197 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of [Massachusetts
Department of Public Safety
"-•i ::\lassaclumrlls Slatr lluildin);Code(7911 C'\IR)
15uiIding Permit Application for any Building other than a One-or'I'wrr Family Dwelling
('This Section For Official Use Onlv)
Iluildiugpennit Nun+ber Date Applied: ---- Building Official: I, .
SECTION I: LOCA'IION Q le
ase indicate Block Nand Lot N fur locations fur which a street address is not allo.andSlrevt City;Town /ip Code Name of Building;(ilapSECTION 2:PROPOSED WORK
F,Iilion A .MA Stale Code used If New Cun.structiun duck here❑or dmckall Thatapph' in the hvo r- F\isliIll; Budding❑ Repair❑ :\Iteration ❑ Addition❑ DcunAition (Please fill out and submit Appendix l)
Change of Use ❑ Changeof Occupancy ❑ - Other ❑ Specify:---- ____
Are building plans and/or cunslruRitIn lit U11ICI11S being Suppliml as part of III is permit application? Yes ❑ No __---
IS on Independent Structural Engince pg Peer Rvview fJ��•yuired? Yew ❑ No
Bricf Description of Proposed lVork:._ :. 19444�f Qri �11VIK __ .._
SECTION 3:COMPLETE THIS SUCTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,Olt
CHANGE IN USE OR OCCUPANCY
Check here tf an Existing Building Investigation and Evaluation is enclosed (See Rio CWt 3T) ❑
Existing Use Group(s): _ Proposed Use Gnmp(s):_--- ----.—
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposal
No.of Floors/Stories(include hosement levels)&Area Per Fluor(sq.ft.)
Total :Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly:\-I ❑ A-2❑ Nightclub ❑ A-3 ❑ :\-a ❑ :\-i❑ B; Business ❑ T T:: Educational ❑
F: Facto F-1 ❑ 172❑ H; I h Hazard Ii-1 ❑. H-2❑ I1-3 ❑ li-4❑ 1.1-5❑
I: Institutional 1-1 ❑ 1-'_❑ 1-3❑ i-a ❑ :M: :Nercantile❑ It: Residential R-I❑ R-2❑ It-t❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please deseribe below:
Special Use -
SECION 6:CONS TRUC rION TYPE(Check as a licable)
IA ❑ IB ❑ HA ❑ !IB ❑ 111A ❑ IIIB ❑- IV ❑ V:\ o I'll ❑
_ SI(CT ION 7: SI TE IN FORN 1AIION(refer to 781)C\IR 111.0 for details on each item)
Water Supply: flood Cone Information: Sewage Disposal:
I'rcnch Permit DCbrix Re'111Ue'al: —
I'll bl is❑ Check if outside hood /_one Q Indicalr uumicip.d ❑ .\ In•nch will non be I.icensvd Di.posol Sity❑
Pro me❑ or indenlih' /ane� nr on sae sestem ❑ naplirrd ❑or trench or rpv,ity: ._
prnnu is rnclosod ❑ _
I Railroad right-art-way: [lizards to .\ir Navigation: ,. . I . ,:,,,..
N,o:\pphcable❑ Is�tnldore„i 111mauportappma,I+•Irre! I Is Ihcn rvcir+.nvuplrinC
,-r l i1n.rnt It,Mudd c min.rd❑ ),,,Cl „r.No❑ lr,❑ .Xu ❑
SPCIIONS:CON I I:NI'l IF CFR TIIIC'ATE OF 1 1.CU'I':\:VC'Y
Idowil,.l( de: Cyr(;n ugl ). I\I" „ICinln hrn k',u
r. : epmll Lra ,n d l,or I ..
o 1 11 Iii11;„•nl un,w�prin kl, r K+strnl` gip,ri.d�1iful.11ion.: - —
till("IION 4: VROITR'I Y OWNFR AUIIIURIZAIION
mi•,mJ \J,In•ssA Proprrlt O+t rnr
Wu
Name (Print) --- — No. ,Ihd Street City/ruwn
Property Owner Cuntail Informal ion:
I isle relcphone No. (bu.sinc.S) -rciclihune No. (cell) _ c-mail address _—
If applicable, the properly owner hereby authuriZes
Name ---- _--_91rs•t Address _city/ruwn State Zip
to act un the pro pert owner's behalf, in all matters relative to work authorized b• this building permit a +,licatiun.
SECTION 10:CONSTRUCTION CONTROL(please fill out Appendix 2)
If building is Icss than{i,UUll cu.fr of endured s pace and or not un.ler Cunstructiun Control then check here O and ski+SVCiun I0.1
lll.1 Ite•istered Professional Res onsible for Construction Control
7<Z1 - 79ri - 7'� 7 1 l6666 fs _
N, u u(Rc stow) / rcl Sh to Nty��P)uC f S mail ac Ir•s 011L3 Registration Number 17 )e/_ •1al
3 —.
tiucet Addns�OS G n City/Two � � Slide Zip Discipline Espiratiun Date
10.2 General Contractor
Company Name
Nance of Person Responsible for Construction License No. and Type if Applicable _---
Street Address City/Town State Zip
Talc ,hove No. business Telephone No. cell a-ntad address _---
SEC'I'1UN 11:tt+ nF1_.I..,'+_r A 11 r N••.\I li+\ t?.a n:. I M.G.L.c. 152.§ 25C6
A Workers'Compensation [list rims. Affidavit from the NIA Department of Industrial Accidents must be cmmplctcd 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 O No ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Toad Construction Cost(from Item 6)'$_-_
I. Building 5 Building Permit Fee'Total Construction Cost s_(Insert here
1 Electrical S appropriate municipal factor) 'S
1. 1'lumbiny, $
Nutc: .\linimum fee"S--(iuntact mumiripelity)
!. Mechanic,d (IiVAC) 4
i. McCh.loiCal Olhcr 5 Pndosc check I+avable lu
1,. I'olal Cost >- QQD.00 (anuact municipality)and write Check number here --_,--_ -_—.
SECTION 13 SIGNA PURE OF BUILDING PERMIT APPLICAN-T
IIv entering my name bclo+v, I hereby MICA under tilt'Pains and penalties of perjury that all of the information coulauwd in this
.ipl,licali, true—and icrurate to the best of my kmm ledge and underst tndimg.
19ra..• __tt aml .it;n name L . . . _ .._... —. Ildc rrlephunc No,, Uele
II �lrcvl \delress _. CiIP; I,nvn �lelc /gyp
i
,Muniiipal luspector to full out this section upon application approval:
.R,unr•_ 1 talc
1
CITY0FS•vU112 NWSACHUSETTS
' ULILDING DEP.IfKMENT
. �� ;. 120 WASHNGTONSTREET, ) FI.UUR
TEL (978) M-9595
FAA(978) 7*-9844
'-ZiNjBriRLEY ORISCOL L
)rLAYO:t _M0.%L13 ST.PIEARR
DIRECTURUF PL•OLIC PROPERTY/8LI2DtN0 C0161ISSIONEti
Workers' Compensation Insurance Alfldavit: f5ufldert/Contra4:tors/Eiectrfctans/Plumbers
li t illeant Inrormutlnn
� la�e L e?ihl
Mime -ns1-
? / r U/
CitylState/Zip: <,.1✓erS Phone is! 791 7t'
"'re gnu an employer!Check the appropriate bast
1.❑ 1 am a cmployer with 4. Q I;ten a general cunlnclot and II- P
project(required);
employees(Rill and/or part-time).• have hired the suis•conlnetorsow cunslruclion
2.® lain a sole proprietor or partner• listed on the attached sheet. : emodeling
.hip and have no employees These subcontractors have emolition
working liar me in any capacity, workers'comp,inwranca.
(No workers',camp. insurance 5. Q We are a corporation and its ilding addition
required•] afllcers have exercised their ectrical regain ar additions
).Q I mn a homeowner doing all work right of exemption per MCL umbing repairs or Additions
myself.(Norvorken'cump, c. 151, 11(J),and wehavano afn:pain insurunee required.) t empluyees.INo workers'
cump,insurance reyuimd.) er
•nny IPPlla:un dW dLaaYr has rl mwt alw rill raw thv W,liae bulaw.howina their wminn'mmPenudun Pull ay matnvatton.
'1 hvnvuways who.uhmit this Affidavit indlealne they ne doing all wVd and then hin uuride eanlmerele mwr nthtnh a new a111Javi1 indlratina.wh
$\�mmatun that chase his box mwrmmhudan addnlunal.hst.hawingthenaamartherultwenlneu1 and their werim'comp,Palley Inremudae.
/ant an onployet that 11 pruvlJing work4reV comprn.rmlun Insurance
in%u/ararlen. far my empluydrs. Below far the poi/ey undJub alas,
In..urmme(:untpany Name:
Policy 4 or Selr•ins. Lic. d:
-----__ Expiration Date:
Iub Sild,Wdress: Cilyi3tut1u2ip;
\113c13 a copy it the worker'companrtloa pulley declarallon page Ohawing the policy number and aspiration data).
h'tiluru w wcuro cuvera,e as required under.Section 1JA of SICL c. 152 can lead to the imposirian of criminal penalties of a
lire tip Io i1.5cQ01)and/or une•yeir imprkrintnenk as well is civil penalties in the Corm of a STOP WORK ORDER and a lino
,:f up ra 52S0.g0 a Jay tgoinst the viulamr. Ile advkcd that a copy of this.utm"unt fray bo furwirdW to the oil
I,trr,ligattwts:d the 17L1 Ibr insurance coverage vcrillcatiun. Ica of
/du hereby rrni% 9lJfr thegotta ten J/rrnv6lrt,r�prrjury r/mft/reins%unnutlmr ruviJeJ ubuvd fv nut,
p arJ rorrra
LLL
l•F�;•L:7,
Data: _
171jic'ia1 u.e:nay. /ha rani write in tlrir unr, td'r cunt
pIHuJ by n'ty ter town,../jlriu2
Armful lc�nte at
I. 1(u-.tnl of Ilcahh !. Iluildln Ur Llrlwent I.
I C"hyi Town Clerk I, NL•etric tl In.pca Dtr i, I'Inithin;; Ln u p ech
l': ,tldal i'r n:tn:
- - — Jhnnc l:
CERTIFICATE OF LIABILITY INSURANCE /za/olz
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
Certificate holder in lieu of such endorsemerd(s).
PRODUCER CONTACT Diana Harris
NAME:
Risk Strategies Company I FAIC AX
No:
15 Pacella Park Drive EMAIL
ADDRE '
Slate 240 INSURE S AFFORDING COVERAGE NAICO
Randolph MA 02368 INSURERAArbella Protection Ins Co
INSURED INSURER B:
Tds Carpentry, INSURERC:
180 Old Burley St INSURER D:
NSURER E
Danvers MA 01923 wsuRER F:
COVERAGES CERTIFICATENUMBERCL1272450963 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE POLICY NUMBER AWL SUEIR MWO�EFF MMI�DIYVXYY LIMITS
LTR
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea o=mence $ 100,000
A CLAIMS-MADE OCCUR 500050882 /1/2012 /1/2013 MED UP(Any one person) $ 10,000
PERSONAL&ADV INJURY $
GENERAL AGGREGATE E 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $
X POLICY PRO- LN $
IFCT
AUTOMOBILE MMUTY COMBINED SINGLE LIMIT
Ea arsidem
ANY AUTO BODILY INJURY(Per Person) S
ALL OWNED SCHEDULED BODILY INJURY(Per aoaden0 $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Peraocidenl
E
UMBRELLA DAB HOCCUR EACH OCCURRENCE $
EXCESS I-MB CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION VVC STATU- OTH-
AND EMPLOYERS'LIABILITY YIN
,IMITS FIR
ANY PROPRIETOR/PARTNER/EXECUTI E E.L.EACH ACCIDENT $
OFFICERAIEMBER EXCLUDED? NIA
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
If yes,tlesaibe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT 1$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required)
Issued as Evidence of Insurance.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
120 Washington Street
Salem, MA 01970 AUTHORIZED REPRESENTATIVE
Bernie Gitlin/DIH `�L'3�•-' --
ACORD 25(2010105) 01988-2010 ACORD CORPORATION. All rights reserved.
INS025 nntnnm n1 Th.ArnRn ..A Inns am ronrafn. d mAhn of ArnRn
I
CITY OF S.It. f, AUSACHUSETTS
1.rj� i3t.LWLNC OEP.1RT1tLNr
I'0 J7.liHtVCTON STAEBT, ) FLOOR
i et. �97� l�S-9S9!
'UJ®F_ArAY OUXOU FAX(973) 749844
tiUY01! I}omu Sr..PMXJLA
OtAUTOA Of PheLJC PROPlATY/st oole,C01ajjs3tONER
Construction Debris Disposal At'ildavit
(required for sU dema"don and renovation work)
rn accordance with the sixth edition olthe State Building Cade, 180 OUR section 111.J
Oebrisr and the provisions of MGL o 40. 3 54;
Building Permit 4 is issued with the condition that the debris resulting from
this work shall be disposed of in a prope
III, 3 1 JOA. rly licensed wrote disposal facility as defined by NIGL c
The debris will be transported by:
W aY it J ok�or
(n,Jma ut Aaular)
The debris will be disposed of in :
Ih �y4h��t�
(nam•of faciluY)
(Jddreu oYr�ciI �Y1
b�0 !0o r KJnt —
�Jfp
t
'! � O1fce o onsumer arts mess egu ahon . .�, ��
HOME IMPROVEMENT CONTRACTOR I
Registration160668 Type: j
Expiration A11Q012 DBA '
�. ARPENTRV k -k,
��
,in E "
- TODD SELIGMAN`
i 180 OLD BURLEY ST '
DANVERS, MA 61923 L4 _c, Undersecretary
i
Massachusetts Department of Pubhc.Safety
Board of Budding Rc;9tl Itions and Standards
Constru'ctlon Supervisor License ..
• - e '.
A - "License: CS 98126 .y
.TODD SELIGMAN 4
180 OLD BURLEY ST
DANVERS, MA 01923
c - g Expiration: 2/6/2013 -