265-267 LAFAYETTE ST - BUILDING INSPECTION (2) The Cont177onwealth of Massachusetts
t 1`� Deptrtntent of Public Safety
h u,1114 Sta lc I It dtl all,Cudt (7,0C\III)
Iluilding Permit Application forany HtlildingOther than a One-or'llvo-Family Dwelling
(I Itis Set film For Offir ial Use Only)
f' 14uilJilq; I'cnnit Vwnbcr _. _ . .. It,lly Applied: - --- -- .._..._ �uilding Offiri,d:
SECTION 1: LOCA PION(Please indicate Mock 9 and I of N fur locations for which a street address is not available)
No. and Start Cit)' ;town /ip Code Name of Itui1,11li;(it opplicable) ._. .
SEC-IION 2: 11HOPOSFO WORK
FJiliun of .MA Slur Code u,od - It.Vew Cunsirtu loom die,k hero❑or thrck.ill That I p
1 I\ in the hvu nnec hrluw
Ii,i,Iinl; IhiilJin), Rri+air :1ltcnition ❑ :1Jdilion❑ Urmolition ❑ (11Ioase till ont anti snbllill.\pprnd ix 1)
C'hangv of CIse ❑ Change of Ocrupallry ❑ Other ❑
-
Ara building plans and/or tnnslruttion Jtk'unicnls being supplied as part uF Ulis permit application? 1'cs ❑ 'Nil ❑ --- --
Nall Independent Slruchir.il Engineering Peer Review royu1iry+J? Yes O Nu ❑
1lrivf Ucatrip ion of I'ropoeed Wurk:lr _ I ) (,(-,y�
SECI-ION):COMI'LL'TE THIS SECTION IF EXISTING UUILDING UNUIiRCO1NG ItENOV.\'(ION,A0UI'1'I0N,(]It
CfL\NGE IN USE OR OCCUPANCY
Chrtk here if an Existing Uuilding Investigation and Evaluation is enclosed (See 781)C.\Ili 3.1) ❑
C:x(vting Use Gnnlp(s): _—____.—_— _— Pnrpowa Use Croup(s):_________ __ __
SECTION is UUILDING IIEIGIIT AND,\REA
Existing Proposed
No. of Flours/Stories(intluJe bascnu'nt levels)dr Area Per Flour(stl, ft.)
1•Ut,iI AreJ(sq. ft.),ilirl rot,11 Height(ft.)
SFC'1'I0N is USE GROUP(Check as a liable)
A: Assembly:\-1 ❑ A-20 Nightclub ❑ :\,1 ❑ A4 ❑ :\-3C U: Uusiness ❑
P: Facto P•I ❑ 1:2❑ F: r:Jucalional O
I I: Ili h flat.vJ 11-1 ❑ H-2 0 I f-t O I I-�❑ I I-;O I: Institutional 1-1 ❑ 1•-'O l.t❑ 1.4❑ SI: Jlercantlle p R: Residential It-Ip R-_'p It-1 O It-� O
S: Storage S-1 ❑ 5.2❑ U: Utility❑ Special Use O and +lease Jest nbe below:
tiprt al C'se
SEC TION6:CONS FRUCIIONIYPF- ((-heck.ls,1) liable)
I.\ ❑ 1110 HAC3 IIU ❑ I11:\ O 11111 ❑ IV13 VA \'U ❑
sl( rioN 7: SHE I.V FOItNf.\IION(refer to 7,41)(',\Ilt I1 Lu fur details on each item)
Water Supply: flood Lunv Information: Sewage OispoeJh Trench Permit Debris Rvuuwal;
Pubht ❑ chits it oul.rJc I L'rd Gmc❑ Inditate municipal ❑ \ Iran It cvdl not be I 1 rn,rJ Iti,po,.il tiile❑
I'm ate❑ .,r tuJcinit /,:nr- _ "r, n ,de,t,l,.m ❑ "' Itowd ❑r,r broth or.prate.
I'rnmt I, -o,lo„'J Clkp ft,iiln mp11'.ibn-uf +s'•'Y 1faiards lu.\ir.\,n'iSition: •
\p}•h, L'❑ I I.�trm taro a rthw.urp, rt al,pn,at h .r era' f h Ihru Tent,. ,rnrl,l,ir,l r
rnrin t , Ilu Jul , u,L ,rrl t7 1rsO � r \', ❑ lrs ❑ \, ❑
yFC l IU.V 9: l U.V I I..V r I lF(pl(flPl('.\Ili Uf l l< Cl l'.\.\'CY
I thin n ,d 1, Jt I11'r .,I l ••u.lim lir'n t`rr up.urt l , .iJ },r-ell,•,•r
14., . Ihr l'n JJury;,.nron.in `•Inm.klr r tit.it iu' '•I,r, 1.11 ' Ii1'ul.inrii. i -
CITY OF SALE1i, NLXSSACHLISE'ITS
BUILDING DEPAR"MENT
130 WASHINGTON STREET, 3A°FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KI\iBERL EY DRISCOLL
MAYOR THo%w ST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/BUILDING CON0.1I5SIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
fn accordance 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 # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported 1by:
o.C� c�if iaulerl
The debris will be disposed of in
(name of facility)
(address of facility)
signature ojpeffnit applicant
date
dcbrismidx
CITY OF S UEEi1, NDiSSACHtiSETTS
BUILDING D EP ARTNff_IT
' tr 120 WASHLNGTON STREET, 3'a FLOOR
TEL. (978) 745-9595
FkX(978) 740-9846
KIN[B RT EY DKISCOLI.
MAYOR T HobtAS ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG CONLNIISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant infirrmation V ` �V\ Please Print Le ibl
Narne(Business:Organization/lndiv�idual): ((t�t`A. i.1,1��0 !'N a D( V, Ai)L G'r ie�L
Address: y � 6 W Ylp,-k'k-6 �cii *,i.�
City/State/Zip: `lfi{ (:�R `5 �� �a�a Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
L I am a employer with fMn_ 4. El 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
workin for me in an capacity. workers'comp.insurance.
g Y4. EJ building addition
(No workers*comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their M❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL I I.❑ Plumbing repairs or additions
myself. (No workers'comp. C. 152, §1(4),and we have no 12.Co R000�f��` airs
insurance required.)t employees.LNo workers' 13.0 Otlf"4 A—S
camp. insurance required.)
•Any applieunt dot checks box xl must also fill out the section below showing their workers'compensation polity information.
t I hvncowner,who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new afndavit indicating such
:Contactors that Occk this box must attached an additional sheet showing the norne of the sub�conlrsetors and their workers'comp.policy infomution.
1 am an employer that is providing workers'compensation insurance for ay employees. Below is the policy and Jab site
Insurance Company Name: I'�i`j`U`(,\fit kC.� -p��--1 ! 5" `�S \ Y\ Y\ '1 \ 14\S C0
Pnlicy t!ur Self-itu. Lic.H: Yi WC �I t(13I�I 07�1 oZ O I Expiration Date, ',t ,+
job Site Address: �� '2-(.Q1 •�.T7� City/State/Zip: VVN I V111 tr) Vo v
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Off ice of
Investiguliumv of the DIA for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjury that the befortnution provided above is true and correct.
i',naltire: /r7__\ t i XT/1q't- / 340
Q Data: f o I I I l�-
Phony X: cell t —�� 1 (P
OJfic•iul use only. Do not write in this urea,to be completed by city or town afflcial
City or'rown: Permit/i.lcense#
Issuing,%ul Ito rily(circle one): —_—_^ --_—_—_--
1. Board of Health 2. Building Department 3.Cilyfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Othcr
Contact Person: .,_ .,,_..____ Phone#:
3 � �
3 1 �
��IMNEW��
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 619-5685 FAX(978)740-0404
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other work
as described below will be appropriate to the preservation of said Historic District, as per the requirements set
forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance.
District Lafayette Street
Address of Propertvi 265-267 Lafayette Street
Name of Record Owner:_ 265-267 Lafayette Street Realty Trust M Frisch Trustee
Description of Work Proposed:
Replace porch railings on 2"d and 3.e floor decks at rear of building in kind ivith the exception that height will
be increased to 42" to meet building code.
Dated: October 4, 2012 SALEM HISTORICAL COM�ION
By.
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
g�00N01T,t�o
3 �4 �:r
��MINE DO
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: Lafayette Street
Address of Property: 265-267 Lafayette 4t
Name of Record Owner: 265-267 i 1fa ette 4t Realty Trust- M. Frish Tr
Description of Work Proposed:
Replace flooring of*2"d and 3rd floor rear decks with Azek, conditional that the Azek flowing ivill not be visible
from the public way. Non-applicable clue to being non-visible from the public way.
Dated: September 13, 2012 S/A S CAL COMMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
?: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803
(800) 876-2765 NCCI NO 26158
POLICY NO. I AWC 7026345012012
PRIOR NO. I NEW BUSINESS
ITEM
1i� The insured Data Burke dba Knockdoe Carpentry
Mail Address:
136 Wrentham Street Dorchester MA 02124
Street No. Town or City County State Zip Code -
FEIN xxxxx9642
®Individual []Partnership ❑Corporation ❑Joint Venture []Association ❑Other
Other workplaces not shown above:
2. The policy period is from 04/20/2012 to 04/20/2013 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident$ 100,000 each accident
Bodily Injury by Disease $ 500.000 policy limit
Bodily Injury by Disease $ 100.000 each employee
C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules:SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Par$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 1001462
SEE E TENSION OF INFORMATI N PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 1,121.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 1,172.00
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly
MA Assessment Chg.
$868.00x 5.9000% n $51.00
l Pan
This policy, including all endorsements,is hereby countersigned by 04/26/2012
Autrwnzed Signature Date
GOV I GOV KIND PLACING CLAIM NAME SAFETY WIC Insurance Inc
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP 230 Second Avenue Suite 105
MA 5645 2 701 Waltham,MA 02451
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council an Compensation Insurance,
used with its permission.