293 LAFAYETTE ST - BUILDING INSPECTION l The Commonwealth of Massachusetts
Department of Public Safety
�`.,�;�,'.✓' \Lv sachusetts Slate Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a I. or - mil el
V_,,t-j
(This Section For Official Use Only) -- --- -
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block® and Lot N for locations for which a street address t of available)
!1-616 (m 0 1q-1 D
No.and Street Citv /Town Zip Code Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair V1 Alteration O 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 Review required? Yes ❑ No ❑
Bri •f Description of Proposed Work; �' S
t v\J YV\
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❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage Sl ❑ S-2 ❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 1180 IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Su m Flood Zone Information: Sewage Disposal: Trench Permit: Debris Remo at:
PublicppI, Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site ❑
required ❑or trench or Specif%
I'rica to❑ or mdentily Zone:_ or on Sile S%Stem ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I:\ I II>t"vi: ..iv„ Pr,
..\nt \PpliCable❑ I.}tructiue wuhin airport approach area' L.their rev ie%c completed.' -
or C o nlent to Budd enClo.ed ❑ 1 Ye. ❑ or No❑ Yes❑ .No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
[.lition of(1111e. L,e(Irnup(.): rope of Gm.truCtion: OCCUpant Load per Floor:
Du•S the building contain an Sprinkler System': Special Slipulali MS:
���� �70 - 4-b `r
L� SE CT ION. 9: PROPERTY OWNER AUTHORIZATION
Nameand ddreso Properh Own•�q 3 ��s Ltbox
Name(Print) No.and treet
C
City/Town zip
Pro�rrh hvnrr Co tact Information: _ /y�r�
t ttr-So I _)0
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to act on the property ory ner's behalf, in all matters relative to work authorized by this build in • permit a >pl ica Iton.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is less than 35,1R)o 2u. ft.of enclosed s pace and/or not under Construction Control then check here O and skip Section 10.1)
10.1 Registered'GSJf-P` Tit 3, 1rofessional Responsible (foutr Construction Control
5tA (QV o, - SaW % 05& COYU(R)A t,, -f
Name(Re�utront) Telephone No. e-mail address Registration Number
S1eViJ, C c %t _ I �Swlch MA NIC ( -0qa`/0
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
SWA1 uyfCSevy
Company NaTe:
C�,h-, q(c,`6) CSC. Go
Name of Person Responsible for Construction ( License No. and Type if Applicable o
t�leV)\A�-C c� '1-�lftn.kc �^ lrA
Street
re ?(A __ City/Town SW�WI,j.-S l� CO �mCgS{tp.r 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❑ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
2
5. Mechanical (Other) $ Enclose check payable to 3
6.Total Cost $ (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 activate to the best of my knowledge and understanding. -
Please print and sign name Title Telephone No. Date
Street address Cit\%Town State Zip
..Municipal Inspector to fill out this section upon application approval:
%a me Date
-6 CITY OF SM.E.`I, A-IiSSACHi:SETTS
BUMDLYG DEP.1timil NT
120 W.%SHLNGTON STREET. )era FLOOR
TEL (978) 745-9595
FAx(978) 740.9846
K(.,(BeRLBYDRISCOLL THom%sST.P[ RRX
MAYOR
DIRECTOR OF PL OLIC PROPERTY/gCRDLNG COSMUSSIONER
Workers' Compensation Insurance Allldavit: Builders/ContractorJElectriclans/Plumbers
-kunlicant Information p Please Print Legibly
Nalne (Huineaa.Organtratiominevidual): \^Lf_// LPI[nf/7�& 1L-
Addrcss: 1 � ( e- �(412-e L0—
City/Statc/Zip: of w l C Phone Al. �' SG�'' S (o CJ
,%re you an employer'Check the appropriate boa: Type of project(rFequlreco:
1.❑ I am a employer with 4. ❑ lam a general contrxter and 1 6. ❑New construction
employees(full and/or part-time).• have hired the wbcontractnrs
2.(yy I am a sole proprietor ar partner- listed on the attached sheet. : 7. ❑Remodeling
\;hip and have no employees Thee sub-contractors have V. ❑ Demolition
workingfor me in an capacity. workers'comp.insuation
Y P tY• 9. ❑pudding addition
[No workers'comp. insurance S. ❑ We am a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
).❑ 1 am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions
myself.(No workers'comp. c. 132,41(41 and we have no 12.0 Roof repairs
insurance required.)t employees. LNo workers' 1I.❑Other
comp. insurance required.]
•Any app a e licam that Ch"kta el must alp fill uW ra the tio.habit absries their workee'cattpwtodun policy infum ages,
'i Lmeuwitpa who sularat this affidavit indicting they am doing all work and dim him amit a emrreeaera must"limb a mw altldwil indi mi g reek
l.wasme on Thai,hack this hex mus attacked an ath ilitatal divia showing do twrlle d flea ah.tymmcawa and thdr wixkeas'rasp.pdiry isrgntaYOa.
i ant as employer that!r proyidlnB workers'compeamtien insaroaee for say employees Below ht the polity oadM sip _
injormufiow, c
Insurance Company Name: C A g n J0 P4
Policy g or Self•ins. Lie.q: Expiration Date:
Job Site Address: City/Statr/Zip:
attack a copy of the workers'compensation policy declaration page(skewing the p9lk7 member and expiration dab).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties ors
tine 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 S230.00 a day against the violator. Ile advimad that a copy of this statement may be forwarded to the Office of
Invcaiigatiuoa of dic DIA for insurance coverage venticalion '
/de hereby cerrijy der the pains and penialdes ajp__erfury thaf the informealott provided above is true and"Preea
/� : GJ(��''"I�W` l_ Dale:
hone d: 7 _ lO�a-J(U9
P ),? - —J u rN
O�ciu!use only. Do nor trrite in this area, re be:urnpletd by city or fawn w/flciuL �
I
city orruwn: _ Permit/LlcenseM____
Issuing.%uthorily (circle tine):
I. Huard of Ilralih 2. fluilding flepartmcnt J. C'ilyfrown Clerk 4. Electrical litipector 5. Plumbing Inipeetor
6. Other
C milact Perion: _ ._. _. Phone#:
T
CITY OF SALEM
PUBLIC PROPRERTY
1 ' ENO DEPARTMENT
.0 120 \Y'.\il 11\G7i1NSCRUT • 5.\I 1'\I, bt.\ii.\I
'fr1:978-'4.+-9395 • I':\x:978-740-9846
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 0 -_ is issued with the condition that the debris resulting from
this work shall he 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 ha�ller)
The debris will be disposed of in
__
� ptame of faci ity)
(address of tacilily)
In A
signature of permit applicant
date
Icbu,all'r.,e
. o
AS
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
`Z 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: 293 Lafayette St_
Name of Record Owner: 293 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 SALEM HISTORIC L COMMISSION
By: ?�
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.