193 LAFAYETTE ST - BUILDING INSPECTION o ' ' ' ► The Commonwealth of Massachusetts
r, t
Department of Public Safety
f:.,b�•y .\la.Sachusetts State Building Code(780 C:\IR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspector: "
SECTIO I: 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
If New Construction check here❑or check all that apply in the two rows below
I Existing Building ❑ Repair❑ Alteration JK Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Pe�f Review requi e z Yes ❑ NoX
Brief Description of Proposed Work: Ixe✓�+��� �� �-r••w-
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): r
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 Per Floor(sq. 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❑ 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 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-i❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
[A [I IB ❑ IIA ❑ IIB ❑ IIIA ❑ II180 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:
I'ublic❑ Check if outside 19uud Zane❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site ❑
Private ❑ or indentifv Zone: nr un.ite system ❑ required Our trench ur.pecik.
permit is enclosed ❑ _
Railroad right-of-way: Hazards to Air.Navigation: xl:\ I li't-t% Hrcir � f'n
\,d Applicabic ❑ L structure�nthut airport a1•prnadi area' 1+ their renew nnnpleted'
, r C -n.cnl 61 Build encln.ed ❑ Ye, ❑ ur.Nu❑ `tea ❑ \n ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edui nn .d G ai c: Cie Gruu f,t.0 fc pc of Cnn.trucUun: (.)ccupant Load per l lunr:
I)ne, the budding amain an Sprinkler Sv,tem': . Sln•cial Stipulations:
a��t�
SECTION 9: PROPERTY W ER AUTHORIZATION
N tme and Add �,( Properly Owner d
n S 1 3 �q1 •
i Cih/ own
Zip
Name(Print) NO. and Slrret
Pruperly Urcnc Contact Into l2r •.-
Title Telephone No. (business) Telephone No. (cell) e-mail address
I�ppllc'.tblr, t property owner hereby authorizes
PP 7J �Wt.fnAarMKlt
None Street Address Citv/Town State Zip
to act un the pro perti. o,aner'.,behalf, in all matters relative to work authorized by this buildin • permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is loss than 35,000 cu. ft.ut endowd s pace and/or not under Construction Control then check here❑and ski,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
DP Z e.,7 r
Company Name: D�� C '✓..-.er,ti..,.^� C.S 9)0�c
Name Of Person Res onsible fur Construction �J J`I License No. and Type if Aep icable G/ ,3
Z,u L-.r•., �c rc s+ %ter
Street Address Ciitty//`Town Statue Zip
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AEFIDAVIT(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
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6) _$
1. Building $ 000 '°" ' Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ ! " "- -' appropriate municipal factor)_$
3. Plumbing $ /u u u- "
Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $ .
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ / o o (contact municipality)and write check number here
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. -
8_
Please print and >ign ne Title Telephone No. Date
-Z1 __ l c(-y4 A Q- L /V—)dl 61E03
�trect Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name
�op CITY OF S.0 E.N[, ,NvL-kSSACti SETTS
BUILDING DEPARTNMNT —
120 WASHINGTON STREET, )ao ROOR
TEL (978) 745-959S
F.ax(978) 740-9846
Kl-
.,[BFRLEY DRISCOLL
MAYORTrMA iOs ST.PtEms
DIRECTOR OF PCBLIC PROPERTY/BCQ.DLNG CO%L%llSSIO%E3L
Workers' Compensation Insurance AMdavit: builders/Contractors/Electricians/Plumber
Applicant Information / Please Print Le 1
lalne (ausirKvOmani:arionlnLv,du+lY D �Z (�Jw rcc�Ilgj
Address, 2-o 3A �e
City/State/Zip: ��'I;�S MA o / b u3 Phone a: W7 �I 2 �' Z g 6 8
Are you an employer'Cheek the appropriate box. Type of project(required):
I.❑ I am a employer with 4. ❑ 1 Am a general contractor and 1 6. ❑New construction
�yemployees(full and/or pan-time).• have hired the sub-contractors �(
2.td`I. 1 am a sole proprietor ar partner- listed on the attached sheet : 7. IQI Remodeling
,hip and have no employees Then sub-contractors have s. ❑ Demolition
workingfor me in an ca ace workers'comp.insimus .
Y P tY• 9. ❑building addition
(No workers' comp. insurance S. ❑ We are a corporation and its
requireJ.]
officers have exercised their 10.0 Electrical repairs or additions
3.❑ t am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself. (No workers'comp. c. 152,41(4),and we have no 12.0 Roof repair
insurance required.] t employees. LNo workers' );.❑Other
comp. insurance required.)
•Any applicant that chocb but el moat alwr rill gat the sortie below thowiag their wmkm'comisen"don policy in iinnador.
'I haneuwrtata who submit Mir affidavit indicating they am doing all work and than him outside contractors must submit a new affidavit indicating auek
:c-, ~am am that cbaek this bar must anwhed an additional short showing an name o(the subeoetnmara and their workors•camp,pwicy intwmauo,,
l am an employer that b providing workers'compensedon Insurance for my employees Below is the policy and fob rife
informuniam
Insurance Company Name:
Policy N or Self-ins. Lic. N: Expiration Date:
Job Site Address: City/Stawzip:
mach a copy of the workers'compensado■policy declaralbn page(showing the policy number and explrsdon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,300.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S230,00 a day against the violator. Ile advi.•.W that a copy of this statement maybe forwarded to the Office of
in%catigatiuna ol'the DIA for insurance coverage vcritication.
f do hereby certify under the pains and penalties of prrfury that the information provided above is Irmo and caned
Phonero ? /- ?L'Z -- Zedg'
iOffirial ass only. Do ,of write ie this area, to be.umpleted by city or town o/fluet
I
City or ruwn: _ Permit/l.icense M
i
1%suing Authurity (circle unc)t
I. Iluard of Ileallh 2. building Department ). City/rows Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
G,ntact Person: _ _ _ ___ __ Phone N•
.,.. . CITY OF SALEM-ntsk,:
.m .
PUBLIC PROPRERTY
' '` _" DEPARTMENT
M ql 120 WAilll\G IONSrRErT 4SAI F.M. M,Asi,\t.I It si 1'ii 9
'frj:978.74."+.9+95 ♦ FAX:978-740.9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accord:utce with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit q _._ 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
l l 1, S 150A.
The debris will be transported by:
65. A4ec Gt�-3ry- �rs�
Iname of hauler)
The debris will be disposed of in
C � /v] 9Z
(name ut fact t y)
(address of facility) _.
signature of perm t applicant
date
dtbi rall u,a: