314-316 LAFAYETTE ST - BUILDING INSPECTION ;l The Commonwealth of Massachusetts
Department of Public Safety
/v '�r>.•Z .\Lis..uhuselts State Building Code(780 CMR)tiecenth Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: p Building Inspector:
SECTION L• LOCATION (Please indicate Block# and Eot# foifocations for which a street address is not available)
Jv� / - 5/6
.No. and Street (-itv /Town /'"AI. 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
r
Building Repair Alteration ❑ Addition ❑ Demolition (Please fill out and submit Appendix 1)f Use ❑ Changeof Occupanc ❑ Other ❑ Specify:
ing plans and/orconstruction documents being supplied as part of this permit application? Yes ❑ No ❑pendent Structural Engineering Peer Review required? Yes ❑ No ❑cription of Proposed Work:
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): p
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)
PP
A: Assembly A-1 ❑ A-2W13-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ FH: Hi h Hazard H-1 ❑ H-2 ❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ 1-2 1-4 ❑ M: Mercantile❑ R: Residential R-I❑ R-2 ❑ R-3❑ - RA ❑
S: Storage S-1 ❑ S-2 U: Utility ❑ Special Use❑and please describe below:
Special Use:
CTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ ❑ JIB ❑ IIIA ❑ [JIB ❑ IV ❑ VA ❑ VB ❑
SECTIITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Floodformation: Sewage Disposal: Trench Permit: Debris Removal:
Public ❑ CheckifFlood Zone❑ Indicate municipal ❑ .4 trench will not be Licensed Disposal Site❑
Pei ca to ❑ or indune: or on site,%stem ❑ rellLored ❑or trench orpermit is cndused ❑
Railroad right-of-wayHazards to Air.Navigation: \I:� l ,t��nrc •anmi��i�•n Roc...„ Pr,,r\nt ,\pl,licA,iv ❑ Is,,tilrurture �cilh . or arnai,rrra' Is then' recir�c c�nn ,e 3 F i f l I�•led'
ur l �nrrnt to Build endo. Ycs ❑ or No ❑ Yes Cl \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Fdlthm .q Gdc: Cse Gnniplsl: Ic pe of Construction: OCCupant I ood per I loor:
Di11" the buildmg contoui.vi Sprinkler Scstern.' Special }tipulations:
�-/��• Ohl fV 2,. l,JNfi�/ ���� 1
SECTION 9: PROPERTY OWNER AUTHORIZATION r
dame and r\ddress of Property Owner �-
t,-/kQ 6 k C.tJEv411 f2 47dmmn;I-e Rol � j t (T4-r�
Name(I nnU
No. and Street City/Town Zip
Property Owner Contact Information: �,y, - - `j _5�96
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner herebv authorizes _
Name Street Address City/Town Slate Zip
to act on the property ow net',behalf,In all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out.Appendix 2)
(If building is less than 35,000 cu.It of enclosed<»ce and/or not under Construction Control then check here❑and skip Section ILL 1)
10.1 Registered Professional Responsible for Construction Controls '
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name:T rA N k IDS 4c -C, S O Z'z -7 15
Name 1 7erso,P Responsible fyr Construction �G �p License No. and Type if Applicable 1
Street Address r Citty//town State Zip
9"! 676 5 D77
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 si ned 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_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $ 'Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $ p/
5. Mechanical (Other) $
Enclose check payable to T
6. Total Cost S ((�) (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv attest Linder 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.
,M gAl l / IWvretr' A 978 -53z6sa6 9-zz
I'Icaa• print and >i};n ngme g N, �tle Telephone No. Date
S� �� Mw- o196a
';treel Address City/Town Ita to Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
' R
i
p+g=� Massachusetts- Dcpa mcnt of Public SnfctA
Board of Builtlim_Regulations and Standards
j Construction Supervisor License
License: CS 82279
Restricted to: 00 A
FRANK TOSTE
17 AYER ST
PEABODY, MA 01906
c�lG_ iyi Expiration: 9/3/2011
('nmmissioner TrK: 5243
CITY OF SALEM
$►&
i PUBLIC PROPRERTY
DEPARTMENT
%I`.1" It 120 W.\i111NItIONS7RLCT 1 SAI r\t, MAti V lit ti1.1'i JI'>•"..
T'rl:'178-745-9;95 ♦ FAX:978J40-9846
Construction Debris Disposal At'tidavit
(required 1'or 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 It _ 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
I 11. S 150A.
The debris will be transported by:
(name of hauler)
The debris
'1 will be disposed of in
V V11 t e Gj--D'
(name of face ity
(address of facility)
signature of permit applicant
9 lay I ,a
date
CITY OF SUE-M, AxSSACHL;SETTS
31: DLNG DEPARTMEINT
120 WASNINGTON STREET, 3'FLOOR
TE3L (978) 745-9595
FAx(978) 740-9&M
KI.-,BERL.EY DRISCOL
H1►YOA -I�foatAs ST.Pm1tRE .
DIRECTOR OF PL BLIC PROPERTY/BV ILDLNG CONMIISSIONER
Workers' Compensation Insurance Affidavit: Guilders/Contractors/Electriclans/Plumbers
k a licant Information PI PrintLegibly
Naine (ousirwv.Orpnizatiorvindividual): G/N -e / P Q
Address: `YdS1/ 1� 6W S t—
City/Statdzip: Phone a: 9 78 —
Are you as employer?Check the appropriate boa: Type of project(required):
I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. (3New construction
employees(full and/or pan-time).• have hired the subcontractors
2.0"I am a sole proprietor ar partner- listed on the attached sheet : 7- ❑ Remodeling
;hip and have no cmploycm These sub-contractors have 11. �Ikmolition
workingfor me in an capacity. workers'comp.insurance.
Y P ry• 9. ❑Building addition
(No workers' comp. insurance S. ❑ We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152,41(4),and we have no 12.❑ Roof repairs
insurance required.1 t employees. (No workers' 13.❑Other
comp. insurance required.)
*Any applicant tho chocks boa el must aim fill ant the section below showing their werken'eampenution policy infutmatlou
'I[,. awma who suMtft this aflldevil indicating they am doing all work and than him ounide conneceos ran eo a,,hocl a now aflldevit indicating suck
:C..i muds shot check this bon[mug aaachod an addiliosel+host showing dw rams(fits suktoeunemre and shei,wuhms-cgnp.policy informab".
/am an employer that it providinjr workers'compensadam Ltsmrsaeefor my empltW"a Below/s the Paley ondm site
information.
Insurance Company Name:
Policy M or Self-ion. Lie.p: Expiration Date: -
Job Site Address: City/State/Zip:
\Hach a copy of the workers'compensation policy declaration 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
nine 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 arias .
of up to 5250.00 a Jay against the violator. Ile advised that a copy of this statement maybe forwarded to the Office or
Invcsttgaiions ul'ilie DIA For insurance coverage verification.
/do hereby certify under the pains and penis/des of perjury that the brforareflon provided above is true and earrtet
�;wfmrurc: Date
Pore .i
iOfeial use aa/y. Do nvt write in this area, to be completed by city or town o/ps-imi �
City or rusrn: _ eermitalcense M__
' lvsuing.\u(hurity (circle one):
I. Ituard of Ileullh 2. Ruilding Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Olher _
C.nitacl Person: -. --, -- Phone p•
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