320 LAFAYETTE ST - BUILDING INSPECTION (3) RECEIVED
INSPECTIONAL SERVICES
The Commonwealth of Ma ,
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)
t Building Permit Number: IDate Applied: Building Official:
Ivf 1J SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
{ 320 Lafayette Street Salem 01970 Park Towers
No.and Street City/Town Zip Code Name of Building(if applicable)
t SECTION 2:PROPOSED WORK
1� Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
L Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition IN (Please fill out and submit Appendix 1)
Change of Use ❑ 1 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 Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Remove existing Metro PCS telecommunications equipment on roof. Restore
location to previously existing condition Majority of the materials removed will be either re-used or recycled
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 CMR 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 ❑ A-4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: igh Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional 1-1❑ 1-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a !cable)
IA IB ❑ HA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ 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: MA Historic Commission Review Process:
Not Applicable❑ 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:
SEav t 2-
S 15
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Park Towers, LLC 320 Lafayette Street Salem, MA 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
r
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less thm 35,000 cu.ft of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
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
New England Electrical Contractors
Company Name
Michael Butters CS-078942
Name of Person Responsible for Construction License No. and Type if Applicable
21 Marion Drive Kingston MA 02364
Street Address City/Town State Zip
781- 585-0040 508.404 - 5361 mbutters@newenglandelectrical.com
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 O No ❑
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor 5000
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 5000
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ 55 (contact municipality)
5.Mechanical Other $ CI Of Salem
Enclose check payable to City
6.Total Cost $ (contact municipality)and write check number here 2022
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 accurate to the best of my knowledge and understanding.
R.Tyler Macallister 508 -758 - 8685 1/14/2015
Please print and sign name Title Telephone No. Date
103 Mattapoisett Neck Road Mattapoisett MA_ 09739
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block# and Lot# for locations for which a street address is not
available)
320 Lafayette Street Salem, MA 01970 Park Tower
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes M No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
3 .I' Office of Investigations
•— . '�i I Congress Street, Suite 100
Boston, MA 02114-2017
" { s lvtvrv.nmss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibh'
ndividuallt New England Electrical Contracting Corporation
Name g3usInes /Drg;miration/l
Address:21 Marion Drive
City/State/Zip:Kingston , MA 02364 Phone #:781-585-0040
Are you an employer?Check the appropriate box: Type of project(required):
1.21 1 am a employer with 45 4. ❑ I am a general contractor and I
employees(fill and/or part-time).
have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.'
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I all a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] c. 152.§I(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box"I niuSt alSO IIII OIII the section below sllo%ving Ihelr workers'compenswion policy intunuation.
I Inmeamers who suhmil This anidavii indicating they nre doing all%cork and then hire oatside conlmctors nmst subioil a new alTidaeil indicating such.
Conmtclors that check This box muss attached an additional sheet showing the nail of the sub-ttnttmerors;md shoe whether or not those entities have
employees. If the sub-contmeiors bave elnplorees,they ntustprovide their workers'comp.policy number,
l ami nu empinper that is prarirling workers'canrpensntiaa iiisurruu e for n{p eniploJ eea. Below is the palicp and job site
information.
Insurance Company Name:Liberty Mutual
Policy#or Self=ins. Lic.9WC531S370327014 Expiration Datc:11/13/2015
Job Site Address: City/State/Zip:
Attach a copy or 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 a
fine up to$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certi under the ia'is rend emtdlies qfiteriurt,that the im orn atiai prvidedabove is trite and correct.
Signatu r e2 Date]
Phone#:
Official use onto Do not write in this area,to be completed by cite or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. Cityrrow•n Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
NEW ENGI RECEIV€0
( � INSRECS1 04AL SERVtC£5:
mN o�G coat/ _
UMM nis FEB S
- a
Thomas J. ST.Pierre,Inspectional Service Director
City of Salem
120 Washington St.,3Ed Floor
Salem, MA 01970
January 14,2015
Dear Mr. St. Pierre:
Thank you for taking the time to speak with me. Please find a Building Permit Application to remove
Metro PCS Telecommunications equipment from 320 Lafayette Street. As we discussed,T-Mobile
acquired Metro PCS a couple of years ago. T-Mobile is in the process of decommissioning duplicative
coverage sites and this installation is one of them.
The decommissioning will remove all antennas,base station radio equipment,coaxial cable,cable ladders
and any other equipment that was installed as part of their installation on the plans dated 5/12/2010 which
are included,restoring the location to its' condition prior to the installation of Metro PCS equipment.
The site will be cleared of any debris. Most of the materials removed will be re-used at other locations or
recycled.
The entire process is expected to last a couple of days.
I have included a self-addressed, stamped envelope to return the approved permit to me.
Your contact during the removal process is Mike Butters from New England Electrical Contractor
Corporation; he can be reached at(508)404-5361
Please feel free to contact me with any questions and thank you for your time on this matter.
Thank you,
-7q[a 7WW4Uvra
(508) 758-8685 o
(508)221-8991 (m)
tmacallister@comeast.net
Tel. 781-585-0040 21 Marion Drive, Kingston MA Fax. 781-585-0090
www.newenglandelectrical.com
adassa a z-x=_ - e --
.-::
Board of R b 3 !un^ ,a% tldids.
CS-078942
ifs
MICHAEL W BUTTE
74 UNION ST k - -
East Btidge aterMA -
ic
@Is
;m,