The URL can be used to link to this page

375 LAFAYETTE ST - BUILDING INSPECTION (2) f � 100 The Commonwealth of Massachusetts 3$CD13c� h}�$ Department of Public Safety VVfJI�� Massachusetts State Building Code(780 CMR) uilding Permit Application for any Building other than a One-or Two-Family Dwelling (� V (rhis.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) ln' 1A Fg e 0 970 No.anA Street City/Town Zip Code Name of Building(U 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 LEx sting Building Repair X1 Alteration ❑ 1 Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1) 1`— Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied m part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description o ropQsed Work: C'�i{/� , J SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY -. Check here din Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Fluor(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 B: Business ❑ T E: Educational ❑ F: Facto F-1❑ F2❑ - H: High Hazard H-1 ❑ H-2❑ -H-3 ❑ H-4❑ H-5❑ I: Institutional [-1❑ 1-2❑ 1-3❑ I-4 O M, Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6.CONSTRUCTION TYPE(Check as applicable) - IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ - IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Trench Permit. Debris Removal:Flood Zone Information: Sewage Disposal: A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify: Private❑ or indentify Zune: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: _\IA Historic Commission Ke.de�r_t'nxess: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes O or No❑ Yes❑- No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Dues the building contain an Sprinkler System?: Special Stipulations: cpLt_. I 5 , SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Addre s of Property Owner 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 roperty owner hereby authorizes ,i Am" �a•�T� Ya7 kk t // s/_ 0116,q¢may 1'n4 01 c 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). . - If building is less than 35,000 cu.ft.of enclosed space and/or/ not under Construction Control then check here O and skip Section 10.1 10.11Registered Professional Responsible for Construction Control Jd , ��ntTi�nIV 97ff_�h/_7�C� ��nr�Ta�n,��JoTraf�uV^ cs G�rTao� Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - 1�d�.r, Corn any Nan, �� -�� r f� Hic- /yr�gz rx y z�l Name of Person Responsi le fur Construction nn License No. and Type if Applicable t/ � l�l s1' IfF��3U21 N?0 �960 Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKE S'COMPENSATION INSUItANCE AFFIDAVrf 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? Ye No ❑ SECTION I2:.CONSTRUCTION COSTS.AND-PERMIT FE . - Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ TE50 Building Permit Fee—Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cos[ $ ��G (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pa i I ny and penalties of perjury that all of the information contained in this application is true and accurate to the e t of/my knon Ce e,nd understanding. ToLe AL 7�0� / / Please print and sign name Title Telephone No. Date yoJ /'u.c 6/ 4 M/, oo' Street Address City/Town ^ State Zip Municipal Inspector to fill out this section upon application approval: - Name Date Details Page 1 of 1 to O wfa Vvo,giio of ire G x cunvu ` iC ofSa;eEy and Sccu,dY(EOI'SS) Fdaa<vcv-lome State Agencies_ U,Qensee Details Inf�rmaf Full ame: " O F PANTAPAS ender: — er Name: dress: ddress 2: City: PEABODY State: MA pcode: 01961 o nt U ted tates License o: CS- 0 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 11/3/2015 Issue Date: Expiration Date: 10/16/2017 License Status: Active Today's Date: 11/4/2015 Secondary License: Doing Business As: atus an e: Lic se Renewal- L o rere uisite Information No Discipline Information Doc umen um Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id—l&license_id=275948& 11/4/2015 CITY OF SALEA MASSAaAEEM BUIMM DEPARTMENT 120 WASHIIVGTOT MEET,3IDFiooR 7kL(978)745-9595. FAX(978)740.9846 KIIvIBERIEYDRiSODLL MAYOR 7MMAS ST.PTERRE DntEcro9tcFPuBiwPxor mlB uimm commsicmR Construction Debris Disposa/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 c40,S 54; Building Permit 8 is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) �+ �� g . YT (address of facility) ignature of applicant Date stG'Q�10 �-- CERTIFICATE OF LIABILITY INSURANCE F °"'E°"N°°A"YY' 1,i02=15 " THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. Nthe certificate holder Is an ADDITIONAL INSURED,the P011cy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain Policies may require an endorsement.A statement On this certificate does not confer rights to the Certificate holder In lieu of such endorsements . PRODUCER E A Kelley CONTACT Bfende CO2ZOlino 450 Veterans Memorial Parkway AfC NO' (401)431-9883 A . i401)431-9889 Building 5 ADOREss brenda eakelley.cem PRODUCER 216303 East Providence RI 02914 INSURED IN A F I John Paotapa5 INSURER A: A.UanhC Casualty Ins Co 42846 407 Lowell Street INSURER& INSURER C: INSURER D: Peabody MA 01960 INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER: NUMBER: THIS is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME D ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR 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, S U P I I ITS t 1AY HA EN R C Y P C IM INS rypE OF INSURANCE ADOL SU R POLICY EFF POLICY EXP POLICY NUMBER uMlTa GENERAL LIABILITY MMMNYWI X t E?CIPI.�C _Rah LI1ti54J / L IPUENCE 1 .1,000.000 1 °I 7777 Si`70 a 50,000 LL V.fy.til0.e. �,-i�.rll} tnF.i E::';.'=nv niti=Gsrs>nl { 5.0D0 AL118001204-1 03r26!_P015 03P-WOie 1.000.000 4 2.000,000 ri£N nSGF F:�wiE AdI A'r.{,:c„FFB X t f b r 1.DOD.QDO AUTOMOBILE LIABILITY ALLUYQYEO.W.!l6+ IuDLI'111j I., wWrsrn'i) S 5-'11EDUl F.iti!!T:iy7 bC_-ILi @!.!IR'i IP��124'.1]willf N:�P:-G:rE DAUYIi'i r i VNBRELLA L W 8 .:.. _i 111+pEiJIE y E%CE$9 LMB Cx I f - CB:dJt:7:EzE Pe,"'NTInAI 4 YKitMERS COMPENSSAATION AND - EMPLDYERS'LIA91LffY VtH 0. IManB�yI�NNJt.a.LLL;,,L N NIA EL Qq,-4 A[Gik:1I f ° F f�a unhf I r vp } f:'i rr L DEBCR TONG OPERATIONS/LOCATIONSf VEMICLESIAaacn ACORD101.AdCal°nNRemaraa Sdaedule.IrmareapaceHIIUu d) Carpentry Contractor. CERTIFICATE HOLDER CANCELLATION Seen Prey SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 375 Lafayette Street. THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Salem MA 01970 AUTHORIPED REPRESENTATIVE ACORD 2512009109) The ACORD name and logo are registered merit of ACORD ACORD CORPORATION.All dghts reserved. The Commonwealth ofMassachuseas Department oflz&cs iialAcddents I Congress Street,Suite 100 Boston,MA 02114 2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FH.ED WITH THE PERMITTING AUTHORITY. ation Name 76 Y1'r`6. _ . Address: 9' �Gx y��✓ �j City/State/Zip: �/� . 2_aV VW q� Phone M / L Are yoo ao emprorerY C6mk the apvraprtate - Type of project(required): 1.Q lame employer with -empoyees(foil ead)orparttime).'- 7. ❑New C011shtrtKlOn 2.RIam esok pmprietmmprmership and have no empbyan w 4=8 formem y 8:�Remodeling . so capacity.[No wotkms'comb.ineure�e regimed] - - 9. Q Demolition 3.Q sin a homeowner doing all work myself.[No worker comP gW A)/ 10 Q Building addition. 4.Q I am a homeowner and will be Was eoabactors to conduct ell work on my property. I will - emure met all conhadms eriher have workers'compemation insurance or are sole I LQ Electrical repairs or additions R WO no�o>'�• 12.QPlumibing"repairs oradditions 5.Q i am a general wmmedoi and Ibave hired the subsonhaaore L90ed on the Maned steel: 13."Roof repairs. 7hae tubsontrsaooi have employees and have wodcttb'a®p.mavanrl 6.0weereacoryoistim msl' fracas hev umciwdmeuii&ofcmmptimpa MGLc. 14�Otber 15Z§1(4).aad we how m employees.[No workers'comp ia9m9aee regmed.] `. .-Anyappliunt met checlu'box#1 must oleo 5a bin the aeetieo below showing me6wmkers pohrymrcrmeh�. t Homeowms who submit this affidavb mdim�g they art doing as work®d meo hue oumde condaiturs must submit a new affidavit mdiretmg each tCmomcm,met check this box must aoarhod as addimaal slodshowing the mme:ofine sub-mnvetl®p sod stale wbdlw or not Pone emaw have employees. If the sob-rsnoaaws have employees,VmY,mwtler vido&eh.workesa':oamp.polurmmber.. .:- . .. I am an esrployer tlea/taproviding rrorAers FyompaW agan imuraacefor my eerplgyees. Below is Thepolley andjob site - inurmatloa � insurance Company Name: Policy#or Self-ins.Lic.M Expu bon Date. _ Job Site Address: CilylStatclZip' Attack a copy of the workers'compensation policy declaration page(showing the policy number and empiration date). Failure to secure coverage as required under MGL c. 15;§25A is a criririnal violation punishable by a fine up to$1,500.00 and/or one-year imprisoMMent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of ap to$250.00 a day agaiort the violator.A copy of this statement may be forwarded to The Office of Investigations of the DIA for romance coverage verification. I do hereby" ' u er lbep d shies ofperjury that the information provided above is true and correct Film OjjkW use only. Do not write in this area,to be completed by city or town t fePai City or Town: Permit/fAcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or writtep." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work urm7 acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)narne(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially damped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be frilled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dqg license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017. Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia