187 LAFAYETTE - BUILDING INSPECTION �. The Commonwealth of (Massachusetts
Department of Public Safety
...
j' .\hissac]III svns tilalc BuilJinfi Codr 179111'.\IR)
111ilding Permit Application far any 1311ildingother than a One_or'I'wo-Fa it by ` •Ing
(This Section For Official Use Chtly)
Ili ildiug Permit Number -.--_ —, -_-- Dale Applied: -___- -__.- Building Official: --..
SECTION 1: LOCAI ION(Please indicate (Hock 4 and Lut p fur locations for which a street address is of availabl
s
No. ,md 51mvn Cit1'/I'own /ip Code Name tit Voila ill;(if dpplitA lr) _.
SECTION 2: PROPOSED WORK
Ldilion of.MA Sl,mv Code turd -. If,New Construe lion lit-,it here❑or check all that apph in (lls`Iwo rule,below- --
Fxi.vling Building lirpair Altenniun ❑ ,\ddilion❑ Demolition ❑ (Plvasu till unt mid submit Appt'ndix 1)
u Change l Use ❑ 1 Change of Qccufalnry ❑ Otltcr ❑ Specify:.----_--,.._
:\to building plans and/or conAruction dtkuments being supplied as part of this permit application? 5"rs ❑ No .------ - -
Is an Independent Structural Engineering Peer Review Mi Llired? Yes ❑ No
thief Description of Propusvd Work:._-_- INCY)eU 6A;g,_I
SECTION J:CONIPLGf E-Tiffs SECTION IF EXISTING BUILDING UNDERGOING RENOV,\TION,,\UUI'1'ION,OR .
CHANGE IN USE OR OCCUPANCY
Cheek here if an Existing Building Investigation and Evaluation is enclosed (See 780 C,\IR 1.1) ❑
r:\isling Use Group(s): —_ Proposed Use Gnmp(s):
SECTION 4:BUILDING IIEIGIIT AND AREA
Existing Proposed
No. of Floors/SWrics(include basement let cis)h Area Per Fluor(sq. ft.)
Total Arva(ski ft.)and Total Height(ft,)
-SECTION 5:USE GROUP(Check as a licabie)
\: Asisentbly:\-1 ❑ A.20 :Nightclubs❑ :\-) ❑ A4 C3 A-50 B: Business ❑ E: Educational ❑
F: Pachu P•I ❑ F_'❑ 11: High Hazed 11-1 ❑ 1-1•2.❑ 11-.1 ❑ I I-4❑ 11-i❑
I: Institutional 1-1 ❑ 1-_7❑ 10❑ 1-I❑ M: Mercantile❑ • tesidentla R-10 R-2❑ R-1❑ R-4 ❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and Iilcasl+dcer rbe I,vlow:
Special Use .. t,-. -
SEC TION 6:CONS 1"RuCrION I'YPF. (Check as applicable)
IA ❑' Ill ❑ IL\ ❑ fill ❑ MA ❑ IIi11 ❑ IV ❑ \':\ ❑ \'B ❑
SECTION 7: SITE INFORMA IION(refer to 7,40(',\fit 111.0 fur details on each item)
Water Supply: hood Lune information: Sewage Disposal: 1'rench Permit Debris Removal:
Publit;l< Cheek d outside Hord /_unt Indit,de numicip,Il f .\ Ironch will nol be I I,rusad Disposal Gilr❑
Pm m'.❑ or iud, (lit /one - _- or on it,s,denl ❑ rryuire,l or Ironcll I or speedy .
prnnn iv rnrinsrJ ❑
liailruad rig ,4 Y Ilaiarde to Air.\ac lgaliun: .
\.,I Appik h], I Iv�Iru,lure 1,mhin .import.ipPmat It ewa' Is their 1, 1, '.11114"le,I '
:a'l :,inonl h, Ilulld rw lu•r,l ❑ 1r \s❑ ,:r 'o� )r.❑ ❑ —
tiFCI [ON B. LO.NI.1..N1 ()}I I I(1111C .\il•. O1 (it C'I'.\NCY --I{
I dingo ::I l"do L .,.l;mupld It t`r::I l�:�n.hwll::n t\,np.ml l :�.i,l per ll,•. r ._---
I14v . IhrLndd ){"in in.un.In rinkh rti,` - -� ' ''1' Irm' �1r,i,d'-lipulalioils
c � )P 3� ���
SIfCIION 'I: I'ItOPFU I'YOWNP:RAUI'Ill)l(l'L,\IIUN
\ nna ul,l \ddn ss of lr p ry Ov,n r
JC4 us 4
Nome(I rint) No u,d Street
I'r„perty Ownt'r Collacl Infonnetion:
. ---- — - -- — —r-mail address -----
filly __—-_._. felophune No. (busivass) rt'lcphone No. (cell)
It.I . '11"Ible, tht' properly owner hereby authorises r
Name
--- Strcrt Address City/ruwll .. State Lip
lu.i t on Iha•pro n•rt o, n•r's behalf, in all n,,,llo rs relative to work authorized by Ihis builJin ,ermit a p,licaliun.
SECTION to: CONSI'RUCHON CONTROL(Please fill nut Appendix 2)
If bu ild ill;is less 111,111 li.l)UII Cu.ft,of endured s pace and or nut under Clnlstruction Control then check here D and Ail,Section tll.l
1(L1 Ite gistemd Professional Res unsible for Construction Control
--a—' — — — — Registration Number
Name(Registrant) I'c�le�pl},un� N� �it address b —
t'FS �c(gr•� Ste__ """"'�' � 2$�
Stale Li Discipline E. pira ion D,oe
Slim Address city/ruwn P
io.2 General Contractor
company Name
aCeS3 �l anHHit- Ll5` 1 ------
.
f ,
Name of Pe m Responsible for Construction Lippc�cnx No. d Type if Applicable
sSSrrt �� r � V-Q-"j _ IA,519- - alIu$
Slim Address City/Town State Zip
rclr ,hone No. business - Tcle,hone No. cell a-Mail address --------
SECTION 11:M lc�I K" I I�wrl v.s ut 1% 1�,�.1 n;.\�t r •V M.G.L.c. 152. 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be Completed,Ind
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance ill the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION t2:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item ,u,d Materials) Total Construction Cost(from [ten,6) '
I. Building S f/S O G Building Permit Fee-Total Construction Cast x _(Insert here
2. Elcc'trieal S Ippr0priatc municipal factor) 'S
4. I'luuil,inl; 5 Note: \lninuun ice"5-_ a(1nlact nuulief,alily
)
1. 11cch•u,iial IIIV;\C) 5
3. \Icchani(al Other) y I?niluse iht'ik pov"We to
n. fetal Cost 1 (i ontacl nnmicip,,lity)and write check number here
SECTION ld:SIGNA IURE OF BUILDING PERNirr APPLICANT
Itv h•ring tin' home below, I hors ily .ntest under tilt' pains dnd prn,dlics of pvrpry that all tit the in(unu,lliun Cl�nt.nncd It this
rn
,Ip(�lic.itinn is Intc aml as tmie to the best of my know Icdg;•enJ uudent,utding,
I'I,•.Ivr prnl aiLl "WI n.une
I iIla. frlchhone No 11a at'
-•tr' Wd"ns Cilc, f.n,n
'ntae /Ip
\luniiip.,l lu'Vector to till out this section upon ap Vlitatiun .Ippr oc
ova _.... _. .. .
Il -
r CITY OF SALE.M. T%"LkSS'kCHUSETI'S
BUlLD04G DEPAWIM&NT
M 120 WASHNGTON STREET, 3° FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KINtgFRt FY DRISCOL[
tiL-YOR THOMAS ST.PIFUE
DIRECTOR of PUBLIC PROPERTY/BCILDNG CONNISSIONER
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 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 be disposed of in a properly licensed waste disposal 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
C
(name of facility)
(address of facility) -
gnature of permit applicant
date
dcbrisa tf dx
i� CITY OF SmE.Nms 1t NSSACHUSETTS
• 9IBUILDING DEPARTMENT
' ) 120 WASHINGTON STREET, 3'o FLOOR
TFL (978) 745-9595
FAX(978) 740-9846
KINfBF1tLEY DRISCOLL
MAYOR TTlon uST.PmM
DIRECCOR OF PUBLIC PROPERTY/BUILDING CONLMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r ilicant infirrmation Please Print Legibly
Nartle(0usitx&Organizatiorvindividual): /
Address: 5
City/State/Zip: CV! K n,— Phone hl: 2 29- ?U R572
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with O 4. 0 I am a general contractor and 1 6. ❑New construction
employees(flall and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached.sheet t 7. Remodeling
ship and have no employees These sub-contractors have V. Demolition
working for me in any capacity. workers'camp.insurance. 9. Building addition
(No workers comp.insurance 5. 0 We are a corporation and its
rcgldreJ.)
0t3icers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MOL i 1.0 Plumbing repairs or additions
myself.[No workers'camp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.LNoworkers, 13,0.Other
comp.insurance required.)
'Any applicant that ciiwks box A 1 most alwr fill out tho saclioe below showing their warken'compenudon polity information.
r I haneowners who submit this affidavit indicating they am doing all work and then him wiside contractors must suhmil a new aitldavil indicating such.
:Conrractars that chick this box most attachod an additional ghat showing the name of the su6avnlraclon and their workm'comp.policy Infomnnon.
1 um an employer that lir providlirg workers'corrtpensadan htsaranee jar my employees Below Is du po/ley and fob site
irrjorrmtion. L
Insurance Company Name: f �l/G �00`e O Z
Policy#or Sclf--its. Lic. d: C!44 0-00 O [ 4 <1 O ( Expiration Daivi&kh2 �'Zr
Job Site Address: Q Cityistate/Zip:
/," �
Attach a copy of the workers'coat ensat n polity declaration page(showing the polley number and expiration data).
Failure to secure coverage as required under Section 23A of MGL e. 152 can lead to the imposition oferiminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S'_30.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invesligations ofthe 1`31A for insurance coverage verification.
1 do here rtijy an he pu! mrJ peso/ties ujperfary drat the injarmullon provided aba is tree and correct.
_ Date:
—SLID"?
P o Y
OJficial use only. Do not write in lids area,to be completed by city at town o flelaL
I
City or'fuwn: Permitn.lcense#
Issuing Authority(circle one)-
1. Board of Health 2. Building Department 3.Cilyffown Clerk 4. Electrical inspector 5. Plumbing inspector
6.Other ._
Conl•act Person:
------ Phone#:
_INK:
CUnsalnerAffairaHOMEIMPROve eso"RegolationRegistration ;.m1MENsCONTRACTOREVfration 2/7J2014 .. '` - Type:JORY individual
7
JOHN PERRY;
$BESSOM S7
f MARBLEHEAD, MA
+ `'.1t; rehmcft�- D artm nt of Public t t'k, a
1 4fl vd of Bititdm �R(tul mom ;tnd.Ct and rrilY
FF construction Supervieor �tcense
` License CS 65399
rY _
JOHN PERRY
5 BESSOM ST STE 232 .+ E
MARBLEHEAD, MA 01945 "
ExPtrati n:_'625Y1014", .
` C"nem eionrr . Tr`�:.8075