310 LAFAYETTE ST - BUILDING INSPECTION (3) 3g oo cr< �I
The Commonwealth of Massachusetts
Department of Public Safety Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ • Alteration,❑ Addition❑ 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 ❑
Is an Independent Structural Engineering Peer Rgview required? Yes ❑ No ❑ D
Brief Description of Proposed Work:
.„,¢i_,¢..Ht�N� . '�- ___ -an rLV ..� �f� � /K.PiL7��r.C.yr✓J
.s
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 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-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
I: Institutional 1-1❑ 1-2❑ 1-3❑ 1-1❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ ITA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zane Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone Cl 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: kgyn", I f.ni,s:
Not Applicable❑ 0 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
�✓1Lf.cciwn,/► 4"O"4� ��r�r�•Pii.o YY/Q�ri4
Name(Print) No.and Street d 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 2roperty owner's behalf, in all matters relative to work authorized by this building per it application. '
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If blulding is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and ski Section 10.1)-
10.1 Registered Professional Res onsible for Construction Control
Name(Re ristvt) Telephone No. e-mail r dress Registration Number
(/w 4 2.em� �csc9 Of 970
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Naa�me
l
t 44
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address `s City/Town State Zip
V-k-7w 5718 Z -y3l - 6 r0 5'
Telephone No. business Telephone No. cell e-mail address
SECTION 11:INORKFNS'C0&1PF.NSY110N h\9UkANCF AFFIOAVIT 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 $ Building Permit Fee=Total Construction Cost x (hisert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municip Ifty) '
5. Mechanical Other $ Enclose check payable to ((�j�(�ff
6.Total Cost $ ..3 OOQ t 0 0 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICA
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all o4hc ed in this
application is true and accurate to the best of my knowledge and understanding.
(?Ay rr e n.l2 r 8r-A,,Pler C'OA;rmHCrbi, 2 Please printand sign name Title Date
Street Address City/Town J
Municipal Inspector to fill out this section upon application approval: f /�
Name Date
i
IZ�fiA CITY OF SALEM
1' PUBLIC PROPRERTY
DEPARTMENT
nu::Mf 1 Y:IMIV to 1
Nittw
i18 CL•1' inl r.u,M.LU.w.ui u I IN
A973
I'll: '/747iS�1393 a 1:IN 97e•74C••.146
Workers' Cumpensation Insurance A(Odavit: Hui lders/CuntracturwElectricians/Plumbers
\ 1 )licant in urination
PI as Print Legibly
V e iT0 I IJuviM:yi gramuarinry Indro.duul Y.�
Cify,.5rllc.%iP' �c'�`-v>•' • '�l�eu„c r 9�nNhune iJ�_ �j �8 —'7 y.T— S SB' `Z
'%re)'to an e1"gsloye117 Check the uppruprlate box:
I1 1)M of pro)vct(required):aaa a ens lu cr with 4. ❑ lain a general cnalnelor and 1
cnlPluyccs(iull and/ur part-time).• huvc hired the.vub•contracturs 6. ❑New Construction
2.❑ 1;In1 a sole prnpricnx or partner• listed on the artached sheet. t 7• ❑ ReinoJelin`
ship and have no cmpluycus These subcontractors have
working tier mr in any capacity, workers'camp, insurance. V. ❑ Demolition
INn workers'comp. insurance 3. ❑ We aro a cmpontinn and its
❑ BuiWing addition
3.❑ nyuireJ.) Wrcers have csemiti d their 10.[]Electrical«pain or additions
1 ant a homcuwner Joing all work right ofe3emptitm par NIOL I LQ plumbing repairs or additinne
myself. INo workers'comp, c. 132,11(4).and we have no
insurance requited.)C clnPluyecs. INo workers' 12•0 Roufrupuirs
camp. insurance,required.) I3•0 Other 4;:E�
4u>µqa min thw ur chucYs b el teas alw fill tw the rccum w t Iwlu awwine iMe kwl
ww eumPettuatun IMaicy nlrurmatiura
'I tumw,w $li who alalmit this at"osvtt indiutirte Ih""I duine all work and Ihim him,halide comrade,mwt.ubmil a new atnds•ia imliW ire tuck.!',utlrxtrtn hst the
this bow must allachad an 4414114 1'hwa Jluwine till named/the rubnemrartON and thew rurkere'C011p.tiolmy mrrrmatius,
Jr uar un employer that Ir praWd/nx Ivorkers I curnprnrnr/on brtarnnce/ar ray ernp/aprrt Be/utv la the pally and/u1 ails
/ajerrnuthI&
Insurance Company Valne: CC- .LISW
I'ulicy 4 ur Sclf•ins. Lic.d;� C Ylr 2Sr'y r(/b — �--
� �/ _/.p E.pirulion Date: 9 J 2
Job 5itc-\ddress: �/0 �yau�/Ae ,�-'
1�--' Cl1yr51ateiGp: r r/
Attach n atyy of tlae workers'rmnpunsatloa pulley duclurweiun Pug@(showing the policy nwubur and rsplraNun data).
Pailuru Ito secure coverage as required under Section 23r\ ul'�IGL c. 132 can lead to the imposition oreriminal penalties of a
tine uP It S LSIIO.tM and/ur one-year imprisnnmcar, as well as civil Pcnallics in Ihit form of a STOP WORK ORDER and a fine
prop to i!SQ.w a Jay.iguinae the violator. lie advised Choi a copy of this I amlcmcnt may be torwarJCJ to the UlJice ur
m vf;liu 01A for or io.orancc tovcra;;u tcrilicahun.
/Ja herrhy acrti�y trnt/cr thr paint Card prrrnbirr u/prr/ury that the iu/unnat/on pruridrJ ubuw is tree and correct,
- I) ta. L/ /
t)//l•ia/Cue oa/y. Do not avast in rhdr urea, to hr swap/e/rd by airy or rorva a/jit
City or Town: ` Pcnnit/Lleemr y. I
Iwuinq ,\ushurity (circle anc):
I. 111,ard n(Ifvelth 2. Ilwldinq IJcparnncul 1. C.il):'I'uuu Clerk 4. C''Iertrical Inspector .. Plumbing Invpeetor
G. 1)ihvr
l'�.nt.ael I'cnun:
Information and Instructions
lurra is s--fl 1p provide euln Iol'their a
w ct of Fira.
dcileJ severy eron in the srvi�e o a n
I'Irsuanl to tlis slaws, aormp -
,1pret,t Or Impltcd. Oral or written."
�n�Inpluyrr is defined s"an Individual,purtnership..lasociuno°-corporation or other legal cnsed or any two r t more
in Cm to «s. However the
d Iho loregmnd engaged m a Jwm enterprise, and including the legal representatives of a deceased employer,or t e
t of the
I CCCIV Cf Jr t(aa1C0 uI .al IIId1Yldlt:ll, pestnenhtp,ssoetatioa Or ocher legal angry,employ g ' P
owner of a dwelling horse having not more than ens to ee maintenance'en
who r ides
ur repair work uherein.or the Occupant
such P welling haute
dwelling huusa of another who employ. Pe
or ,it the grounritt or building appurtenant thereto shall lac beeatua of such employment be deemed to tx an employer.
mU chapter 132, §25C(6)also states that"svrry SCSI@ or local lieensla dings I shall withhold the lb for ar or
Vases with the Insurance coverage required:
renewal of r license or permit to operate a business or to construct buildings In the commonwealth for any
Applicant"he has not produced acceptable sv-Neither
of sump
AJJiriunally, MOL chapter 151, 3=5C(7)states"Neither the commonwealth not any of its Political withsubdivisionsi rant
onter into any contract for the perfomtanca Of PIT
work until acceptable evidence of cuntpliarca with the insurance
requirements of this chapar have been presented to the contracting authority."
Applicants
pleatur rill out the workers' compensation affidavit completely,by checking the boxes that apply rt your situation attd if
necessary,supply sub contractors)nume(s),adrhess(es)and prang numbel(s)along with Thickcen e employees of.
LLP)with IT
Insul ince. Limitad Liability Companies(LLCworkero'feompenaaed ftft/oe insurance,(if an LLC oroLLP does have
er than the
netnban or paRnaro, are not required 3 to carry
employees,a policy is required Be aJviud that this alVtdavit may be gis an di to the DepaRment of affidavit
Accidents for confirmation of insurance coverage. Also be sun to Slga and being
the ulsted.8 The onitiav(t should
uestions regarding the low or if you are required to obtain u workers'
he rofrtmeJ ro rite city or town that the application for rho permit or license is being requested,not the [h paRment o
Industrial Accidents. Should you have any 4
compensation policy, please call the Department A the number listed below. Self-insuceJ companies should enter rhea
solf-insurance license number on the appropriate lima.
City or Town Officials rinted
epartment has provided u spalid at
rMast t lira he jute that
the or you to rill outsin the ictcand IIIeve the O T e otllnlvestiurt�y. The DOna has to contact you regarding the tapplitcam.
1'I:asa be aura to till in the permit license nwicbr:eras a a�ill been ee s lead onl csub nitunar. lm idavit ndica in ting currP ic fent
any given y y tit Or
that must submit mulfiplenec ssary)'and VICunder
er ' locations
provided to the
policy informati"t if ha aftlJuvityhut has been attic ally stamcped or marrkedlbys Ilia ald city oretown Inlay be
p o (' Y
town).".\coPY be
applicants proof that a valid affidavit is on tilt for future permits or licenses. t now atusines must m Tilled out tee
year. Where A home Owner or citizen is obtaining a license or pennit not relate)to any business or commercial venture
I i.e. a Jug Ilcen:le or permit to burn leaves cre.)said person is NOT required to complete this affidavit. uasttotts,
I ha I Mica of Investigations would it"w thank you in advance fur your cooperation and shuu ro a
ld you hatnY 4
lease du nut hesitate to give us a call.
p
fhc Ucp:uuncnl's aJdtass, rcicphuna and fax number.
The Commonwealth of Massachusetts'
Nparment of Industrial Accidents
Off ile of[evadQadons
600 Washington Street
Boston, MA 02111
Tel. q 617-727.4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
r;•.I. d 9.'o-ns www.mass.gov/dia
i
I,
CITY OF S.U.&N1, NL Ws.AcHUSETTS
BL ILDLYG DEPARTMENT
120 WASHLNGTON STREET, Yo FLOOR
` TEL (978) 745-959S
FAX(978) 740.9846
KIJBERLEY DR.ISCOLL
MAYOR THo.�tu ST.Pmjtitw
DIRECTOR OF PLBLIC PROPERTY/BLILEING 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 I l 1.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit tl is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c
111,S 150A.
The debris will be transportcd by:
name of hau er)
The debris will be disposed of in
`1e
(name of facility)
(address of facility)
signatuor oermit
applicainr—
date
dchrivdJw
f
courur�
� 34fL .
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978) 740-0404
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the ro ose p p d.
❑ Construction ❑ Moving
❑ Reconstruction Alteration
❑ Demolition Painting
❑ Signage ❑ Other work
as described below will be appropriate to the preservation of said Historic District, as per the requirements set
forth in the Historic District's Act M.G.L. Ch. 4( OC) and the Salem Historic
Districts Ordinance.
District: Lafayette Street
Address of Property_ 310 Lafayette Street
Name of Record Owner: Joel Green
Description of Work Proposed:
Replace existing wood gutters ivith OG prgfile seamless aluminum white gutters to replicate the gutters existuts{
on the house. Repairs to sglltst to replicate existing.
Dated: July 11, 2011 SALEM STORICAL C S>
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.