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312 1-2 LAFAYETTE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts 6[31111ding Department of Public SafetyV.t.SAChtnrlt.State Budding Cede I:BU C. IR)Seventh Edioon City of Salem Buildin Permit A lication for an Buildin other than a I- or 2-Famil Dwellin (This Section Fur Official Use Onlv) Permit Number: Date Applied: Building Ins pr.TION (:/LOCATION (Please indicate Block N and Lot M for locations for w ich a street is e 1� 3L�_�,.�(A6AN�TTli NIA- No.and Street City /Town Zip Code Name ut Building(ita lica le) SECTION 2:PROPOSED WORK It New Construction check here Our check all that apply in the two rows below Existing Building(>I( Repair❑ Alteration ❑ Addition�'d Demolition Cl (Please fill out and submit Appendix I) Cha nge of Use ❑ Changeof Occupancy ❑ Uthrr ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes Ot No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No 10 Brief Description of Proposed Work: /' Yuen?' Z L/A4i7-S 7F) 49AJA &qOD ,O Dt✓r:Lt.i yG i T /L LPL&ren _ ht/LGtzs mw;"0L+.cwz 06!x eLLAtF- 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): /2-2 f Existing Hazard Index 790 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.) 30 Total Area(sq.ft.)and Total Height(ft.) #91la 3 ' 7?-7(( 1 3`1 � SECTION 5:USE GROUP(Check as ap licable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H. Hi Hazard H-i ❑ H-2 Cl H-3 ❑ H-4 O H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 b$• R-3❑ R-4❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: NSTRUC"lION TYPE(Check as a licable)[,:..�SECT�ION6; ❑ IIfA O IIIB ❑ IV ❑ VA � VB ❑ SECTION 7:SITE INFORMATION(refer t ,7B0 CMR 111.0 for details on each item) I Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Pub It,14 C heck if nW>ide 19ood Gme l� Indicile municipal Jill '\ trench wdl nut be Ltcen.,d Deposal Site I$ PI 1"Ite❑ or indrnotc Zone:_ car un mite+v,tem ❑ rrquoed ❑or trench r�pcuiN.JJ / - prrnt a enclo,ed y I Railroad right-of-way: Hazards to Air Navigation: tl:\ I Lib n, i ...ni I"-„..: \ q \hFd t:,tble)3( I.Stnrcturc\ rth u\,\uport approach art•a' I.then'n•\ic\.".mfdctvd' .al •,nrnt I'. Budd V,16"ed ❑ Yr.❑ SECTION 9:CONTENT OF CERTIFICA TE OF OCCUPANCY I.,t it ism •1 C •de 77cak— L`v(.r,,ufn.c v fv pve -t t.,n,trucI1,m . ticcupow Lned l.ur Boor I) o.thv Dmldinq.ont.un an Spnnklvr}\.tent': .L� Spvc tat Shpulaoon. SECTION9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Z,4My,FT7�- :447- Thus'- QD AQA 2033 -<AG/>M MA O/97v 7_y33 Name(print) No.and Slruet City/Town Zip Pnaperty Uwner Contact Inturm.uiun: y�� ('Au�a4c�rs [/ALD2atU 979 - .7z- 7-29� _— CAL4 4JEH Wr V ORG Title Telephone No.(business) Telephone No. (cell) a-mail address If,applicable, the pn+perly owner hereby authorizes (',00/1L.l:S MAN/( /3 944-1 ST- &ANGNJSS� fG A C/ Name Street Address City/Town Slate Zip to act on the ro pertc o+v nets behalf, n all matters relati+a to work authorized by this building +ermn.i +dic.ation. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (if building is Icss than 35,UW cu.tr tit rndoscd s+ace and/or not under Construction Control then check here O and skip 5ecliun 10,I l 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name: Al s S4rzn/o S-S�B9 CsG u Name of Person Responsible for Construction License No. and Type if Applicable /3 /£[AI Sr- MIA O/9 4,k Street Address City/Town State Zip C/7t -R.1- 9etlo 2e/ -29-e- 4-qa lV1AfDh1re fLr CdAn Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 2506)) 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 031� No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) =S�ZOr UVQ 1. Building $ Building Permit Fee=Total Construction Cost x.0!r (Insert here 2. Electrical $ 9.F /j appropriate municipal factor)=S /O4/Zp 3. Plumbing S 4. Mechanical (HVAC) S 44, U Note: Minimum fee=8 (contact municipality) 5. Mechanical (Other) S 2a Enclose check payable to 6.Total Cust S 9zd O (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Hs,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 th�e/vest/ol y nuOwl-edg�e an—d understanding. Mir r/a:L C SAlLND /��k��tY / S4PlriU/rrnuoFr+r �p/-2Y�4SrW f /3 /O I'led.p print,md sign n.nnc• ride telephone No. Date _/-7 .r9Mr71! LIAY ! 4utNs MA Ci9oL ti wvi Wdrel, l itc/'T..cn Sl.i to Gp I municipal Inspector to fill out this section upon application approval: _ I \ame Date f I� . . . • • -\dJAO-GNI N WIoNDO oR MMILWHERE TEAMWORK BUILDS RESULTS l it 13 ELM STREET MANCHESTER MA 01944 C.HARLES MANN _ Po 978s25.6034 CHARLIE@WINDOVERLLC.COM F: 9%6.526.9409 M: 61 7.839.6278 C The Commonwealth of Massachusetts Department of Industrial Accidents _= OMCO 011MOSIIll0Il0IIS 600 Washington Street, 7th Floor Boston,Mass. 02111 Workers'Compensation Insurance Affidavit. Building/Plumbing/Electrical Contractors •i--ayC;"qww ^-u••ua�.p—}f'®s_.+q.P'6 J a? ^'.vgislr'. 'aM^. :;'r�'�t :;FF. n1 AppdcantinformaHon. -:�Please�AItINT.lemlih' name: C (-1J1nL/nS MrPIA-e/f address: /3 f/fit el� city P'I-lLe44o 07r,-eL state: Yt9/a- zip' 621.01'9 ohone# work site location(full address), y"lA4 0 i 97to ❑ I am a homeowner performing all work myself. Project Type U New Construction 14Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition »,..w•araw+��€ r� ;&�'". ., ,r:%e:...�.�.a._..r..:,�r""w� ."m�..,...a�:,n.,i�,.:..,�z•`�..�....3'...:"�i.err L�""''R;�'•arw'-' I am an employer providing workers' compensation for my employees working on this job. company name; L.VIN00VA rt I''i?HS77EAce- &e 02 7N4 address, /-? F40" 9 city, M.6KGtfx.S, lI -L M, 0/9 y 4- phone#: 97,f- Sz L 1 q/Ai insurance co �Li14e4W"A t lAeq-4 R 7 GG 5— 2 77 S ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: commmv name: address: city phone#: insurance co policy# commuty name: address city, phone#;_ insurance co. Policy# _Att_achaddrflonal'sheet d'neces ,rt _ ..o..�.. .u.w.�.:..�. r:.s. u..a Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains anyd penalties of perjury that the information provided above is true and correct. Signature / ��' Date Print name ir'ffroie4,z„ /✓//frH/J Phone# 97 fr— _rZ.S—�1DZ� Lcontact cial use only do not write in this area to be completed by city or town official or town: permit/license# ❑Building Department ❑Licensing Board heck if immediate response is required ❑Selectmen's Office ❑Health Department person: phone#; ❑Other �a Sept.20031 — Frorn Amanda L.Morgan FaAD:McLaughlin Insurance Page 2 of 2 Date:t/112010 04:54 PM Page:2 of ACORD CERTIFICATE OF LIABILITY INSURANCE °nL° DATE O1M11 io PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE McLaughlin Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 828 Lynn Fells Parkway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Melrose MA 02176 Phone: 781-665-2775 Fax:781-665-0295 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A: Aspen Specialty Ins. .CO. INSURER B. Commerce Insurance Company 34754 Mr. Justin Belliveau P M Construction, Inc. INSURER C: *Ziean intornatll ecepardes r. Justin 13 Elm Street INSURER D: Manchester MA 01944 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOU IREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CON DR IONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. rQL LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMOD/YY DATE. MMD/YV LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIALGENERAL LIABILITY CR0946109 01/01/10 01/01/11 PREMISES(Ea oc mnce) $50,000 CLAIMS MADE ;C I OCCUR MED EXP(Any one person) $ 1O,OOO X ISO Form C00001 10/01 EDITION PERSONAL B ADV IN XRY $ 1,000,000 X Contractual Liab. GENERAL AGGREGATE s2,000,000 GEN-L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY X JECT LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ee emiden[) ALL OWNED AUTOS BODILY INJURY B SCHEDULEDNJTOS 09MMLP6481 06/15/09 06/15/10 (Per person) $ X HIREDAUTOS BODILY IN JURY $ X NON-OWNEDAUTOS (Pereccident) PROPERTY DAMAGE $ (Pereccident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANYAUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ 5,000,000 A X I OCCUR CLAIMSMADE CXA4GS709 01/01/10 01/01/11 AGGREGATE $ 5,000,000 DEDUCTIBLE X RETENTION $10000 $ WORKERS COMPENSATION AND X TORYLIMITS ER C EMPLOYERS'LIABILITYWC009399316 03/20/09 03/20/10 E.L.EACH ACCIDENT $500,000 OFFIANY PROPRIETOR/EXCLUDED? It Ws,dRIMEMBER EXCLUDED? EL DISEASE-EA EMPLOYEE $ 500,000 S yes,AL PRO under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMB $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Project: Job #WC09038 - Lafayette Realty Trust. Additional Insured is listed as follows for GL if required by written contract with the named insured: Lafayette Realty Trust. CERTIFICATE HOLDER CANCELLATION LAFAY-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WNITTEN Lafayette Realty Trust NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$0 SHALL 312 Lafayette Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR PO Box 2033 Salem, MA 01970 REPRESENTATIVES. AUTHORIZE PR NTA O ACORD 25(2001/09) ©ACORD CORPORATION 198E i CITY OF S.uzm. NLkSSACHUSETTS • BUILDING DEP kRT i&NT 130 WASHNGTON STREET, 340 F100R TEL. (978) 745-9595 Fax(978) 740-9846 KL,jBERi R.Y DRISCOLL T ,MAYOR ftot�tas ST.PIERRI3 DIRECTOR OF PUBLIC PROPERTY/BUILDING CON IISSIO.iER 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 e 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: J—/aSTY_ D/Si0OS4L (name of hauler) The debris will be disposed of in (name of facility) Tones; s—. �r.,az�oy r-ra. (address of facility) signature of permit applicant date JcbriviY.duc ''�� y �`� 1111111111111111111111111111111111111111111111 2@09073106072 Bk;28827 Pg;96 07/3112009 08:53 DEED P9 112 Southern Essex District ROD Date: 07/31/2009 08:53 Rn e 738858 OocC 20090731000720 Fee: E1,545.84 Cana: $339,000.00 QUITCLAIM DEED Locus: 312 Lafayette Street, Salem, Essex County, Massachusetts 01970 1, MARY T. COLLINS of Salem,Essex County, Massachusetts, in consideration of Three Hundred Thirty-Nine Thousand and 00/100 Dollars ($339,000.00)paid, grant to JOHN M. HARTLEY, Trustee of THE 312 LAFAYETTE REALTY TRUST established under a declaration of Trust dated '5_ 114 3c t 2009 and recorded with the Essex South Registry of Deeds herewith 6ving a mailing address of 152 The Lynnway, Suite 3A, Lynn, MA 01903, WITH QUITCLAIM COVENANTS the land in Salem together with the buildings thereon, situated at 312 Lafayette Street and bounded and described as follows: EASTERLY by Lafayette Street, forty-four and 4/1001h (44.04) feet; NORTHERLY by Forest Avenue, one hundred twenty (120)feet; WESTERLY by land now or formerly of Edward C. Mack as shown on a plan hereinafter referred to forty-two and 89/100 (42.89) feet; and SOUTHERLY by Lot A as shown on said plan,one hundred twenty and 1/1 OO'h (120.01)feet. Containing 5,216 S.F according to said plan and being shown as Lot B on a plan of "Gladys M. O'Malley, Lafayette Street, Salem, Mass", dated February 1949 and prepared by Edwin T. Brudzynski, Registered Surveyor, and recorded with said Registry in Book 3658, Page 190. �aX3� Said premises are conveyed subject to, and with the benefit of, all easements, restrictions and agreements of record, insofar as the same are now in force and applicable. Said premises are conveyed subject to real estate taxes assessed by the City of Salem for the fiscal year ending June 30, 2010, which have been apportioned as of the date hereof. Being the same premises conveyed to me by deed of Ann M. Dominick, Trustee of the Dominick Investment Trust which deed is dated April 16, 1998 and recorded with the Essex South Registry of Deeds in Book 14742,Page 309. WITNESS my hand and seal this M day of July, 2009. ary T. Coll' COMMONWEALTH OF MASSAC14USETTS Essex, ss July 29, 2009 On this 29'" day of July, 2009 before me, the undersigned notary public, personally appeared Mary T. Collins, proved to me through satisfactory evidence of identification which were MPr DY1V_ Lt(' to be the person whose name is signed on the preceding or attached document, and acknowledged the foregoing instrument to be their free act and deed. Ep""VgENST'•e, r . .ex i r :�. �•:ur fs. J hionui benstein /Notary P� ission Expires. a-a ••ti• N07AFtt Q ``:, Board of Buis d ng Rem gafioeata�o P < Co nstruction Supervisor License I CS 58289 . }' !4/2010 Trk 17046 �es t i _ MICHAELS SAR 17 BLACKSMITH - - SAUGUS,MA 01906 Commissioner ;r 1 I I 1 1 1 1UP I 1 I I 1 I 1 I I 1 (E)1J IOISTS 1 � 1 LIFT 1 I 1 I I FIRST FLOOR PART PLAN 1/4'-1'-0' w/# 632OCL 2x4A16'0.C. S.B.W. GROUT CORES x r r H REBAR r_________ ________________ I I L - X LIFT 2x4.16'0.C. S.B.W BASEMENT PART PLAN N .zaos U RAL ^ z 1/4'=1'-0' 9�,Gr �o SS/ONAL ECG 312 LAFAYETTE ST. ABERJONA ENGINEERING INC. +' DATE: 1/11/10 BTPolC1U9AL ME M/ESTID TM RENOVATM IEBTgUTM SALEM, MA ONE MOLNr VERNM STREET TEL 7 8172 8 818 8 JOB 1k - P.O.BOX 2I5 FAX 781.729.7880 DWG WWCHrSTEK MA 0=0 DRAWN BY, CLW SCALE 1/4'-1'-0' S-1 i i i i I i i i i l i i I (E)iJOI&S i I ' I i i i i DN I i I ATTIC PART PLAN UP i (E)LIO&S i DN. i i LIFT �SNOFPggs SECOND FLOOR PART PLA T URAL 0.24067 9FG1ST`cP�O iakkQ '•�FSS/OVAL ABERJONA ENGINEERING INC. DATE, 1/n/10 312 LAFAYE�E ST. 9}f8K'1UTAL OE9W N IXiOTIOtl i AT IE9rdUT SALEM, MA ONE MOUNrVEMMBrts-Er TEL78V296M JOB NO,BOX 215 FAX 781729.7960 DWG YAIJCHESIE MA GIM DRAWN BY CLW SCALE, 1/4'-T-0' S-2 LINE OF CMU P.T. 20 SHOE WALL BEYOND P.T. 20 SILL 2x4 S.B.W. W/ 1/2'+ E.B. 6'-0' O.C. II I II Z-0' NOTE: SAWCUT EXIST. SLAB SECTION X-X -"OF •`> 9p JO U RAL 1. o. 067 A GtSlEPdo y> RSStONAL E��'� 312 LAFAYETTE ST. ABERJONA ENGINEERING INC. DATE 1/11/10 41H1CTl99lIL OEBCN fNLSIl0Al10N IQ1GVAlICW IESrdMT09 SALEM, MA olE reouw VErmaa srlEEr TEL 7M.729.M JOB Nm - P.O.BOX 2G FAX 78t729.7960 DWG WNCHEgret MA OMO DRAWN BY CLW SCALE: 1/4'-1'-0' S-3 I _ Lp mrzxpzr�IsM OF DfM4 So.D1SLSAL , . .0 Fitp�1�asNs A aoq., EDWARD C. MACK FENCE ..... . 42.11 42.89 0 0 GARAGE ++ RIGHT OF WAY i CONCRETE 1J11.6,AREA Li X Q Z o O C W oLOT A a ma A A 4984S.F. S•F. IN W 3 w a 1 w E Z ' a w312yy i 312 < O Ll Ll 40. 440 LAFAYETTE ST. PLAN OF GLADYS M. UMALLEY LAFAYETTE ST. SALEM, MASS. SCALE IUN=20FT. FEB.1949 �1 , /. RECI.ST ERED EYOR iRVI-YA's" i