330 LAFAYETTE ST - BUILDING INSPECTION (2) .. a
�1
__� ,, ^,► The Commonwealth of Massachusetts
I Department of Public Safety
\Loss,echo.cttsState Building Code(780C\IR)SevenlhEdition
\ \ City of Salem
Building Permit A lication for any Building other than a 1-or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block 0 and Lot 0 for locations for which a street address is not available)
No-and Street City /To%%n Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Additiun❑ Demolition ❑ (Please fill out and submit Appendix 1) +
P-
Change of Use ❑ Change of Occupancy O Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineerin Peer Review required?��pp Yes ❑ No
Brief Dves crpth—o=: d Work: e_( CXL -2 a F(Gof
nF
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
Exising Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
[N,,.,,')f Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Tta Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ T H. Hi Hazard H-1 Cl - H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑, 1-4❑ M: Mercantile❑ Residen R-1❑ R-2❑ R-3❑ R-4❑
S: Storage 9-1 ❑ S-2 ❑ U: Utility❑ Specta se❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 111B ❑ IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 78o CMR I11.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
PP Y°
Public Check if outside Flood Zone❑ Indicate municipal'K A trench will not be Licensed Disposal Sit'A
I'ri va to❑ or mdentik Zone: or un site system❑ required❑or trench ur�pccif%:
permit is enclosed Cl
Railroad right-of-way: Hazards to Air Navigation: MA I li,ttm, t"�nnmi—wn Itcci,+,
\ot AI+I+hcoble❑ I.Structure,cnhm airport appru,tch area' Is their re\iecv onnpleted'
oi.(' ni�cnt lu Budd cnck"ed ❑ Ycs❑ or No❑ 1'es❑ \n ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edmmm tit Co • Lse Group(,): r,pe of Construction: Ocaipdnl Lund per Iluuc
I)..• Ie bwlding contain an Spri cm'' Spca,il Stipulations
1
SECTION 9: PR[O/PERTY OWNER AUTHORIZATION i e
N.}a�mean/dAddrrssolPn�purtyOwn3O� 4 t° C/� �91e4�1 !/"(A
Name(Print) Nu.and 5 reel City/Town Zip
Property Owner Contact Information:
Title •Telephone No. (business) Telephone No. (cell) a-mail address
It a �plicable, thr ro pert •owner hereby authorizes ;� J � / / „^ ,Y14 eyF
. game eet Address City/Town State Zip
to act on the pro pert%owner's behalf, trial[ 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,M)O cu.ft.of enclosed s pace and/or not tinder Construction Control then check here O and skip Section M i)
10.1 Registered Professional Res onsible 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
Cm any C-5 90
Name of Person Responsible It unstruction License No. and Type if Applicabllee'7 5.-
s�r Address f�sE? City/Town State Zip
373� 97F a��—�D°—�
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 $ 3UUZ7"CIV Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ C700.Ufl appropriate municipal factor)=$
3. Plumbing $ (7660.-Gy>
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to �l�
6.Total Cost 8 �G (1C9C,' (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 aanndd accuRrate to the best of my knowledge and understanding.
l r•Isi� V �r•,UeS+ pre�tdsa t 478 . 47s- 3�7):l; NJ fi
I e c p int an .i • e —4 -Title Telephone No. Dale
slreel A rc Lhe�i City/Town State Zip
V y
Municipal Inspector to fill out this section upon application approval:
Na e I ate
10
0
64b CITY OF SaU.&M, AxSSACHL;SEM
BL BDLYG DmATIEINT
120 WASHNGTON STREET, )era FLOOR
TEL (978) 745-9595
FAX(978) 740-9SM
KIJfBEXLEY DRlSCOLL
MAYORTams ST.PIERRR
DIRECTOR OFPLaLICPROPERTY/flUtLO VGCOSOnSSIONER
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electric]ansiPlumber s
>nnlicant Information //��j) Please Print Le iblr
Vainc ItlusinnrOrQamratiotilnJrvidual):nnl &),57aipke I Dave q
Address: S!� JLrWiuq� 3 V'0,<4
cily/st'tcizip:Nd 6)Fgs Phone*
f .\re you are emplayat Cheek the appropriate pea: Type of project(requised):
1.ClI am a employer with a. 'fP6'{1 am a Sencral contractor and 1 6. Q New construction
onployees(full and/or part-time).• have hired the sub.contmctora
2.a I am a sole proprietor or partner- listed on the attached sheet. I 7. (4 Remodeling i5 tit pro i�a
ship and have no employees Then subcontractors have a. Q Demolition
working for me in any capacity. tu
worker'comp.irnage e. 9. Q Building addition
1No workers'comp. insurance S. Q We are a corporation and is IO.Q Electrical repairs or additions
offices have exercised their
).Q 1 am a komcownw doing all work right of exemption per MOL 11.[3 Plumbing repairs or additions
myself.(No workers'comp. C. 152.¢IM and we have no 12.❑Roof repairs
insurance required.]t employeata.LNo workers' I).Q Other
comp.insurance required.]
-Aar applicant mr chocks bee n mow era no uma the aachan below showing their wkatsI cons w.'d a Pulley n.wm,ulao,
't I..
aM subetil this affidavit indicating ihcy am doing all we*set des hate Oneida cowetams mew submil a new of dwil indicating awe►
r,wi ion AM chock this box mural anachad so atdiliwal Jut'hawing tinter of the nA.ceantao.s sed.hd waAe.r'ton p.Policy inrsmaria.
I one eiv ernpbryer that bOreviding workere'compenat des leaeremee for,coy employees) jeieha te fMe pellry gnarl"161111,
informedom
Insurance Company Name:
Policy M or Self-ins. Lis.p: Expiration Date:
Job Site Address: City/State/zip:
,attack a cc"of the workers'compensation policy deeiaslloa pap(showing the policy number and expiration date)6
Failure to secure coverage a required under Section 2JA of%1GL c. 152 can lad to the imposition of criminal penalties of s
fine up to S 1.500.00 and/or one-year imprisonment,as wall as civil penalties in the form of it STOP WORK ORDER and a lice
Of up to S250.00 a day against the violator. Ile advi.%W that a copy of this sralemem may be furwarded to the OlYlce of
Invc.ugaiium of ilia DIA forinsw2rice coverage veritieatioa.
1,10 hereby corn/' nadir thw pains and peno/tles of per/ary'hor the in/brarodaa provided above is true and cowed
—
O/Jlccal use wily. De/tor Write In this arrw,to be,ump/aed by city or rows a//1cioL
Cary or fawn:
Atuing Awhurity (circle tine):
I. Ituard of Ileallh 2. Rudding Department J. City/roan Clerk 4. Electrical Inspector S. Plumbing Inipeetor
6.Uther
Phone l/•
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.r,u: Nl n � 111ti 1.0
..\I ,1,qt I!c w.,,,i,m;.o.NSmrT •SA HNi-f M-%' '
l Fl:478.74 9M ♦1'.\X:978.740.1846
Construction Debris Disposal Af idavit
(required I'ur 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 # _ 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
l 11, S 150A.
The debris will be transported by:
Inane ut hauler)
The debris will be disposed of in :
_ 7�*
(nam
e of a�my)
(11d11ress 11f aclllly)
.ignatu of lxrm' a plicant
date
Ic6i i.dl d,w
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 34690
Restricted to: 00
CHRISTOPHER J DAVEY
545 SHARPNERS POND RD
N ANDOVER, MA 01895
�-�- �=:* _ Expiration: 1219MIl
('unm�issiuner Tr#: 13645
I � Bo�"d"o w mg �uTefio7fs n an arts-
HOMEIMPROVEMENTCONTRACTOR
Registration 110256
Expiration 1011.3/2010 Tr# 275112
T .
v� ype Individual
CHRISTOPHERII�DAEY7�'
-i
CHRISTOPHER DAVEY i �F��
545 SHARPNERS POND R Q�,.eGLe�.`
N ANDOVER,MA 01845`._,-' Administrator
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03/02/2010 15:38 7816310219 BOBBLES PAGE 01
AWN. lliowos Mc Gya4i
3/1/10
To whom it may concern,
I, Derek Rando, of 330 Lafayette St. Unit #2, am proposing to have the
bathroom on my first floor remodeled. All of the work is interior and includes
installation of a new tub, new sink and new tile.
The purpose of this document is to be sure that none of the other members
of our Lafayette Condo Association are in opposition to the remodeling of
the interior of the first floor bathroom of unit #2. 1 believe your signatures
are required to obtain the proper permits.
3 W Iu (978)