175 LAFAYETTE ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
c Department of Public Safety
Massachusetts State Building Code(780 CMR)
��� Building Permit Application for any Building other than a One-or Two- a w 11ing
(This Section For Official Use Only)F°5 -
Buildu g-Permit Nuri b'ec - Date Applied ; '13uildmg Ofhctal::.
SECTION 1:LOCATION,(Please indicate Block-#and,Lot#fo'r localions for wlpcli a s address s not available)
n No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION2 PROPOSED.WORK
m
Edition of MA State Code used_ If New Construction check here W"'or check all that apply in the two rows below
Existing Building❑ Repair❑ 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 re uirlIed? Yes ❑ No ❑
Brief Description f Proposed Work:
C - C
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,-ADDITION'OR
CHANGE IN USEOR OCCUPANCY'•
Check here if an Existing Building Investigation and Evaluation is enclosed(See.780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
.i•SECTION.4:BUILDING'HEIGHT AND,AREA:..
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) a
Total Area(sq. ft.)and Total Height(ft.) S
SECTION S:USE GROUP Checkas'a licable
( PP ) 1=
- A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
�F: Facto F-1 ❑ FZ❑ M Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ I-4[1M: 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: _
x 'SECTION 6:CONSTRUCTION-TYPE(Check as applicable) x '
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ -� VA ❑ VB ❑
' - SECTION7:SITE.INFORMATION (refer to780:CMR 111.0 for details ome_ach item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public Check if outside Flood Zone❑ Indicate municipal E ' A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or gpecify:
permit is enclosed i�.� � \jam
Railroad right-of-way: Hazards to Air Navigation: MA,Historic Commission Reelew i rmcss:
Not Applicable e tin airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No g' Yes �K No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): —Type of Construction: - Occupant Load per Floor:
n
Does the building contain an Sprinkler System?: Special Stipulations:
f r
v
.....
SECTION;9.'PROPEI2TY OWNER AUTHORIZATION,
Name and Address of Property Owner
A ,L. �� \ e �e�c�v \\% 5cu)ak'-� no-
Name(Print) �`No.and Street City/Town Zip
o er Owner Contact InformaYfb rS-,S N2.{
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
`tP.S gkask-,
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.
SECTIONIO CON TRUCTION CONTROL(Please fill'out Appendix 2)'N 4
If buildin` is less than 35,000 cuift.of endoseiis ace andjo`r not vnderConstruchon Control-therrch"eck here0 and ski'Sechon 10.1 '.
<10.1 Registered ProfessionalRes'onsible for'Constiuctidn Control-'; -
\d\Gt �ah� "�Le� \Co\
am (Registrant) \Telephone No. e-mail address Registration Number
.(')_ 5\LA 'axe,\#r n l\k C
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contiactor= ;• ` ., , ,,` ,.. a\ ,_ ..r:: .., s:. �s, . i`1 ..,^r,- r:
Company Name
7 e
Name of Person Responsible for Construction ` License No. and Type if Applicable
\_�r L-{'!\r2_.\f?,t- r'� � 1�1')C�`\�1C.(\0_0 � cs\°a�L\
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
;t.SECTION'11:.WORKERS'.CO\1PENSATION 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®-No ❑
m,SECTION 12:CONSTRUCTION-COSTS AND PERMIT-FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building v Se Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ q appropriate municipal factor)=$
3.Plumbing $ QMz
4.Mechanical (I-IVAC) $ a% Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ (� Enclose check payable to
6.Total Cost $ d \ (contact municipality)and write check number here
SECTION 13:SIGNATURE OE 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 off my wl dge and understanding.
�pw Q\c�c c c1J �% -
Please print and sign name I ( i Title Telephone No. Date
5cr1e ct--, c�
Street Address City/Town State Zip
Municipal Inspector to fill out this section:upon application approval
Name:. .Date -
1
n i
CITY OF 5.1LE: [, L L1S&. CHUSEM
Bust-nING DEPARTNWENT
120 C0.1SHLNGTON STREET, 3w FLOOR
'ILL (978) 745-9595
F.a((978) 7-10-9844
KIJIBFRf RY DRISCOLL T'40.% \SST.Pmu s
NLhYOR
DIRECTOR OF Pt:OLIC PROPERTY/EI:ILDNG COSLUISSIONER
Workers' Compensation insurance affidavit: lluilders/Contractorv/Electricians/Plumbers
.\lililleant information Plcase Print Legibly
Name Il3osinesr.Urgmirariary Individual): �.1..'YC�"C'\t! 1-•t�eSA\f
�
Address: \2
City/State/Zip: ne,. Phone N: —1 '�k 1Cn()
Are you an employer?Cheek the appropriate box: Type at Project(required):
I. 1 am a amployor with \ O 4. 0 1 am a general contractor and 1 6. tQl1ow construction
employees(full and/or Part-time).* have hired the sub-contractors
2.0 I am a solo proprietor us,partner. listed on the attached sheet,t 1• ❑Remodeling
ship and have no employees These subcontractors have a. 0 Demolition
working for me in any capacity. workers'camp.Insurance. 9. 0 Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MOL I LE3 Plumbing repairs or additions
myself.[No workers'comp. C. 152,$I(4),and we have no 12.0 Roof repairs
insurance required.) t employees.LNG workere'
comp.insurance required.? 13.0 Other,
•Any applllaun Thal vheellr box t 1 mutt alw all uul the iavlion Mew allowing(hair watksm'compmudon Volley ina,mtanon
'I N.,oa.nas who sollmil ills atlkGvit indleming they am doing all work and thin h1m outside collimators mtal submit a new aflldavil indloling such.
�Cuntmatun that cheslt this box moat attached an a"llunul+halt showing Ill name of the n+64vmraeron and their workers'comp.pulley intamudoo.
l aim on employer that Is provfdfn y workerrs'companrraden lnsurunee far my employees Below la theVolley and Job site
injormuNan.
Insurance Company Name:
Policy 4 or Sclf-itu. Lic,4: (0 (c UI.`L\FS -t-\C lAM -A -1 '�-\ Expiration Data• ��-\ y
lobsite.\ddress: -C��G.�12t'.e.�_ City/State/7ip:
.\ttach a copy of the workers'comps sullon pulley declaration page(showing the policy numbor and expiration data).
Fuilurn to secure coverage as required under Sccilaa 21a\of&fGL e. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonmenk as well as civil penalties in the rants of a STOP WORK ORDER and a line
of up to 5250.00 a day against ilia violator. Ile advised that a copy of this slacemcnt may ba forwarded to the Oflica of
Invcstigwimis of dto DIA fur insunnca covcrago writicaliun.
/du lureby certify under ore n it )eital lot v/perjury that the abuve in irue and correct,
Phunc 4:
i rlj/icru!rue only. Do not wrire in thlr urrW for be completed by city at town alj7clut
City or town: _., Pertrijo.lcense,g
I ssuLlg,\ulhurily (circle one):
1. Iluard of Ifeallh L. lluildinq Ilepartlnwll 1.City/fawn Clerk 1. Gfeetrinl Inspector 5. Plumbing Inspector
6.other
Contact PUSIIIG ..__. .. _ .. Phtlila It•
4
CITY OF S:UzNf, AASSACHUSETTS
BI:=LYG DEPARTMFUNT
120 WASHNGTON STREET, 3' FLOOa
`h 3' T FL (978) 745-9595
t<i\tBERLBY DR.ISCOLL Fla(978) 740-9344
,bUYO/i T�tOS(A3ST.1?LERRS
DIRECTOR OF PUBLIC PROPERTY/BI.•A.OLYG CONNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 730 CNIR section 111.5
Debris, and the provisions of tb1GL c 40, S 54;
Building Permit A is issued with the condition that the debris resulting from
this work shall be ddsposcd of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by;
"C's-ve-sl-�A�, ,tom
— ' (nJnle ut•haulcr)
The ilebris %vill be disposed of in :
�1 \1 (nnma of facility)
�-(Address of t'acihty)
si' iature ofpermit applicant
C�1L1 \'�,
Jatc
175- tray e
CITY OF SALEM FY
ROUTING SLIP
New Construction X
Certificate of Occupancy
LOCATION,�I y 2 _DATE
YASSESSORS DATE
93 Washington St.
CITY CLERK DATE - 44, '�
93 Washington S
PUBLICSERVICES ATE
120 Washing �St.
WATER v"" DATE
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING DATE L
120 Washington St.
CONSERVATION DATE
120 Washington St.
ELECTRICAL DATE
48 Lafayette St.
FIRE PREVENTION d D„DATE 5::hl
29 Fort Avenue 2
HEALTH— �-- DATE
120 Washington S .
p /3
BUILDING INSPECTOR A IE p /3
120 Washington St.