ❑ We are a corporation and its required ) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing ail work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself. [\o workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t employees.[No workers' cornp, insurance required.l I3.❑ Other •Aqv npplicam ilwt checks box al must alsu fill out the uctiun below showing their worken'compensation policy infl,matiun: 'I lummwtxn who submll this afficinvii indicating they arc doing all work and then hire outside contmeton most suhmit anew affidavit indicating such. :C,mrmctun Out chuck this box most ailachcd an addiliurwl sheet showing the name of the sub-contnctun and their workers'comp.policy information. I ann an employer that is providing workers'compensation Insurance for my employees. Belo lv Is the policy mtd fob site information. lnsurancc Company Name: L A.y t�eln TR1Vvrw K-ei /Q-c' cW Policy 4 or Self-iris. Lic.d: /��0 b 6 Cv p 0 YG a Expiration Date: �p �-f' ( � —Z.� t Job Site Address: 10 t 44F Cily/Stute/Zip:_]3_e✓rca Attach a copy of the workers'compensation policy declaration page(showing the policy number and a (ration date). Failure to secure coverage as required under Section 25A ot','vIGL c. 152 can lead to the imposition of criminal penalties of a line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$230.00 a day against the violator. Be advised that a copy of this,statement may be forwarded to the OI'lice of Investigations ofthe DIA for insurance coverage verification. I da hereby c rdfy a ode dos pu is id renolt s of per' ry that the information provided above is true and correct. ZVI Phone Y ��! /�� O 62 72 ly Official use only. Oa nor write in this'area, ra be completed by city or town offiviaL City or fawn: ___.. .__ Permil/l.lcense# ___ I+suing,\ulhurity(circle one): - 1. Board of lleahh 2- Building Deparlinvat 3.Cityffo sn Clerk 4. Flectrical Inspector 5. Plumbing Inspector 6.Other Phone fl: t Massachusetts -Department of Puohc Safeiy 1- <Board of Building Regulations and Standards '. Cnns[rr._ticn Supcn isnr ° License: CS402121 W UYRED M AUDETTE } 48 Denver St#109; • _ Saugus MA 01906 ' # 4 Expiration i Commissioner 07/01/2014 o� . .OI'(iceoP ConsumeF ns� 4 VTrEHOME IMP.RDV6EMpvm---- ACTgR Rdgcstr-a0on:, 8 . '' Type yy6L71 'Expira0on: :4/8(' `1S'y DBA Y B SONS HOME4MPROkVEMENI' WILFRED.AUDETfE--__„ x - 8 REED'•RD PEABODY MA0198Q;; Undersecretary Unrestricted-Buildings of any use group which I contain less than 35,000 cubic feet (991m)of i enclosed space. a i a Failure toposseWa-current editiomoube.Massachusetts— State Building code is cause for revocation of this license.. j For DPs licensing information visit: vry -Mass.Gov(DPS a �� ♦ - _ "> �•e•••""'" �at4oavalyd.foc m"dividuf use only .. . e eapuatton.date. If found return to:-• .''al Codsumer Affairs drod Business Regulation "°€s♦ B�ar6lilaaa Sarte ost�ou,117A:02116 ,� Y i / otv IHwithou signature -- FIRE PROTECTION KEY PEABODY 5TREET EMERGENCY UGHF © FIRE EXDNGUISHER _ © PULL STATION Rn PlA mP 42' 7 3 2 5-6-8 11 17 © HORN STROBE Q O O O O O CDN 18 MI EXIT SIGN WH 7 ro u O SMOKE DETECTOR 1 1 1 10 10 _ om7cu+xm N b TT0� H b i W N W 13 EQUIPMENT KEY 00000 0 0 c O 1 GLASS DISPLAY CASES r unxc au ma az' O 9®®® O 18 2 FREEZER �i 53'-4- 3 FROZEN YOGURT Q NOTE5: -4 ICE MACHINE W INFILL EXI5TING OPENING. 5 JUICE SQUEEZER TYPE X,G.W.B.EACH SIDE OVER 2X4 Q I G"O.C. - 20 6 JUICE MACHINE 7 BEVERAGE REFRIGERATOR 8 FROZEN JUICE MACHINE 9 STORAGE 10 COUNTERTOPS 11 NINJA 13 HANDSINK 14 3 BAY SINK 15 MOP SINK FI RST FLOOR PLAN �aExA��x 16 60" STOVE AND GRILLE 17 FRYERS 18 PREP TABLE no e�al 19 GREASE TRAP m[ 20 WALK IN FREEZER OPMxg O' S' 10' 20' Li U RENOVATIONS DATE: JONATHAN RAISZ 26 THORNDIKE STREET FLOOR PLAN APR 3,2014 A 1 PHON,EK(61'7E)7MA 34-1 6 I O I LAFAYETTE STREET REv1sloNs: ARCHITECT 7oN(aRAISZ.COM SALEM, MASSACHUSETTS 01970 SCALE: 1/8"=1'-0" PEAI30DY 5TREET 6- k �FIRE PROTECTION. KEY w o EMERGENCY UGHT «1 v ON © FIRE EXTINGUISHER r PULL STATION K - `" ❑N HORN STROBE N k O O O O SMOKE Q w ® SIGN W p m O SMOKE DETECTOR � 53 4" NOTE5 - INPRL EXI5TING OPENING. J'TYPE X,G.W.D.EACH 5IDE OVER 2X4 91 G"O.C. ifH FIRST FLOOR PLAN ` "" IN. O' 5' 10, 20, rx�sa' ua'- 1'-0„ JONATHAN RAISZ RENOVATIONS DATE: z6 OO LINE,M STREET FLOOR PLAN FEE.zs,zma A 1 BROOKLINE,M4-1040 101 LAFAYETTE STREET REVISIONS: ARCHITECT PHONE AIS 7341040 70x @ RAiSz.COM SALEM, MASSACHUSETTS 01970 SCALE: 1/8"=1'-0" PC, CITY OF SALEM HA 021 �ptEsr BUILDING INSPECTOR r o ti (��®/® 1 .120 Washington Street 3`d floor .,�. 7 rrnuEv eovuEs Salem,MA 01970 � 0� 48c) ' , � 02 iR . Y 000 655 70 30 APR25 2014 MAILEDFROM ZIPCODE 01970 I?C-w2>ov ,. NIXIE 015 4E 1009 7204/29/14 RETURN TO SENDER ATTEMPTED — T40T KNOWN :UNABLE TO FORWARD .� 0.1970354595 - 1721-_0455a-25 -64 i