265-267 LAFAYETTE ST - BUILDING INSPECTION "t► The Commonwealth of Massachusetts', t
V, I Department of Public Safety
%IOS.achu.etts State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1-or amily D e i
(This Section For Official Use Only) 0 If
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block A and Lot N for locations for which a street address is InM available)
No.and Street JCity /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
Existing Building ❑ Repair❑ Alteration ❑ Addition ❑ Demolition 0 (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 Ije�view required? f+ nn Yes ❑ - No ❑
Br of Description of Proposed Work: Ce—pl C'f-I n
I0C P ry\19, ✓ + Ot ti.SC,(� Sf ;-�S :t n tM a vA eA
r�1JYY��v��mrn g )I��S �2 r��eAltf,�� -Pvis rNat .
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): S
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: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑
1: Institutional 1-1 ❑ I-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2 R-3❑ R-4 ❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use: U
SECTION 6:CONSTRUCTION TYPE (Check as applicable) -
IA ❑ IB ❑ - IIA ❑ 1IB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 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:
Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site ❑
required ❑or trench or specov:
I'riya h•❑ or indentily Zone: or on site smstem❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: NI:\ I li,torir C Hry ivo Fr,% .:
Not Apl licobly Cl I.4tfultUre mcithin airport aF+proach area.' 1. [heir review completed,
�n Cnn.cnl to Build enclosed ❑ Yes❑ or No❑ Yes ❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I diiion of Code Lbe Gnnq+(,) Tm pe of Cominiction: Occupant Load per door:
Do,-, the building cont.iman Sprinkler tivaem.': Special Stipulations:
��� fro
SECTION 9: PROPERTY OWNER AUTHORIZATION
Namv and A.4•-ire s Pro,erty Owner
Name(Print) No.and Street City/Town Zip
Property O yner Cu t Inlurmalion:
c T-61 -5g9-H-1�040— aa5 O0
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner herebv authorizes
Name Street Address Citv/Town State Zip
to act on the property owner's behalf, mail matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,tNx1 cu.ft.of enclosed s pace and/or not under Construction Control then check here O and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
.Scab// � (�PSIPu /I 978 S�`1 SaG �( S��tA IN1LOcc>„en4-,- 1K9 51
N, me(Re ristrant) Tele phone Nu. e-mail address Registration Number
7 l hlnNL � V- J «i^ Y``A ca I tit C r ,0- 10
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
o''ntractor
Company Nafn - (A (P U(- 60
Name of Person Responsible fur Construction l License No. and Type if App`li/cabl�
�`� VQxnyMC �J yyfc iA � ,PX of �V
tree[ A11dr� � City/Town 3 A @ State Zip
Zi tie f-
�l irS p
Telephone 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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
I. Building $ L4 0 O jEnclose
lding Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $ //d
4. Mechanical (H VAC) $ Note: Minimum fee=$ �7" � (contact municipality)
5. Mechanical (Other) $ check payable to
6. Total Cost S ct 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.
Please print and sign name Title Telephone No. Date
Street Address Cityi Town St.tte Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
L2 /2(
it
CITY OF SALEM
PUBLIC PROPRERTY
Q > DEPARTMENT
rJtll:: HI I I I'K11
\I`.1,�It 120 W.\il UNG:D.N SrRLrT •S,U P\1,Sl-"Nt 1II it I l I:I'�
TCI:VS-143-9;95 ♦ ls%x:978-Ia4'1846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In 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 t __ 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 by:
�riL Z ViSPD��
The debris will be disposed of in
(name of fociI ity)
(address of facility) 1
si nature of permit applicant
date
Ieb i.�a toe
CITY OF SM.&M. NLkSSACHUSETTS
BUUMLNG DEP.\RTNlVgT
• 120 WASHLYGTON STREET. Yes FLOOR
TEL (978) 745-9595
FAX(978) 740.9846
KI.1%fgEALEY DRISCOLL THo&LuST.PtFIIRt[
MAYOR - - —
DIRECTOR OF 1K'gL[C PROPERTY/gl'1LDLVG CO.%L%rtSStON'ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Blectrfcfans/Plumbers
>nnllcant Information / y Please Print Lezibly
cv.Nalne IBusin OrtatsuatiomindsvtdualY. f��f)14 `,'(D ( () - lL
Address: LP 11
city/statdzip: `Sec-14 ✓vvF Phone Al. f I8- fG Cl
Are you to employer?Check the appropriate boa: Type of project(required):
I.❑ I am a employe with 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the subcontractors
2.(V 1 am a sale proprietor are partner- listed on the attached shceL: 7. 0 Remodeling
.hip and have no employees Thee subcontractors have tt. 0 demolition
workin for me in an capacity. worker'comp.inswaaoe.
t Y P� tY• 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
J.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[Na workcri comp. c. 152,§1(4).and we have no 12.0 Roof repairs
insurance required)► employees. two workers'
comp. insurance mquired.j 13.0 Other
'Any Applicant this chocks boa♦1 mum also no Out the action below Anteing Their workan'catttpene>eGm policy wk metim
't hmnewa ese who submit this aHldavis indlaring they are doing all work and there him outside enormities m w mhmb a nw'Mcievit inclicmitq suck
:r'.mtm:toa AM cheek this but mud anachod an addition sh ns showing the noma of the wtktppnetps and thew w rkan'cp V.policy iorormm m
l one an employer that b provid/nir workers'campensadent buatrome for try exphtyers. Below/s the pollry andm rlar
informatiaw. I I_
Insurance Company Name:
Policy N or Self•ins. Lic.N: Expiration Date:
Job Site Address: City/State/Zip:
,%ttsck a copy of the workers'componsatloa policy declaration page(showing the policy somber and expiration date)`
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
rune up to 51.500.00 and/or one-year imprisonment,as well as civil penalties is the form of o STOP WORK ORDER and a Rd
of up to 5250.00 a day against the violator. Ile advised that a copy of this matemont may be rortieurded to the Office of
Invcstegatiuna ul'dre DIA for insurance coverage verification. .
l dot hereby a•rlffy under the paiws aid penaties of perfury that the beformadow provided above is true aid aarrret
Dale: 10141-) /U,J
Phone A:
Official eat Only. Do nor write in this afro,10 be cutnpletd by city or lawn offlria!
City or futon: _- eermit/I.Icense N _..
I
Nsuing Aulhurity (circle une): - -- - —
I
I. Iluard of IleAlb 2. Ruilding Department ). Cityfrown Clerk J. Electrical Itupector 5. Plumbing Inmpeeror
6. Other
l.mttact Person: _ .__ _.. Phoneat:
I
Salem Historical Commission - - --_
120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT.311 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 6L967 T afayelte St
Name of Record Owner: 265-267 Lafayette Street Realty Trust
Description of Work Proposed:
Repair/replacement of fascia, soffits, trim and aluminum gutters to replicate existing. Repainting in existing
colors as needed. No change in color, material, design, location or outward appearance. Non-applicable due
to being in kind maintenance/replacement.
Dated: October 22, 2009 SAL HISTOXCAL COMMISSION
By:
_.: t >s >=�� yet
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.