102 LAFAYETTE ST - BUILDING INSPECTION i I :,,\`,►�� : The Commonwealth of Massachusetts
I,i• Department of Public Safety
.XI.t>sachusetls State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelli
(This Section For Official Use Only)
Building Permit Number. Date Applied: Building Inspector: `
SECTION 1: LOCATION (Please indicate Block M and Lot M for locations for which a street address is not availabl
Io2 Ld {f, SoIJ
No. and Street Cih• /Town Zip Code Name of Building (it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ 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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
Yy w�1(S as—Lr i" sO c s i t
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) ❑
Existing Use Group(s): Proposed Use Group(s): t•
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]PeErFlo®rsq. 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 I-1 ❑ 1-2 El 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 ❑
Special Use❑and please describe below
S: Storage SI ❑ S-2 ❑ U: Utility❑ :
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ 111A ❑ IIIB ❑ 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:
Public ❑ Check if Outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
131 ica to❑ Or indentiA Zone: or un sit required ❑or trench or npecih':
e st:a[em ❑ permit in enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA I li,tori, Conn......nn Rcrir., I'n vr�.•
\nt Applicable❑ I.Stru Clore%whin airport approach area' Is their rec ietc onnpleted'
"I C-on.cnt to Budd endowd ❑ Yes ❑ nr No❑ Yes ❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
lidtlion nl Caic: L'+e Group(sl: Tcpeof Gmstruction: OCaipant Load per Fluor
I)oe> the buildin};contain an Sprinkler St stem.': Special Stipulations: //�[J,,/�✓, �t �J��
SECTION 9: PROPERTY OWNER AUTHORIZATION ,
Name af�td Address of Property Owner
5o G o� jOZ L �7k S
Name(Print) No.and Street City/Town Zip
Property k)%.'ner Contact information: 9 / 0 ^16S 3/ 35
t) cS �iipc _ —
Title Telephone No. (business) Telephone No. (cell) e-mail address
11'applicable, the properly owner hereby authorizes
Name Street Address City/Town State Zip
to act on the pro pert%owner's behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It building is less than 35,0)0 cu.ft.of endos d s pace and/or not under Construction Control then check here O and skip Section 10 1)
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
Co Pang ame: / es q 6K91- pkp 4 �L !r`t1 y %5 717-r1
Name of P�tersYn Responsible for Cur��struy[�ti�u<j/1 License No. and Type if Applicable
SI'- `�2
Street Address City/Town State - Zip
97y90 a-i on
Telephone 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 issuance of the building permit.
Is a signed Affidavit submitted with this application.? Yes 0 No Cl
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item - Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ - Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate mum ipal factor)=$ .
3. Plumbing $
Note: Minimum fee= (contact municipality)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ �,� C7 0 " a (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest tinder 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.
Please printqt and �ihn name / Title Telephone Nu. Date
/t o�r�-ram
titreet Addres. City/Town„ .Sta Zip
Municipal Inspector to fill out this section upon application approval: l t
g� Name Date
1
CITY OF S. .E�N[, LLAss kcHL;SETTS
BL DVOIG DEPA E2i RTJIT
/t 120
W.tmoicrON STREET, )'o FLOOR
w/ TM (978) 74S9595
FA2t(978) 740-9846
KISIBFPIEY DRISCOLL
MAYOR IltOslAi ST.Pt2i.ItRl
DiREGTOR OP PLeLIC PROPERTY/gl'RDLNG CONMOSSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricirns/Plumbers
a s licant Information Plesse Print
.Nairle(ausintess,OryaOraliotvindvtdral): �/I�1 i6� Cio� y f
Address: G � Ate Ol S
City/StatdZip: toot- Phone N:
.ire you to employer!Check the appropriate boa:
1. 1 am•employe with 1 4. 0 1 am a general contractor and 1 Type of project(required):
employees(full and/or part-tuna).• have hired the subcosusacaus 6. ❑New constructioo
2.0 1 am a sole propriety tr partner. listed on the attached sheet : 7. aRemodi ling
:hip and have no employees These subcontractors have N. 0 Demolition
working for me in any capacity. workers'comp.imurasaa 9. Building addition
(No workers'comp. insurance S. 0 We am a corporation and its
rsquirsaL( ailkers haw exercised their 10.0 Electrical repairs or additions
).0 1 am a homeowrwr doing all work right of exemption per Moll. 11.0 plumbing repairs or addidoro
myself.(No workers'comp. c. 152.41(4),and we have no 12.0 Roof repairs
insurance required.) t employees.LNo wadmal I S.D Otbv
comp. insurancerequired.j
.Any apPata t mar shacks has 01 muY ate as our Dior rcria below showing thdr who•conVigOrsolm popsy inerrn Ines.
,if, 11111.who submit rhls aMdsvi indicating sky arm doing all work sae the hie ewsi s samracawa meat SAM&a tie a1lhYvi indiaming meek
T.enOanora AN shack Ohio bon mum an:had m addirwrd rind showing dw ndN of des arbaambwwo and'heir warkaaa'coral•PdKy idatnWs
!ass act eatployer that b pravidlnd workers I compensodow twsomere/er aq act
informudoxi pluyawst eNuw b/he pe!!cy ew1/o1 s/ar
Insurance Company Name: 1 C
Policy N or Self•ins. Lic. M: C C 5 OOG .2 S S 6/ l -'� oo 9 Expiration Date-
Job Site Address: 10�L �/t o r vi Sr- City/state/Zip �O
A sack a copy of the workers'codtpeoatba policy declaration pap(showing the policy Dumber and expiration do").
Failure to secure coverage as required undar Section 23A of MGL e. 152 can lead to the imposition of criminal penalties of
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties is the form of a STOP WORK ORDER and a fitas
of up to S250.00 a day against the violator. Ile advivatl that a copy of this statement maybe furwur&.d to the Olylee of
Invesisdatium of ilia MA for insurance coveralls v.riticatian.
/Ja hereby erraft rile iwa an/penaplp ofper/wry that the in/orwallow provided abew tr
ue un an✓tar►rei
u.�r_ uuca d c� I� Data:
/J
P. onct J? O ! 90 Y025 —
ofllrie/use only. Do mot write in this area,Oahe surxp1e1d by city ay.torv=iMunibing
City or fuivn: Yrrmit/l.lccnsehsuinrAuihurtty (circle one):
1. Ituard ofIlvullb 2. Ruilding Department 5. Glyfrown Clerk J. Elec6. Oiher
Person: _ Phone
v
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
W.I+III\I,:. )1'XLrT �.\I I'\I, St.Ni\I ill it I
N
l'FI:47tl•N 7iys � I°.\%:97tl-N4'1tlM
Construction Debris Disposal Af idavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the Slate Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit _ _ 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
ll1. S 150A.
The debris will be transported by:
4
I name of,hauler)
The debris will be disposed of in
(name ofaci Ity)
laddress or Cacility)
' signal of permit applicant
d40
date
Icln i.�II,luc