17 MESSERVY ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
��� '3' •�L ------- --- —L- Department of Public Safety --
"
Ahrss,achusetls Sl.nc luilding Code(i H11C\IR)
Building Permit Application for any Building other than a One-or'Fwo-Family Dwelling
(-I lily Section For Official Use Ooly)
Building Permit Number: Date Applied: ._ Building Official'.
SECTION 1:LOCATION(Please indicate Block N and Lot k for locations for which a street address- nut available)
No. and Street ily Town Zip Code Name of Building(it appli(able)
SECTION 2: PROPOSED WORK
Etlitiun AMA State.Code uscJ If New Construction check here❑or clicck all that apply in the two rows below --
lixisling Building❑ Repair❑ Alteration ❑ Addition ❑ 1 Demolition (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occup,iiicy ❑ Other ❑ Specify:----- _
Are•building plans and/ur construction dtw'uments being supplied as part of this permit application? Yes ❑ No ❑Is in Independent Structural Engineering Peer�R�eviiew required? Yes ❑ No ❑
Brief Description of Proposed Work:.-_Deis vt+-rlc-4
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here Ban Existing Building Investigation and Evaluation is enclosed(Sue 780 CNIR 34) ❑
Existing Use Gruup(s): . __ Proposed Use Gruup(s): —
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)dr Area Per Floor(sq. ft.)
Total :\n•a(sq. ft.)ana Total bleight lit.) -
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-3❑ Nightclub ❑ A-3 ❑ A-4 ❑ A-i❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ I H: Ili h Hazard H-1 ❑ H-2❑ 11-3 ❑ 11-4❑ 11-5❑
1: Institutional I-1 ❑ 1-2❑ 1.3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-'_❑ 11-1❑ R-1❑
S: Storage S-t ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use ;+ _
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA_❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VII ❑
SECTION 7: SITE INFORMATION(refer to 7H0 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
A trunclt twill not be Licensed Disposal Sit'!❑
Public❑ Chock it outside Hood !_one❑ Indicate numicipal❑ ,
required ❑or trench or.pvoh:..
t'rirale❑ nr indvntil)' Luna __—_— or on site sysh•m❑ permit is enclosed ❑ _
Railroad right-of-way: IIJ/Jrd5 it) Air Navigation: \I I I i .I• . , ,. ., ., , .
Not Applicable❑ Is Sl nic to n•within airport apprnai It,trra' Is Ihvir rve'iew omrl,wd'
or C omsenl hi Build cnclused ❑ Y r i❑ or.No❑ I Y,•s❑ No ❑
SECTION 8: CON I FN'r OF CFR I'IFICA IT OF OCCUPANCY
I`dltwo ,IC ode. - ,- --. Coe Graup(e): _ _ . . . _ I\1a•ol Con.Lruc1wo. lktupanl Load per l-ho+r.
I too. lhebu i l,I in?;c rnteio.m L;prmklvr S\ wn i Special slipulaliens: - _
f
SECTION 9: PROPFR'IY OWNER AUI'1IORIZA-1ION
Natue and AJJ ress ut Pryoprrly Utcncr -�... r`_ % ,N,une(Print) No. and Street --- City/Town - — -- --- Zip
Pro x•rty Owner Contact In forma lion:
I itle I'vlephone No. (business) Telephone No. (cull) c-mail address
It applicable, the property owner hereby authorizes
Name Street Address --- -City/Town State -_ Zip —
lo act on the property owner's behalf, in all matters relative to work authorized b • this building u•rnlit a t,lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
1f buildin g is less than 33,000 cu.ft.of enclosed space and/or not tinder Construction Control then check here O and skip Sect inn 10,1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No, c-mail dddress Registration Number _
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Cont r ctor
nmpany Nan,
Name of Person Responsible for Construction License No. and Type if Applicable
t'ee ddress City/Town State Zip
O n
'Fete,hone Nu. business Telephone No. cell e-mail address
SECTION 11: ttt )vl,&:P, t t AII'lV0I It IN INa•UR.\Nt.'r A) I it'Avl l 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 ❑
SECTION-12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S_
'_.
I. Building S Building Permit Fee=Total Constnretion Cost x (Insert here
[hstrirll S appropriate municipal factor)=S
1. Plumbing S
i. Mechanical (I-IVAQ 5 Notc: :\lininuun (cc=S__(contact municipality)
5. .Mcch,micdl Other S
Enclose check payable to
I,. Fatal Cost S (Contact municipality)and write chock number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
IIv entering my twetic•below, I herabv,west under the pains and penalties of perjury (hat.dl of the information contained in this
.Ipplication is true and duurate to the best of no, knots ledge and understanding.
Please print ,utd .ign u,une I itle k1cphom! No.
ytn•et AddresS Cily/Town State /it)
Municipal Inspector to fill out this section upon application approval: _ ----______._____ .
Name ---I),de. .--
CITY OF SALEM
[PUBLIC PROPRERTY
DEPARTME
NT
uc. M'1 Y'rnlV,•11
\111,Yt
12: \VnlrnA+:ur.�)tatt)' a inu•u. At.N1.11.1t1 a I nJp�7,',
Workers' Cumpensotion (nsurunctt UflduviC
lillollcillt Inonn•rtio llufiderl/Cuntrrcturs/Ele.triclyns/Plumberlt
PI In Le 'hl
Vdlnd I Ihr.nluayl)rpytvninrvinJn�duull:
ltltlry.s.v:_��1 ' LA%
.t,rv�.+nu an vnyiloytr:'Cheek box-
Ph I 1•,eJ r:Inr.I empluyvr wish 4. ❑ 1 :un a yvnvroi cuuuaelor and 1 I fit
/pru)vvf(rvqulrW);
❑ annyluycys(lull and/ur port-bald).a huvv hirvJ thv.rub-vunnactup 0 Q New cunstruclion
1.I111 a sole prnpricn+r ar partner• lisrcd on rho anachtd.vhcet f �• ❑Unwilling
•rhip;ald have no umpluycer Thesr dubtontrecters have,
+aurkind tin Inv In any capacity, worill comp, Insur9nq, d' ❑De,molirion
I No workers'sump, insurance, J. ❑ We arl o cal q• ❑ lluilding addititrn
nquirvJ.J ponlinn and ito
1.❑ I um a hmnvu+vncr Juing all work fight u/vrvin Linn Ir`l their 10•Q Eitcrrieal repair or additions
myu ll.Ill anrkvrs'sum p par lvg n I I.Q Plumbing m-puirs or additi+ns
p• e. l Jl, t}I(o).anJ wt h11vv no
insurance required.) It anpll he,worker' 12•Q Ruul'repuin
camf% ilNuranvv rcquiryd.J 1 J•Q C)ther
•a nr.•,rplwad rhw ahucYl sas,11 mual.dw till uw IN aaunaw lwhrw'I I.,nwl,Irnra . I iIIYI hlwl Auwnr I
Aln wwlasap.AAr still(his al"Ill iWlutin I uwkm Stoolyrnnrraiwwauiar dlu,And IMs him uvM tullnronwlh
IrN inykrdm
r rwsT,rnrnwnn that I'll this te TW .hu+rirfloor n3"no a/the nazi% arxnd ther awkas'cal Pool l Ion un sinra yloyn Mae
fill/vrnruNu /r pry vJJlgr nurAars'rurnpaernllte,brrunurat/w Any anp/oprat Salon to ar pu/lay uNJ u1,
Inaurancy C'umpany .Vlnntr 5Gv`�
Policy v ur Svlr-ins. Lie.fill
lob Sits dddrei.r: 3- +"U)cxAl �—
\ltach it drys u(111t workers' culnp radon polls) duvlurallun page(showing rhe,tpollcy nu`ilSibu►a^nr----61p-- u date).
I-jolily (u wcura cu+aroge L required undw Scl;tiun:JA\ul'.\ICiL c. 1)2 eau lead re,the iln
fin. Iy+ nr SI Sur7.rM�nJ/ur -g hnpri.vonrncnr, as well.rr civJ fool in Ihv lurun Ufa TOP%Il ORDERI•anJ Of
a fine
+i up re, i?Jn NI.I Jay Ig• alai Iht via,tine. I Ic advn.tcd Phil i copy orthu dmumunn may be turw,ArdyJ to the Utlicv of
Im.ali"Jlnnb Us ;nu I11, ,or nl.nr.n' c :,�acra3y tau liaanun.
/drA/r.arhy r,rrijr tunly r/ra pr r�nrJ pennh/er ujper/nry that dra iu ur,evl/oe/ prorrJat/u0 yr is oar null torevet\P�'lli
err, • ,
r1///Aiu!ire on/y, /1a,141 ,,ite ill tlll.l Jeru. to At runty/rgal/by airY ur/olrrr u//lriuL
( try ur Iblrn; _
Permittl.levnra r
I+a airy .l ulhurily (circle,anal;
I ILr.rrJ I(Ifv.Jlh !. Ihu6lnr; lgp.Innlcul I. I:It1. l'ur+na•rk t. A'icclric.Il Iis PUP, 5. pit, to+senor
G. 1)J IIa•I C'l
'I ('aqt KI I'a hU11:
I'Annu 1•
I
ation and Instructions
[ ntormr -•
fined as". every pct+an In the seal:e ITf another under,lily :unlrlct Of hire,
vg,,,;.Khuaeus d:neral Lucas :hayter I i2'Cgwrcs all euyduyen o prarlJe workers :ITmpensuuon till Ihclrcutyloyce+.
Pur'umt o rots'uluta,an iesplgN+t+J
:'prcas or imphcJ. ITral or wnuen ' or any Iwo or snore
artrlenhip,aasaclallue,:OrPuratlon or Other IC gal Canty, ,,r or the
An;,nplayer la JCtincJ]a"an individual. p' to m vm loyags. Nawgver the
I the t;uegmng enga�CJ in a joint enlerpnse, and utcluding the Ill representativeslO deceased emp uY'
c:erveI Or uuatae of.m indivtJual, pa+tnenhtp, dsoalanoo Or Other legal inn sIdly. crop Y g ' P
owner, f a dwelling house having{nnotYnaltrea than three apamnents and who resides therein,or the occupant el the
uRenant thereto shall not because
of such em to ntant be deemed to be an employer."
.hvclhng tease Of another who em la r+oils w Jo maintrnunCe, cunavut lien yr repair wurk can such dwelling owe
or on the.,rounds or building app shag withhold the Issu,aer or
�IGL chapter 132. 415C(6) also states that"every slats or legal licensing dl,se Is Ill#y ogled:
renesl of a license of perNll to uperale a business or to construct U `theainsuranc/overag Iregith or any
s tSC 71 aratea"Neither the commonwealth not any ol•its political subJivisiam.+hall
;typllcont cabs has not produced ageeptabla evldsace of sump
\ddilionally, \IGL chapter I S_• i-
entar sole any:omroct for the Perfomtan a anwJbo die emtascl g am'h rilyviJanCe ui cootpli;ulce with the insurance
requiramgnls of this:hupter haw been p'
�yyllcsnu 1 to our situation and,if
checking the bocce that upp Y Y
es and phone nwubeds)along Wilk their cartillcale(s)of
Vlua+e rill out the workers' compensation atridavit completely,by LLP)with no employttes what than the
necessary, supply sulscontraetor(s) name"), uddnss( )
workan. compensation uuuranee. If an LLC or LLP does have
insurance: Limited Liability Companie,(LLCI or Limited Liability Pantwn P�
nernbars or pannen.are not required to carry be submitted to the Deportment of Industrial
en,pinyaae,a Policy is requited 8e advised that this alTidavit may aliment of
Accidents for Confirmation of insurance covoroge Also be sure to icen and dune he wtlda n the at)ltlavtt should
his I Viumed o the city or town that the applicatdon for the rdi n i is license is being req lasted, nob the la workers'
nu haw any 4uestioo,regarding flu low or if you ate requited to nies s u uldent
industrial ACulddnt Shoutcall the 041 myunent st the nulnbar listed below. Salf-insured companies should enter their
cotnlaensutiun policy,gleam' iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillin
self-insurance license number on the a ro rluta linoiiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillilillillilim
City or Town 01111clats
tum
the applicant.
Pfuasc he:era that the af7lduvit is emnplete and printed legibly. "fhe Department has provided u sp see at this tltcant
„f the aifiJuvit fur you o fill Out in the event the 011tee Of Investigations ha+to comact you regarding
applications in an given rtr, need only submit once atlidovit indicating current
1'f:aae be sure to till in the purmit/licatae number which will be uadd;ts a reference nunlbsr• In addition,an applicant
than moat submit multiple Pennit'licsltsa
policy information(if nacaasary) Ind under")ob Site AJdres`dfur niukedtbt +die city oraown tnautbe provided o theiuns in y
town)."A copy OI''I'd urylds" that vil been o e I.Olt ly sump'
y y Y
applicant as proof that a valieach
d afflduvit is can file far ILttare patmiu at license. A new a111Jnts norm be lllled out venture
car,'`lu�m alh+ume Owner
ne t to citizen is burn leaves vile)sad paroanus NOTtrequired ot not f mpleo to any uhisC ilidas or v 1mntareial venture
tit
I h: N li:: ill Inve'rigIliuns aOuld ItA• to dlattk yUV In JJVnn:g YVr Your:aapefaUITn and should you have.,ny ywauons.
I,I:a+e du MITI Itesttao to glvc us a:all.
ncu U:p•uuncnt's d lre+s, rcicphune IThe Commonwealth of Masaaehusetu-
Department of Industrial Accidents
Onlee of lsvtesdQadona
600 Washington Street
Boston, MA 02111
ref. M 617.727E 00 Calt 406 ofI.97TMASSAFE
www.mass.jov/dia