287 LAFAYETTE ST - BUILDING INSPECTION t y6 -jo
The Commonwealth of Massachusetts
Department of Public Safety
��•/• .\ ASSaCh USCIIS State Building Cade(780 C%IR)S-%-,nth Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
' (This Section For Official Use Only)
\� Building Permit Number: Date Applied: Building Inspector:
\\ SECTION 1: LOCATION (Please indicate Block B and Lot M for locations for which a street address is not available)
2 9-7 LA,cAYe�TTe 5T Sa4LFin TEMPLE s vAGom
(�\ No. and Street City /Town Zip Code Name of Building(if applicable)
` O SECTION 2;PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration Addition ❑ 1 Demolition ❑ (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 I V
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 3r
Brief Description of Proposed Work: P0LL rc- y /ST/NG KfTCF/E/V RAND /QEOL6CF
t.!/ G/{ B S/ N/< N/7 GFl,4AlG P /M1( LOGRT/ON e) F �/1(/-( -r
No t.a/ 2ciNG
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): m• �,
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 ap licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3 ❑ R-4 ❑
S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use 10"ind please describe below:
Special Use: OO D ffEp, F,17A 5/WA G L- /7N L L
SECTION 6:CONSTRUCTION TYPE (Check as applicable) -
IA ❑ IB ❑ IIA ❑ JIB ❑ IIIA ❑ 1118 ❑ 1 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'Llbhc❑ Check if outside Flared Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
I'ri%.t le ❑ or utderink Zanv: ar on site ncstem ❑ required ❑or trench ar,pecifv:
permit is enchr..ed,❑
Railroad right-of-way. Hazards to Air Navigation: xI.\ I lia . C, nnnir�im Rev w, (`n •,..;
\nl :\i•phioble ❑ I.StFUCtUrc,r(thin airport approach area' I. lhco review nnnplctud'
ur( nrcnl to Build enClo.ed ❑ Ycs ❑ or No❑ Yea❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
G.i m, n..IGalr: C.rC�roupl.0 ry pu of Conrtnidion: t.lcaipant Lead per Floor
I)' the bwl.lint;iontain an Sprinkler tic>tvm.': Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name.Ind Address of Property Owner ---_- J
jEMeL� 5f-1ALOn1 '7 LA -6 XETTE ,AC-EI
Name(Print) Nu. and Street
Cite/Town Zip
Properly Owner Contact Information: 6�rp T/f z
Pj UtLD/NGL�I)t, GN/4lft /�S- '�bS�I- .�- J7.SZ ..J� Vee GIww-J .
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town Slate Zip
to act on the properh owner's behalf, in all matters relative to work authorized by this building permit a p Il icat ion
.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,000 cu. ft.of endoscd s pace and/ur not under Construction Canlrol then check here O and skip Section IQ U
10.1 Registered Professional Responsible for Construction Control
w tU 1A ref f- iNt 6t 9,7g-_,5
oSw J b f'-,0-0 3
Name (Registrant) Telephone Nu. e-mail address Registration las
Numbe_�_
jO 7rvmBLTY AD D�R �oDY IVA a% raa 4A <_a
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
8 /L L F
Company Name: D3
WILL- ti') IYI /=tNEi2 GS � �F
Name of Person Resple for Construction - License No. and Type if Applicable -
I Tt/ /?tEL7onsib Y RD /Jc1j0O0Y mA oi9G �
Street Address City/Town State
_Ite&<, Z—
Tele hone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COfVU'ENSA HON 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
Estimated Costs: (Labor r_
Item - and Materials) Total Construction Cost(from Item 6)_$
1. Building 5 _ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ — appropriate municipal factor)=$
3. Plumbing $
Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) - $
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ !{z UD (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.
wict1&m
Please print and sign name - rifle Telephone No Dale
/v Tvrn ELTY RO DEfIl3oPJY M 0t96o
,;Ireet Address Cih/Town SO to Zip
Municipal In see dor to fill out this section upon application approval: O
Name Dat
�6
CITY OF S.U.EM, ,NLLkSSACHL""SETTS
,is BUILDING DEPART.%M14T
x 120 WASHINGTON STREET, 3'a FLOOR
er TEL (971) 745-9595
FAX(978) 740-9&M
IV%t$FRi FY DRISCOLl
MAYOR -- THowLsST.MM
DIRECTOR OF PLBLIC PROPERTY/SVI DLNG cow% ISstOV ER
Workers' Compensation Insurance AMdavit: guilders/Contractors/ElectrlciansiPlumbers
applicant Information Please Print l.eeibly
Nalnc IBusimk organi:atiomindrvidual): B/G C F/NE9 e-_o/1J S T
Address: 1,e T u rn L T Y R D
City/State/Zip: ✓e�_� ft,OY 07A /9CG Phone At- 535-- e 41-
Are you an employer?Cheek the appropriate box: Ty
pe of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the subcontractors
2.ffI am a sole proprietor or partner- listed on the attached sheeL : y ❑ Remodeling
ship and have no employees These subcontractors have V. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
INo workers' comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.) otYcers have exercised their
3.❑ 1 am a homeowner doing all work - right of exemption per MGL 1 1.❑Plumbing repairs or additions
myself.[No workers' comp. C. 152,41(4),and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers' l3.❑Other.
insurance required.]
-Any applicant that checks hoe sl must also rill out the seclim below ahewieg their worker'compmutkfn policy information.
t I Lvnruwrva who submit this aflldevit indicting they ane doing all work and then hits otmide eentroetor must auhmil a new afRdsvil indicating such.
:C mji rton list check this box must anxhed an all Ounal shen showing the name of tM nrb,,,,Wson and their workm'comp.policy infmrouan.
I am an employer that is providing workers'compensation insurance for my employers Below is the pulley and job site
information.
Insurance Company Name:
Policy 4 or Self-its. Lic. p: Expiration Date:
Job Site Address: City/State/Zip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm 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 Office of
Inveaugatiuna of the DIA for insurance coverage verification.
f do hereby certify under rho pains and petoldes of perjury that the beformadon provided above is tare and carreea
�t nature' � Dat : 9 i�/o9
Phonej: 57e - .535
iOfficial use only. Oo nor write in this area,to be aurrrpleted by city or town ajfu-nii
City or ruwn: _- Permit/LlcenseN___
Issuing.\uthurity (circle one):
L Huard of Health 2. Buildlnii; Department 3. city/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person. _ _ - __ Phone lt:
,t
CITY OF SALEM
PUBLIC: PROPRERTY
s••. .�Iryr
DEPARTMENT
Ili •.v 'r: ,:.,: • I \ •.'d v: .1,.
Construction Debris Disposal Al'lida-v it
(relluircd lilr all demolition and renu%allon caulk)
In accurtlanec %11th the sixth edition of the State Building Code, 7S0 CAIR section 11 1 5
Dcbris, and the provisions of MGL c 40, S 54:
Building Permit H Is issued with the condition that the dchris resulting front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by ,NGL c
111. S 150A.
The debris will be transported by:
� o /ls %.
1 name tit haulier)
I he debris will be disposed of in
(,uDo05 TRA >tlS FEr¢ gTf} 7a77!
(n.rme ul I,ru ny)
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