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292 LAFAYETTE ST - BUILDING INSPECTION (6) �t The Commonwealth of Massachusetts T; I,� Department of Public Safety -, � ..%la>sachuselts State Building Code(780 CMR)Seventh Edition U _ City of Salem Building Permit Application for any Building other than a 1- or - amil Dwel n (This Section For Official Use Only) Building Permit Number: Date Applied: Building Inspector _ SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available) 2q2 I-A PQ y e 1-1-e Sl- 41er, Dt9�b �f2sl /�aPhs� C� � �< L� ..\'o.and Street Citv /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 Qf Repair Alteration ❑ Addition❑ 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 91 -- Is an Independent Structural Engineering Peer Review require Yes ❑ No 0' Brief Description of Proposed Work: P-e P/-}1i1 - �o— -k- �EpA•112 Go RN 4=C� C7OS'T" 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): r 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 T4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ ', H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ L• Institutional 1-1 Cl 1-2 ❑ 1-3❑ '1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE (Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA V SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Fbris Removal: t PP Y� Public ❑ Check it oulzide Flood Zone❑ III nuimapal ❑ A trench ,will not bedrcyuired ❑ur trenchls: Ihicale ❑ nr indenufc Zone:_ or on.ite>t,tem.❑ permit i.enclnard ❑ Railroad right-of-wav: Hazards to Air.Navigation: \IA Iolinr c. •inmi��iin Rr,i,„ I'n r.,: \art :\pp iiablc O thin aiipurt apprna Ch area.' I. their ret let, nnnpleted' • I l „n.I'nl to Rudd cncln"od ❑ 1'c,❑ or.Ao❑ Yea ❑ \'i ❑ SECTION 8:CONTENT OF CERTIFICA FE OF OCCUPANCY Ialllun nl C gate. L,v peuf CnnaruCtlon: l)cCpanl Load per Flour _ D''I" the budding;contain an �prinklrr tit-.Icm` tipeCial Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION t .Name•Ind Address of PrupertY Owner } Name(I rent) No.and Street C itv/Town Zip Properly 0%%ner Contact Intormation: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the prupert% owner herebv authorizes Name Street Address City/Town State Zip to act on the property acv,ner's behalf• in all matters relative to work authorized by this building permit application SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (It building is less than 35J)00 cu. tt,of enclosed s race and/ur not wider Construction Control then check here❑and skip Section 10 1) 10.1 Registered Professional Responsible for Construction Control Flame(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor I n '��/ J`m /y�O/nSII�''y f--/Gl'fOh 2eller47 I/I A4 Company Mime-P� /ytr-CAP Y 1 �S 6 J � � Name of Person Resplo�nsible fur onstruction License No. and Type if Applicable Z. W 1 n l-�.o P /A (3n -41 04- O! ! S Street Address City/Town 1 Mate �-�- f g/ 4 q)7 - D - 24 CcnSIi-vL/ie ? ;C-C- oPL , CS/7., 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 st ned Affidavit submitted with this application? Yes❑ No M�— SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor �OQDy D D Item and Materials) Total Construction Cost(from Item 6) _$ 1. Building $ Dbt © Q Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate mun pat factor)_$ 3. Plumbing $ r. %� Note: Minimum fee='$ Y�`� (contact municipality) 4. Mechanical (HVAQ $ 5. Mechanical (Other) 5 Enclose pay able check a ible to o 6.Total Cost $ pQD v o (cntact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By vmerin�'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. I'Icax Tint and . gn nam • C (e z Title Tcicphone \o, Date ll Cet Addle" (`it%I T11 Municipal Inspector to fill out this section upon application approval: _ w CITY OF S.UEM, NAkSSACHL;SETTS J � BU iLDING DEPARTJt&,%-r 120 WASHINGTON STREET, Yo FLOOR TEL (978) 745-9595 F.Ut(978)740-9846 KI,(gERIEY DRISCOI L I MAYOR ?tODtAS ST.P�RRS DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONMSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly f Vatne (Busing»,organi:atiorolndividual): _C ChS•P � - �` ��4—�1`'� n Address: `z> 3 City/State/Zip: Do 'J eT-- y 'r--. O \41 'Phone H: n ?� - 190 2L� Are you to employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 mployees(full and/or part-time).* have hired the subcontractor 6. ❑New construction 2.E 1 am a sole proprietor or partner- listed on the attached sheeL 1 7. ❑ Remodeling ship and have no employees These subcontractor have g. ❑ Demolition working for me in any capacity. worker'comp. insurance. 9. ❑ Building addition [No workers' comp. insurance S. ❑ We ate a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised the 3.❑ I am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repair or additions myself. (No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs_ insurance required.]t employees. (No workers' 13.❑Other P6rf l�el kV S comp. insurance required.] 'Any applicant this chocks bot sl must also fill aul the section below showing their worker'compen Grim,Nllcy infurmaliot� 'I hntwtrwnea who submit this affidavit indicating they are doing all wax and thm hue o mi&carnrnctee.1 submit anew aTdavit indicting such. :C.mtrryon that check this box must amached m aaditiond slain showing the arms,of the eukavmrcfon and their woman'comp.policy inforinmien, lam an employer that b providing workers'compensadon Insurance for my employees. Below/s the pollay and fob ylte information. Insurance Company Name: Palicy N or Self-ins. Lic. H: Expiration Date: Job Site Address: City/StawiZip: Attach a copy of the workers'compensgtioa policy declaration palls(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. He advised that a copy of this statement may be forwarded to the Office of Ins•esugativas oFthe DIA for insurance coverage verification. Ida hereby certify carder the puins utt d ppetraldes of pci: ry that the information providtted above is true and correct Date: l9� 2q p Phone d: OJfcial use duly. Donor write in this area,to be curnplered by city or town official City or Tuwn: _ __ Yermit/L)ccnse N -------- ----- Nsuing Authority (circle one): I. Board of Millis 2. Building Department 3.Cilyfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other I Cuntact Person: _ __ _ ___ _.. Phone p: R Zd 2-q f.- ) 00oo o ® \ CITY OF SALEM l ; j1 PUBLIC PROPRERTY •.. DEPARTMENT Construction Debris Disposal Affidavit (reiluired lur all demolition :md renovation work) In accordance \1 ith the sixth edition of the State Building Code, 780 C NIR section 11 1.5 Debris, and the provisions of:b1GL c 40, S 54; Building Permit K is issued with the condition that the debris resulting from this work shall he disposed of in it properly licensed waste disposal Iacility as defined by MGL c I1I. S 150A. The debris will be transported by: CON rr-CA_G 1-0 I- mam-ut hauler) The debris will be disposed ofin P-CC'Sr--S � (name ur t'acihnty) rn P '. I,uldreYv of I�cilitvl �IL'lIJ1Ull ,>t penult applicant date