172 LAFAYETTE ST - BUILDING INSPECTION (3) 2-(0L4 1 C--r— I1 12
The Commonwealthio$t'lkI 8 1kbls8@19ES
Department of Public Safety
Massachusetts State Buildingda{eiSpl(�V1R'n 5-'
Building Permit Application for any Building of r han a ne-or wo-Family Dwelling
rye (This Section For Official Use Only)
t ` 1 Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
172 Lafayette Street Salem 01970 Richdale Convienence Store
No.and Street City/Town Zip Code Name of Building(if applicable)
t
SECTION 2:PROPOSED WORK
lr - Edition of MA State Code.used_ If New Construction check here❑or check all that apply in the two rows below
IF— Existing Building C;k I Repair❑ 1 Alteration f Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change( Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? �& Yes ❑ No .
Brief Description of Proposed Work: installation of new flooring ceilings lighting HVAC diffusers
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILD NG UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.) l+t$OO
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2 0 Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4 ❑
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 ❑ IIIB ❑ 1 N ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zane Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public Q Check if outside Flood Zone 29 Indicate municipal W A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required 29 or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable n Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Q Yes❑ No 0
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?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Paritosh Patel 172 Lafayette Street Salem 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Owner 617- 835_ 7261 617- 835. 7261
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable;the property owner hereby authorizes
Scott Dean 1899 Main Street Tewksbury MA 01876
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 budding is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here lXand skip Section 10.7
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
Imperial Demolition Corp
Company Name
Keith Pearson CS-089103 IF-30 - 1 g
Name of Person Responsible for Construction License No. and Type if Applicable
49 Hingham Road N. Grafton MA 01536
Street Address City/Town State Zip
508- 320 5815 508 320 5815 kpearson430(a)msn.com
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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes IR No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$ 24.000
1.Building S 2.500 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ 15,000 appropriate municipal factor)
3.Plumbing $ 0
4.,Mechanical (HVAC) $ 6,500 Note:Minimum fee=S (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 24,000 (contact municipality)and write check number here 0 V�yZ
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.
Keith Pearson /l2z;61� P¢a/L¢BN. Superintendent 508 -320 -5815 4/21/16
Please print and sign name Title Telephone No. Date
49 Hingham Road N.Grafton MA 01536
Street Address City/Town S e Zip
Municipal Inspector to fill out this section upon application approval:
No 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)
172 Lafayette St Salem 01970 Richdale Convienence Store
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No Ck Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No Q Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No Q Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)