292 LAFAYETTE ST - BUILDING INSPECTION (5) The Commonwealth of Massachusetts
*�
Department of Public Safety
nn Massachusetts State Building Code(780 CMR)
`+. J Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Apphed: I Building Official:
t SECTION 1:LOCATION(Please indicate Block#and Lot#f�orr locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
1
^ SECTION 2 PROPOSED WORK
\1 Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 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 eview equ ed? `` Yes ❑ No ❑
Brief escriptionofProposed Work:
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITfON,O.
CHANGE IN USE OR OCCUPANCY c''t
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s): _
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-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F., Facto F-I ❑ F2❑ -. Hi Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I4❑ 1 M: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage Sl❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 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:
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:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
/ZS Go�L �E� ; mil L gals PULL.
(AD t L,L.
-712_& G�u�D; SEND 1-0 t 5-1- BFspT CW .
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title 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 owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 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
NameN(Re an T le hone No. e-mail address Registration Number,
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cp'
Company Name
u;\\ : �"' 5 h C-
Name of Person Responsible for Construction License No. and Type if Applicable
\�\ %Tcm o , Lcl\.t Ae, 0IC\1.-)
Street Address City/Town State Zip
Telephone No. (business) Telephone No. cell - e-mail address
SECTION 11:WORKERS'COWENSATION 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ V!;� Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ j 60 (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 kn wI a and understanding. -1 1_ 1 IL
Please[1yrmtandsignp�n,�7e. S TitlG/�/,,� Telephonoe/N�o. Date
Street Address City/Town Mate Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF &U EN4 N'IASSACHUSETTS
• BUILDING DEPARTMENT
120 WASHINGTON STREET,3'a FLOOR
TEL (978) 745-9595
FAX(978) 740-98"
Ki.,%IBFRi FY DRISCOLL
MAYORTt-Ionus S'r.PD3RRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLNDSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
1
Name(Busirtess.OrgattizarioNlrttlivitfual): � , �` t t^^ S���
Address: � � -•
City/State/Zip: P,— Phone#: ok�1�J��� `—)-1
Are you an employer?Check the appropriate box: Type of project(required):
11 am a axraployet widt 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the subcontractors 6. New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and have no employees These sub-contracmrs have 11. ❑Demolition
working for me in any capacity, workers'comp,insumnce. 9. Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 1011 Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152.§1(4),and we have no 12.2�Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp. insurance required.]
•Any applicant that checks box 81 most also fill uut the section below showing their workes'compensation policy infomtadon.
I Iomoaamets who submit this affidavit indicating they an doing all work and then hire outside contractors must submit a new affidavit inditatins sued
lContracton that check this heat must attached an additional sheet showing the name of ate sub.commmas and their woken'comp,policy infenratton.
!am an employer that Is providing workers'compensadom Insurance for,my employees. Below Is the polley and Job site
information.
Insurance Company Flame:
Policy#or Self-ins.Lie.#: Expiration Date: D -bpi —1 '
Job Site Address: ��`) t —\ (� City/State/Zip: S0�\fLY1� >As, O )q t j
Attacb a copy of the workers'compensation policy declaratlen 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 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 Office of
Investigations or the DIA for insurance coverage verification.
1 de lrereby certify under the palms a rd penahles�oj/fperJury that the information provided above is true/and correeL
. i•n titre- /(ryJ, �_L6'�---� Date,c � 1 7— ) l/V
Phone ti ( 7 5f J'rf1f)77'LlO ,r—�
OBicial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone M
i CITY OF S.UX.N1, iNvLkSSACHUSETTS
• BU ILDIING DEP,,RT%tErT
130 WASHIINGTON STREET, 320 FLOOR
TVL (978) 745-9595
FAX(978) 740-9846
K13tSERLEY DRiSCOLL
MAYOR THonus ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BU;II.DING COMMISSIONER
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 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 by:
(name of hauler)
The debris will be disposed of in :
Ib 10�.s eo-5 Z\
(name of facility)
(address of fac' ity)
M
signature of permit applicant
date
Jcbri>JI7Ja:
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL July 6,2018
suemirrw To: First Baptist Church of Salem
292 Lafayette Street
a.
Salem, Ma.
We hereby submit specifications and estimates for.
To remove all existing roof shingles from remaining top three sides of
front tower roof.
To install ice and water shield covering all lower roof edges and under all
flashing points prior to re-roofing.To Install up to 50 linear feet of roof boarding as necessary.
To Install synthetic underlayment paper covering all roof boarding prior
to re-roofing.
To install all new metal drip edge along all roof edges.
To Install GAF standard three tab charcoal roof shingles matching
existing roof, covering complete roof as mentioned above.
To counter flash, re-flash and/or reseal power vent and skylight as
necessary.
To replace numerous broken and missing slate on main building using
matching black Munson slate.
To clean up and remove all roofing debris from job site.
We propose hereby to furnish material and labor—complete in accordance withsbovs,specifications,for the sum cf.
Seventy Five Hundred ----Dollars ($7,500.00)
Payment to be made as follows;
One third to start balance upon completion
All matertal Is guaranteed to be specified. All work to be compietad in a workmanlike manner according to
standard practices. Any alearation or deviation from above specificauons Involving extra costs will be executed
only upon written orders,and will became an extra charge over the esdmats. All agreements contingent upon
stokes,accidents or delays beyond our control. Owner to carry are,tornado and other necessary insurance.
Our workers are fully cove bye rkiran's'Compnation Insurance.
Acceptance of Proposal—Yo re authorized to do the as
Authorized Signature: /!
Signature: —7
Date of Acceptance: C -b