287 LAFAYETTE ST - BUILDING INSPECTION (2)r
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�F �� Zc �/ OI L] b � IN�i jC( L SERVICES
The Commonwealth of
Department of Public Safeetyy 59
(�fr W Massachusetts State Building Code(780CMR)
Building Permit Application for any Building other than a One-or Two-Fa y D ing
(This Section For Official Use Out )
Building Permit Number: IDane Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot N for locations for which a skeet address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION2 PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply I Ili the two rows below
Existing Building 0'- Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use 0� 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 Peer Review required? - Yes ❑ No 0'
Brief Description of Proposed Work: CDNUs�� f7)y s�Nr:,r- " R-T-fPL6- 11JIL4?4A1ar TT>
tbuC.A?lora ! FIG_, l ITY
SECTION 3:COMPLETE T1110 SECTION 11-EX15TING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANCE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Croup(s): Propel is Use Croup(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing ProposedNo.of Floors/Stories(include basement levels)k Area Per Flux(sq.ft.) 3 h
Total Area(sq.ft)and Total Height(ft.) -
tQ7 zrRas;7
SECTION 5:USE GROUP(Check as a licab e)
A: Assembly A-1 A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-1❑ B: Business ❑ E: Educational ❑
F; Facto F-1❑ F2❑ H:—High Hazard H-1❑ H-2❑ 11-3 ❑ - H-4❑ H-5❑
L- institutional f-l❑ 1-2❑ 1-3❑ 1-4❑ IV,,,: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-0❑
-- S: Storage S-t❑ S-2❑ Utility❑ Special Use❑and please describe below:
Speci:Sl-Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable) _/
GA ❑ ❑I0 IIA ❑ 1100 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VBM
5EC1I0N 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl : 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❑
Private❑ or indentify Zone; or on site system❑ required ❑or trench or specify: f':C4C'_4
permit is enclosed❑
Railroad right-of-way; Hazards to Air Navigation: NM 1 lea ri i nuti.yi n R m,.•I'n4cs:
Not Applicable t9/ Is Structure within airport approach area? _ Is their review completed? -
or Consent to Build enclosed❑ Yes❑ or No IRS Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Codu2p) — use Croup(s): Type of Construction: WIS
Occupant Load per Floor:
Does the building,contain an Sprinkler System?:_ Special Slipulations:
ZStETS — WLu f5j- � , v f3Lf; Dp PO
- ,SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner """'
l'x`1x kL WT&5 (_ I I 1A)AWIA&W 4—_ MA- ltv_
Name(Print) a:7 O1 A UC `UtNo,anld Street City/Town Zip
Property Owner Contact Informations
Title I Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name - Street Address City/Town State Zip
to act on the property owners behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
o2p 3CJlOS
Name(Re•istrent) Ty.Iephone No. e-mail address Registration Number
jr73a � .�Q Ltm M a)q AaiHfAzr -
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Ni
Name of erson(teseonsible for Construction License No. and Type' plicable
41
Street Address City/Town I" /State Zip
Telephone No. business - Telephone No. cell e-mail address
SECTION 11:wcn:KMS'C(.)MPFNSA I ON INSURANCE AHIUAVIf M.G.L.c.152.§25C 6
A Workers Compensation Insurance Affidavit from the NIA 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 budding permit.
Is a signed Affidavit submitted with this application? Yes r] No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)_$
1. Building Building Permit Fee-Total Construction Cost x_(Insert here
2 Electrical S .00r oo o appropriate municipal factor)=$
3. Plumbing 5. jv,�060a -
4.Mechanical (HVAC) Note.Mininmm fee=$ (contact municipality)
5. Mechanical Other S 55,005 Enclose check Y payable able to
6.Total Cost 3 (350,000 (contact municipality)and write check number here
S N 13: GNATURE OF BUILDING I ERblrr APPLICANT
By entering my name below, I her y attest u Ter the pains and penalties of perjury that all of the information contained in this
application is true and accurate to th best my knowledge and understanding.
Plea se p ii and sign na ne Title Telephone No. Date
Street A wn - State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
r
QTY OF Si _EM, A�sSACHUSETTS
, T
BUILDING DEPAR'f>l&`iT •
i
3v b�r ) 120 WASHLYGTON STREET, 3'o FLOOR
T EL-(978) 745-9595
RILX(978) 740-9846
KI\tBERLEY DRISCOLL
tiL1YOR THo\tAs ST.PiERn
' DIRECTOR OF PUBLIC PROPERTY/BUILMNIG CO\LNBSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians Plumbers
At plictnt_I_n_formation Please Print Lc ti�'bly
NainC Ll C— - -.
Address: W AS hl�ti
City/State/Zip: C AAA (� om Phonelt: M +S 9 7 0) cry/2�
" Are you un employer:'Check the appropriate bust:
,�/ F9. E]
otect(required): _
I.l� t am a employer with 1 4, Q I am a general contractor and 1 consWction
moployees(full and/or part-time)." have hired the sins-contractors
2.❑ I arts a soie proprietor or partner- listed on the attached sheet, t odeling
ship and have no employees These sub-contractors have olition
working for me in any capacity, workers'comp. insurance ding addition[No workers'comp, insurance 5. ❑ We are a corporation mid itsrequired.)' ' officers have exercised their trical repairs or additions
3.❑ I am a homeowner doing atl-work right of exemption per MGL I I.Q Plumbing repuirs or additions
myself.(Nor workers',iump. c. 152, §1(4),and we have no 12:Q Roof repairs '
insurance requited.) r employees. (No workers' 13,Q Other
comp. insurance required.)
•,any upplivan dwl checks box 91 must also fill out the sediun blow showing their workcn'cumpensedun policy inlirtmmlun.
'I lommrwncrs oho wbmil this allirinvil indicating they arc doing ail work and then hire uuaido cantnctun most.nthmll a new 31rdavil indiclaing such,
$•11nm ion thus check this bus mml anachal in addiliurul sbmt showing the nwne of rho mbaentncton and their wnrken'comp.pulley infurmmion.
sss
i ant can employer that is pruvfdinK workers'conipensadun ht.turonce for my eurployees. lfeluw lr rho policy andJub silo
itlfornlation.
Insurance Company Name: Isoi
Policy it or Self-ins. Lie.d: Expiration Dnte: -
Job Site Address: City/State/zip:
Attach a copy of the workers'compensatloo policy#daratlan page(showing the policy number and expiration data).
Failure to secure coverage- - quire under Section 25t\of N1GL c. 152 can lead to the imposition nfcriniinal penalties of a • -
fine up to S1,500.00 u or one-year mprisdnmen4 as Well as civil pdnaitics in the form of a STOP WORK ORDER and aline
of up us S230.00 a 'y against rile olalor. Ile advised that a copy of this statement may be furwardcd to the 011ice of
Invc,ligatiun.s of•d - DIA for ins 'lice coverage verification.
Ida hereby certify ruder t/ Rabb told pernaldec of perjury that the it furolutlott pro viduJd abuve is true and correct.
;i.•n I re p,aq o�7 Data.
Phone -!- /"1 1 /f.-
official use only. Do not write is this area, ra be cuatpleted by city or town gj1ciaL
City or'fnwn: _ _-_ lacrmit/Llecnsc q
Issuing Authority(circle one): �_ - -" ---- --
1. Board cal'ilcallh 2. I)uilJlnq Department .i.Ciiyffnwn Clerk J. Electrical lospector S. Plunlbiug Inspector
6. Other
Contact Perim):
... Phone !s:_- �
I f'
• LA
CITY OF SALEM, MASSACHUSEM
K S 'ail BUILDING DEPARTMENT
120 WASHINGTON STREET,3m FLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR TxoMAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING G01aUSSIONER
Construction Debris Disposal Affidavit
(required for 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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
S-Ao
(address of facility)
Signature of applicant
Date
f
r
YW��ou �A CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
m' 120 WASHINGTON STREET, 3RD FLOOR
s 1,l\ _ /f Q SALEM, MASSACHUSETTS 01970
TELEPHONE: 978-745-9595 EXT. 380
FAX: 978-740-9846
KIMBERLEY DRISCOLL
MAYOR
CONSTRUCTION CONTROL AFFIDAVIT
Project Number. Data:. • Zb/y
Project Title: 287 GA2,s-w a7r6 • $u,Z&I 1G Z&j2y,o'liv4,3
Project Location: 2Y7 l G�Ta ? .4 yv1 .4
Name of BuildingE-,,
Scope of Project:;(,/r A,,oyt A"y rf/OwSTgf;,a az' 1OF/�� ,/Im fLwa Sr�rt m .
IN�CCORDANCE WITH SECTION 118.0 OF THE MASSACHUSETTS STATE BUIDING CODE, 1
CO m-y A. 5 E'G MASS. REGISTRATION NO.3n i � BEING A REGISTERED
PROFESSIONALENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY
SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCERNING: , //
Civil Architectural y Structural Mechanical
Electrical Fire Protection Other(specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING
AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix I.
am ,
PY�W, SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
�dGI�T +PERTINENT COMMENTS TO THE BUILDING INSPECTOR, UPON COMPLETION
ALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION
�Vr A.0 s E PROJECT FOR OCCUPANCY.
u. Signature
SWORN TO BEFORE ME THIS Ii DAY OF 20V
My commission Expires: ! � 2 7.�2 1
Naf<3ry PubIiC ,