185 LAFAYETTE - BUILDING INSPECTION The Commonwealth of Massachusetts
44 Department of Public Safety
Vy-( Massachusetts State Building Code(780 CbIR)
_ Building Permit Application for any Building other than a One-or Two-Family Dwelling
at
(This S&tioruFotOfficial Use Only)#._
1
? Iding Permit Number. Date Applied Bwld ng Officral
(� SECTION I;LOCATION(Please indicate Block#and Lot#for locations for whtch`a street address is not available)
�OIIVVII 1 q) 5- k-aM k- , a 11.z o
No.and Street City/Town Zip Code Name of Building(if applicable)
"SECTION2PROPOSEDWORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building ElRepair IT Alteration,(] Addition❑ Demolition ❑ (Please fill out and submit ADpendix 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 a—
Is an Independent Structural Engineering Peer Review required? Yes ❑ No a—
Brief Description of Proposed Work: '—P P eP �-✓ i en ..�l 's repo CL.S
SECTION 3:COMPLETE THIS SECTION.IF EXISTING BUILDING UNDERGOING RENOVATION ADDITION,OR
CHANGE IN USEOit 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 AREAS".
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 a' plfcable).-
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4 Cl
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION.TYPE(Check as applicable) .
[A ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA El - 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 incientify Zone:• or on site system❑ required El or trench or specify:
} , f - permit is enclosed❑ -
Railroad right-of-way: Hazards to Air Navigation: `. 'iPdA Historic Commission Review Pr<r:ess:
Not Applicable❑ L Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes ❑ or No❑ ' Yes❑ N ❑ -
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:
i SECTION,9:_PROPERTYOWNERAUTHORIZATION
Name and Addres Pr perty Owner ,
la
Name(Pr' t) No.and Street City/Town Zip
Property Owner Contact Information: 1
Title Telephone No.(business) Telephone No. (cell) e-mail address Q(�
If ap I cable, the property owpper hereby authorizes
Name Street Address City/Town State Zip
to act on the 2roperty owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Pleaie fill out Ajpendtx 2)' o-
if butldiii is less than 35,000 cu ff of enelosed's ace�ariii/or not under.Constniction Control then check here:O'and'ski-.Secnon 10.1
10.1 Re 'steied Professional'Res` onsible for Construction Control''a
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
-10.2 General.Contractor
t- - - -
Company Name45a- :a-J\ ,,cA (�, r; Ci Z{q -7 'f
Name of f Person Responsible for Construction 'D License No. and Type if Applicable
Ark 'd2, (.w(oaw L ENrA e V eQ�2.c d�1 E✓ c, o l ` az
Street Address City/Town State Zip
:3f `3 (( `3 S7et 32-0_ `fce(Z (! �Jc. ® td2✓trl.avt vieF
Telephone No. business Telephone No. cell e-mail address
SECTION II:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M:GL.c.152i. 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[B--No 0
<'r SECTION 42:.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 $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ 2 ( op O (contact municipality)and write check number he e
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 accura th best"nnikid and understanding. ran u i
'In VC
Pleas int an i n name �,�n �Title Tele h
x
Street t\ddress City/Town State Zip /
Municipal Inspector to fill out this section upon application approval:
Name" - Date
i
5
i'
i
CITY OF SA! EMI, A-1SSAcHUSETCS
BL'1LONGDEP.1RT MNT
1 30 �� ASHNGTON STREET.
T, 3" FLOOR
\ ~�=� • TEL (978) 745-9595
F,1x(978) 740-9846
;CI%[3ERLEY DRISCOLL
,N+L4YOR T-10-NUS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/aUll-ONG COSL%I1SSIO1YE3t
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
Debris, and the provisions of tNIGL c 40, S 54; l l I.S
Building Permit tt this work shall be is issued with the condition that the debris resulting from
l 11, S (SOA. disposed of in a properly licensed waste disposal facility as defined by MGL c
The de/brislwill be transported(by: L e
IQ..Cl (W Cm,, Crc of J
(name of hauler)
The debris will be disposed of in
Pvr StA-e e-Ry-4ivL I
S;
(name of facility)
(address ot'ra�ility)
signature of i it applicant
✓ ' cr -
date
. Jcbn:• if.l.w
r
i
r
° CITY OF S U E1rI, 1%I sikCHUSETTS
" y + BUILDING DEP1tiTSIEVT
120%V.hSHLNGTON STREET, 3"FLOOR
T FL. (978) 745-9595
RkX(973) 140-9844
�IBERf RY DR)SC011
.;vfAYO.q ItioatASST.FmaRB
DIRECTOROF PUBLIC PROPERTY/BUMDLNG CONCWSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractorr/Electricians/Plumbers
Applicant Information y� / Please Print Leelbly
Mama(Ousiii,snoeganizariervindividual): f/�f t/I_I rl 4
Address: ( q 2-4 ( yl V 04A.1 it VZJ.t _
city/state/zip:EQo-6 QK0 Phonehl S08��DY(T{/ z
Are you a employer?Check the appropriate bolt Type of project(required):
I, am a cmploycr with / 4. 111 am a general contractor and 1 g, 0 New construction
employed(full and/or part-lima).* have hired the subcontractors
2.0 1 am a sole proprietor or partner. listed on the attached.sheet.t 7• ❑Remodeling
ship and have no employees These subcontractors have g. 0 Demolition
working fur me In any capacity. workers'comp.Insurance. 0, 0 Building addition
(No workers'camp.insurance S. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 (am a homeowner doing all work right of axemptiun per MOL 11.0 Plumbing repairs or additions
myself.(No workers'cutup. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.) t cmplaynes.(No workers' 13.0 Other
comp.insurance requircd.j
'bony appllead awl chccka box rl must aim all sew IN section Wow ahow(ng Iha(r"bass,campenualun policy inlurmallon
'I kvnvuwms who submit this amdsvil indicaing they mdoing all work and than hits outside contract=must auhank a now amdavit indicating such.
:C onimaon that chktlt this bee most anaahud an addiaunnl sheer showing the arse of the tubcdntrretara and their wurkars'camp policy Intermaaon.
lain eueployn shut li provldlnR lvorkert'rempauatlen luturance jot my smpluyerrt Bdow/s the polley and Jab site
h1fonnarlom r
Insurance Company Nam /�e. !" w-,I-V'L/5'1��
Policy 4 or Self-itu. Lic. H: �T(-1,(Cni 3 , '"f(�303 Expiration Date: M��1 t ` �(3
Job Site Address. .o f i f S� City/StatclZip: Wen PC o l S-7 d
,%ttacb s copy of the workers'compensation pulley declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of s
tine up to S 1,500.00 and/or one-year imprisonmcnk as well as civil penalties in the rarm of a STOP WORK ORDER and it line
°f up to$330.00 a day against Ilia violator. Ile advised that a copy of this statement may be rurwutdcd to the OIITca of
Investigut(uns of ilia DIA fur inmrance coverago vuriticatiun.
/rlu/rrrrby re ljy under te pu l
ri /n wr r J peon/Nat ulperjury t/rut that/ajurnmNar provided above is raw turd cunrct
aky
i 0111cful use ordA Da nor write in drlr urru,robe cuarp/eted by arty ur town njJ&•lo! I
i
Citynr l'uwn: __ ._ Pcrmlt/Llccnse.9 i
6sulna,%uthurily (circio Oita): - - -
i1. Huard of Ilculth 1. Ouildlmg Deportment .1.City/town Clerk J. Clectrlcal Lupectur 5. Ilumbing Impector i
6.other _
Contact Perron__.._.._ .__ .... Mittel:
Taylor E.Blake
185 Lafayette Street,#4
,+ Salem,Massachusetts 01970
taylor.e.blake@gmail.com
(617)909.0515
April 9,2013
Mr, Thomas J.St.Pierre
Inspectional Services Director
City of Salem Inspectional Services
120 Washington Street,3rd Floor
Salem,MA 01970
Re: 185 Lafayette Street
Dear Mr.St.Pierre:
I,Taylor E. Blake,am an owner and trustee of the condominium association located 185 Lafayette
Street in Salem, Massachusetts. As a representative of the 185 Lafayette Street Condominium
Association, please accept this letter as confirmation that a building permit is being requested in my
name for the installation of new windows and doors at said property.
Please feel free to contact me directly should there be any questions or concerns. Thank you for
your kind attention to this matter.
Ib
ly yours, ^Blake
cc: 185 Lafayette Street Condominium Association