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17 MESSERVY ST - BUILDING INSPECTION (4) to r The Commonwealth of Massachusetts C I`-i ;, Department of Public Safety State 0udalmg Code t:S0 C\IR)Seven lh Edltlun City of Salem 11 , ,• Building Permit Application for any Building other than a 1- or 2-Family Dwelling ^ \{ r I ihls Section For Official U:r Only) /\ 1 Building Perrmt .Number: Dale Applied: Building Inspector: r I SECTION L-LOCATION (Please indicate Black a and Lot a for locations for which a street address is not available) obuilding et Cot% /Town Zip Code Name of Building b I ipphcoble) SECTION 2:PROPOSED WORK If New Cumlructiun check here Oor checkall Ihatapply m the two rows belowdinF14e ❑ Changeut(hcupancy ❑ Uthrr ❑ Specify: plansand/ur curutnrcuunducuments being suppliedas partof this permitapplica lion? Yes No ❑ dent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: aj%20V A'rC- 2 �tN(l.`� n:•J1]1-1 fVt 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 Gruup(s): Proposed Use Group(s): F Existing Hazard Index 780 CMR.34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA xisting Proposed Nu.of Floors/Stories(include basement levels)Ar Area Per Floor(sq. ft.) Total Area(.sal. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-I ❑ A-2r ❑ A-2ne❑ A-3 ❑ A-4❑ A-S❑ •B: Business ClE: Educational ❑ VA..: : Facto F-1 ❑ F2❑ H: HI Hazard. H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-I ❑ 1.2 ❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-7 R-4 ❑ S: Storage S-I ❑ 5.2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ - IB ❑ IIA ❑ lie a JIIA ❑ 1118 ❑ 1 IV Cl VA ❑ V8 ❑ I SECTION 7: 517E INFORMATION(refer to 780 CSIR I11.0 fordetails on each item) Water Supply: I Flood Zone Information: Sewage Disposal: bench .11 not. . Debris Removal:- I'ubhc � Chcd tl.nitrldv PIu,.I Lona InJir.,tr murnapal A trench wdl not he Llicmrd Ur./"..,,I ?rtr required rr trvnch ,•r�pcirt% ('rivals•❑ ,v indcnbit Zone:_ ,m„n.,Ir�c�lrm❑ permits,enclosed ❑ I -- Itidroid rightul-way: Ilorards to Air Navigation: ,,nn,......I:,,., ' \,•1 \�•fdi..rblc❑ I�Vnulun-u uhutaup,al,,ppu ach.,n•a' Llhcn' n•a ira. onnplclaJ' ..r ......•nl b• It Sal""(.-"d ❑ I h••❑ ,.r\.,❑ )e. ❑ ❑ SECiIO.V 8:CO!a,'TENT OF CFRTIFICA fE OF OCCUPANCY I .idnm.Jl ••..Ic _— L-c t.nviw-I _ fa 1'a ..I l • n.lru:lr,ql .___ 14iuF`dnt L,,d,l �•cr lLnn __. __.__ _..._ ' Iit the hl I.I,I Is t -nl.trn.u, t, `rin A lvr?t,I rnt' cc ial�I ipu la l it,n. 5-79 e 5ECTION9: PROPERTY OWNER AUTHORIZATION l+n�perty Owner �� Ree,eua etniy� L►L 641 lt�aCkv vim_. S� ( — } \.one lPnno .No.and Slrr ('ih, r.nvn - Lip I r 4I�'n I+rrlt' 0%,tier(-•.ntart lnlurm.mon: Cca_ue t4 ,re rifle relephone Nu. (busme>o) Iviephone No. (ce11) email .t.fdre.. If.ipphc;blr, the prupvrlt uw ner herebs•.urihatn[es Name Streel Addrr>. Citvi Tuwn State Lip h+act un the ro •erly oic ner behalf, in.ill matters relauyr to work.iwhuneed by tht.buildin• •remit.; + dic.0 nnl. SECTION 10:CONSTRUCTION CONTROL tPlease fill out Appendix 2) - 111 l•uJdm•u Lros Ilan ti.M1UC u.It.ul rndasaJ<+acr.mJ/or nut under C.nulruChun Conlrvl then rhec4 here D.md .k.+r•J enl to 1) 10.1 Re istered Professional Responsible for Construction Control a rJ '� ft- 020 3�105 �i�irtxT(R h.a rp one u. a-man a rrss egislrition Number �©rTl�. Street Addres - City/Tuwn State Zip Discipline Expiration Date 10.2 GeneralContractor aa.nc.�' �(l-�l C /O/ S Na r of ersrm It-r.•c r .1 Ie fur u tructiun License No. and Type if Ap licab 111� sh(r�'1�� 'P' c r 17 S �dre�sa -- City/Town State Zip Telephone No.(business) Telephone No.(cell) -e-mail address SECTION 11:WORKERS'COWENSATION INSURANCE AFFIDAVrT(M.G.L.c. 152.§ 2SC(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 O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=f ( SoZ3 1. Building f roo Building Permit Fee=Total Construction Cost x f Dryy� g _(Insert here 2. Electrical �N appropriate municipal factor)=f 3. Plumbing f a. Mechanical (HVAC) f 0t� Note:Minimum fee=3 (contact municipality) S. Mechanical (Other) f Enclose check payable to fi. Total Cult (contact munici alit )and write check number here �c7 Q(`}F7 SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Hv rntenng my name below, I herebv attest under the pains and pen.lher of prqury that all of the ;nfi rmattein „meimrJ in Ihr. I •plicalmn to true d a�to to the brsl of my knu.vledgeand understanding. c- I9c.n •n it in.l IT+.un• ride -. — 11irct %ddrv— Citt: r.."rt . Ir i %lunicipal Inepectur to fill out this section upon application approval: CITY OF S.U.E.NI, tiL-uS.kcHUSETTS • BLILDLZIG DEPARTMENT 120 WASHNGTON STREET, Y°FLOOR TEL (978) 74S-9595 FAX(978) 740-9846 KI.N(BFRr FY DRISCOLL MAYOR THOMU ST.PIF.RRS DIRECTOR OF PUBLIC PROPEATY/BCIIDLNG CONWISSIONER 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 dcbris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c x 111, S 150A. The debris will be transported by: (name Of hauler) ` The debris will be disposed of in (name of facility) (a dress f facility) s o ermit applicant bate debnvlf�•K r CITY OF 5:11.E��I, ANSSACHL'SETTS f3L'IIDLNG DEPARTMENT • 120%VASHLNGTON STREET, 3i'FLOOR ��^� TEL (978)745-9595 F."(9 7 8) 740-9846 KI, RtFYDRISC011 THO&LksST.PIERRa MAYOR DIRECTOR OF FLBLIC PRO PERTY/aui D[\G CO.,,L%I I SS ION E R Workers' Compensation insurance Affidavit: Builders/Contractors/Eiectricians/PlumberI A r Ilcant Infnrmatlon Please Print Legibly Naine lBusiiw•ss.Urganiratiamindividual): Address: �141 �`h[�'� ! ` City/State/Zip: A- (1�� Phone N: / 2� Are you a cmployerI Check the appropriate box: 'type of project(required): 4. ❑ 1 am a general contractor and 1 6. Now construction 1. I am a employer witb� ❑ ees cin to full and/or P art-time).• have hired the sub-coruractara ,._,�� P y ( listed on the attached shacL i �• L7 nemodeiing 2.❑ I area sole proprietor or partner- ship=41 have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers'comp. insurance. 9, ❑ Building addition No workers cam insurance 5. ❑ We are a corporation and its 1 P• 10.0Electrical repairs or additions required.) officer have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.[No workers'comp. C. 152,¢1(4).and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13,❑Other comp.insurance required.] •Any oppllc:un nut treks boa rl mW also On out the stttian below slmwing their vakui compmwiun policy mhurmatiun. t I Lrreeuweaaa who submit this aflldtrvil indicating ihey am doing all work and the,hue muoti contmom man suhmit a new a?Jarit indicting such :Contmcwn that chch ibis boa Mud anahod an additiurW+hest showing iho name of the cub cantracterr and their wurkrn•comp,policy infamudon. I um un employer that is providing,lw�orkers'compenrat/on Insurance for my employers. Below is the po//cy and jab site information. tCRrtrsl-e/— \ Insurance Company Name: f TESL.Af�L llxl� /` Policy 4 or Self-its. Lic.tie .©0 �29 S/�S F�rpirdtion Date: 1/o6/ /2- Job Site Address: / r lz? 1�1`i�l�lS� City/State/Zip: � r `A L) Attacb a copy of the workers'eompensdtlon poUey dedaratlon page(showing the policy number and expiration data). Failure to secure coverage as required under Section 23A of VIOL c. 132 can lead to the imposition of criminal penalties of a tine up to Sl,Sll or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to 5230.0 a Jay age st the violator. Ile advised that a copy of this statement may be forwarded to the Oflice of Investigutions ul to DIA fo insurance coverage verification. I do hereby cerr/j der a puns and peauldes of perjury that the information provided ubyr�i true and correct Pho c 4, QIJirial ux oody. Du not write in this area,to be cowpleted by city or town njjlclat City or Town: ___ Permlt/f.lcemte p ._.— Issuing Aulborily(circle one): 1. Board of Ileahh 2. nuilding Department 3.Cilyfrown Clerk 4. Electrical Inspcdur 5. Plumbing luspeclor 6.Other Contact Person: __. . . Phoned: Information and Instructions >Iassachuscus Gcneral Laws chapter 152 requires all employers to provide workers' compensation tier their employees. Pursuant to tills aatule, an empruree is defined as"._every person in the service of another under any contract of hire, spreas or implied.oral or written." An emplujler is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more r the lOrewing engaged in a joint enterprise,and Including the legal representatives of a deceased employer,or the. receiver or uustee uf'.ut individual,parmership,association or other legal entity,employing employees. However the owner of a dwelling house having not snore than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maimenunce, curtstruction or repair work on such dwelling house or tit the grounds or building appurtenant thereto shall not because of such employment be deemed to be an cinployec" .1GL chapter 152, ¢25C(6)ilso states shut"every state or local licensing agency shall withhold the Issuance or renewed of it license ear permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of cumptlance with the Insurance coverage required." Additionally. XIGL chapter 152. i 25C(7)slates"Neither the commonwealth nut any of its political subtfivisions shall enter into any contract fbr the performance ufpublic work until acceptable evidence of cumpliunce with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please lilt out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply suds-contractors) nanle(s), address(es)and phone nunlber(s)along with their certifmcatc(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 dude 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 Omcials Please he sure that the affidavit is complcte tmd printed legibly. The Department has provided a space at the bottom " Of the affiduvit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in she permnit>license number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicetue 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 stamped or marked by cite city or town may be provided to the applicant as proof that a valid 'affidavit is on tile der future permits or licenses. A new affidavit must be tilled out each year. Where a hurtle owner or citizen is Obtaining a license or permit not related to any business or commercial venture t Le. it dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. I he t)t dice tit liivesrlgations would like to thank you mil advance for your cooperation acid should you 11a\'e:my gUesl Wlls, please Jo not hesitate to give us it call. fhe Departincnt's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Ol11ce of IttvesdUadons 600 Washington Street Boston, MA 02111 Tel. k 617-7274900 ext 406 or 1-877-MASSAFE Fax p 617-727-7749 www.mass.gov/dia