28 NORMAN ST - BUILDING INSPECTION (3) 47 pe
The Commonwealth of Massac w ett
Department of Public Safety
�iJ? Vlassaehusrtls 51etc RuilJittg Code(74 ChIR
Building Permit Application for any Building other than O or'I o- ily Dwelling
(This Section For Official Use Only) r
Building Permit Number: _ Dale Applied: _ Building Ot tciol:• '
SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for w ich a eet address• not av
g �oh1nBN_ �P f M
No.and Street City/Town, Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of CIA Slate Code used. If New Construction check here❑or check all that apply in the two rums below
Existin); lh ildiog3k Repair❑ - Alteration K Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy. ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this pennft application? Yes ❑ No XI
Is an Independent Structural Eoginecrin Peer Review reyu. d7 x Yes ❑ No 19
Brief e.'-nptiun of Propposed Work: 44 ViO U__�{gr1'T �'O 3(thaee)
\LY r 'Fo t2� � S-j (LAjon
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Gruup(s):
SECTION 4:BUILDING HEIGHT AND AREA
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 applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4 ❑ A-5❑ 1 B: Business Cl E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-I ❑ H-2❑ H-4 ❑ H-3❑ H-5❑
1: Institutional .I-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-ICI R-2❑ R-3❑ R4❑
S: Storage �5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable) 6
IA ❑ IB.❑ IIA ❑ 118 ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CDIR 111.0 for details on each item)
French Permit Debris Removal:
'
Water Supply: Flood Zone Information: Sewage Disposal: French
DiS6 ursal Site
PublicM 'Cheek if outside Flood Zonex Indicate municipal Kl roqA mind Xor trench or specifv
will not be
Private❑ or indenlih Znna____ or an sih s)stern ❑ permit is rnrlused❑
Railroad right-of-way: h .........lizards to Air Navigation: �i i:�.i.•n, , .,,no ,,
Nut Applicahlex Is Structure within airport approach area? IS their review contldclvd.'
or Cou9ent to Build enclosed ❑ Ycs❑ or NO.4d )us O .No ❑
SECTION A:CON"I ENT OF CERTIFIC LE OF OCCUPANCY
Ildiliun of Code: Use Gruup(s): IN pe oI Cons tit rc l it CC Occupant Load prr Eluur.
I)uoe Ihr building{contain an Sprinkler Syshvn' .N� tiprci,Q Slipulatimts: ..___
q ..
SECTION 9: I'ROPIiRTY OWNER AU'I'IIORIZATION
N,uue.uxl Address of Properly OI%'ner
- 17cLeo � Pvype✓4('eL L-L (f 5 tjov vJA7 "y
JY
Name(Print) No.and Street —_- City/Town Zip
Property Owner Contact Information:
d„- "e%-- q7$ 3ll - 446c6 7gl -367 _ ?S63
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the properly owner hereby authorizes
a.3 SeAoL A %4—: gna d',
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 thin 33,M)cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
i aav��c C � f� ��S F f beta ear,�r
Company Name
c (s. C S q S--3 9 6
Name of Person Responsible for Construction License No. and Type if Applicable
-2-3 Ji'no r w 1qy -plia v ji e ti11� 3 Z l el
Street Address Cf /Town State Zip
QA 300 1 ? SS 1 N/r9
Telephone No. business Telephone No. cell e-mail address
SECTION 11: ( UMIll NS.a rn IN [VS URANCF.arI maw f M.G.L.c.152.8 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,K No ❑
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor ^�^
and Materials) Total Construction Cost(from Item 6)=S
1. Building $ 0-1,006^— Building Permit Fee-Total Construction Cost x_(Insert here
?. Electrical S 16043 — appropriate municipal factor)=$
3. Plumbing 5
4. Mechanical (HVAC) S Note: Mininnun fee-$ —(contact municipality)
3. Mochanical Other $ 6ulose check payable to
n.Tidal Cost 5 3a0 O (eon tact municipality)and write check number here_
SEC-HON 13:SIGNATURE OF BUILDING PERMIT APPLICANT
14v entering me name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the b, t�if my knkn rap Ie Ige and understanding.
}}., DeLeu Ca t/ l/ a `e — 70 .36? - �S-C act?G �i
I'lease print and (gn name ��/11 r / I itle lelephone No Date _
$ /1av wvTcCGC j/v1 /4 QIgYO
tilrecl :Address - Cit)'i Town State Zip-�--_-�
Municipal Inspector to fill out this section upon application approval:
Name Date
,•, >ti
r
,
CITY OF SALEM
PUBLIC PROPR E
RT Y
n I Y DEPARTMENT
1Y, ll
\l,1•M
I!C \Vnon.\,.tv.\ic,cct' • i•\Iru.M.ta.u.ln w I nJl'u�
I'r.t..))a.,•IS•tfuy • P,.r v7N.+IC.'IxM
Workers' Cumpenjatfon Insuruncc tilfTduvit: fluilders/Cuntracturwclectriclens/Plumben
t tllcant Infi,nnuflo
-•� In a 'hi
V,111)v I Iluuip,{.,)raanv�linrvinJnduull�,J {�O'1�
a r— I
lildrcx.v:
u
CIIy,Slafc,/;I�pu- �� C
.lry Phone 5
nu it,vuq,loyer:'Cheek tho;lpprnprlu(#burr
I I ❑ I:ten a cmpluyvr with 4. Q 1 aln a gcnersi cunllacut and t LyM urpro)uet(required):
cnlpluycvs(lull fll{Yur pin-lintel e huv,l hireJ tho.vuh.cuntracturs
,ten i aoil pmprictne or punnvr• listed in rht anaehcd sheet y'
f Q New cunsuucNun
.rhip and love no umpluyevtl Them subcontractors have ®Retnodtlind
"Irking tier mu in any capacity, ,varken'comp. msunnce. d• ®Demolition
IKn worker'comp, iosunnct J. ❑ We are a Cooperation and its 9. ❑OulWind additiun
nyuirell.) )Iyrcen h rvn
.rvo virad their
3.❑ 1 wtt a holnvu,atcr duind ulf work fight of anent tion i�'❑Electrical repair ter additions
myself.ING workers'cum D per hICL I L❑Plumbing repairs ter aJJitinea
inruruncu required.) r p• c. 132,til(4),and wt hilve no
.Inpluycve.IPb workeq' 12•0 Ruurnpuirs
comp, insur+ncv rcyuinvl.) IJ.❑Qlher
•.%.I ,timm d he v�.4mut We el mum alw lilt uw IM veII M hutur YW W,.g nn,r wwlW'vunq„Il,yiuw
'I I,nn,n.rnrn-he ram4l this uAdevll imfly,in i
COIN hI,Y.IAM ahe,h IAI Eea r11,W nrxhed,�n al,L�u�Jumv YI fur A,W,tprl him"side rumme tlulivy f„rur,rletiW►
MI.burin IM little e/I 1O1f n Ill •uhnY raw.tRYerN irwtlav,l,na rN'o,
/Ytn on,vnplayer/hut lr pruulal"%'vurAe/s'ru,npenrn//on larY/rrnre/ter, ern savis A�Ihe~rurtas'coop•p„I,cy,nfbman„�
in`Y/IIIY/Gna J te.R 41,e/Yw/s/lyI pu/Gy Yn il/Y� ,%/I
Insurunue('untpauy .Vmner
I'ulicy 4 ter SCIf•ins. Cic.til —
lab Sity d EAplratlan D;Ire:��—_
dJra•cs;
\ttua'A a a•u City'Slate/Zlp:py of tow lrerken' cutnpenwtloa prole) dueloratlun page(showing the
Policy nutnbur and Crpbatlua dote),
Ildcr
rinclupt.ul'I� rg
ln0.rM+rld/urutayearquireJnprivomn`ef is�i llf,.i�t'f•I�, 1luh i finehuto lit*
nteemaJTt7polOR
position%VORKinal penelfiq of,
,)lap rn i?!A OA a Ju I
sl��• Y guuut Ihst v6,l.lnv. Ire 34vlacJ thin a copy urlhill .I,ttcmcnt may bu rurw uJuJ Wthe ORIDiavR and
��rn,nr vr;lw UI,1 :or nnnru•cc N„vcra a But
yu I e 11164pun.
/du h:rrAy{vr/i/y under rh mint�tnJ p/na/Irer u
p {•O
/nry rho he in�b/,nY//On pNYi,/fr/ubYrt i!/ 4e Yrld /rlrR
u
7%ulhwity
r only, pu Olaf lvrirr in Nai jreu. /u Ae run, / rd Dter lien a//lrivLrn: _hant Krminl.lty file tl
y (cirvlo lle.,it It i. I hn� fill'
,,p.lrrnrcut 1. Cie l.'f ono (leek t. llcafric.,l lu, tc,rur :,
I Plumbing lu,ycclar
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Information and tnstructions
it is'V.usa:huseus L,i:neral Laws:huytef I i2 leyuues all cugde`a`on In Iha"sary Je ut another¢mist nny joir their
t�tract of hires.
I•u nuant w mix .talule, an�m0/gYp Is JeuneJ as.•
every p'
at airy two or more
;.pre%*err unpile)• oral Of wrluan." lu tr or Iha
rr I4 JefineJ as"are Individual. Purtnanhip. dineiaaoe.coroorasrmuativ 7 otla dean eJ enlp Y '
\n ,•'nolvl, u nt enierpnse, and nxluJtnd the loyal rep ere loyms atnpioyees. However the
t the I;uegoJly enyuyeJ In a t 1 lauoa or other legal¢nary. D i ant of the
Iq IN er Jf IrUa1Ce UI .et 111d1VIJuaI. pesmer loop. also¢
owner ut'a dwelling house having not more rhea Ihree ap3nomenu and who resides therein,err the
occupant
mcnt be JeemeJ w M an empluytr."
uwnt my Iwuaa of another who employs per+ons to Je maintanunce.:umuuction or repair work on such A e employer
er
,,r ,:1 the grounds or building appunenant thereto shall not because of such employ
ttxu or local licensing agxsey had widthold the Isw r ae or
\WL chapter 152. t)23C(6) also slatOx that"sv+ry ulnd."
renewal of a Ilcansa or P Ueaa wIU the insurance go Poll eaigsubdivisions shall
errult W operate a husle+acor to construct both the le tha tammeow+alt or °
produced acceptable arldeace of comp of itr p
uyplWunt "too has not p , ilCl�l aralas"Neither the commonwealth not mY
\JJiltonally.%IGL:huptar 152. i- ubliu work until acceptable evidansr utcunlpli uic° with the insurance
,nor into any euntract for the parfomtanc+ o1'p
re tdr into
enls of this clwpar have been PfesameJ w the cmuracting authority."
\ypllauu° checking the boxes that upPly to your situation an4 if
n unafQ,uJJre+olos)and phone numlbef(s)along with then carrpluyu(s)of
pia;, a lilt out the worker,' compensation affidavit cmnpletaly.by putrltrship,(LLwi with it employees other than the
naeV+xary.supply sulseontraclor(s) have
work+n' compensation y btnilted to the Oapar. lurance. if an LLC oanam of Industrial
itauranca, Limited Liability Companies(LLC)or Limited Liability
ne,nbare err purtnen, are not required to tarn
employees a policy is required 9a advised that thin allidavit may sRment of
Ala be sure to rigs and Juta the ufllJarib TI1a otlltlavit shoo
ld
permit at license is being requuss to obtain 0 not the workers'
\ccidanta for eontlrme►iun of insurance eoverede• rho the low err if you are tag
he ratttmaJ w dv eley or town nu Ir+a that rho unyt4j3°"•iafcibeiale na regarding
I ndusuial,\ceiddnL , Should
call the *any uids a ill@ awnber listed blow. self-insure)companies should enter their
cumpan+ation policy. Pigs"
salf•insurr on the o ro riots lino.
once license numbe
('it, arrows Otflelals beam.
printed legibly. 'rue Deparo mans ho' provided l space
i bottom
Please he.ure that the affidavit is cmnplete and p licant -
Jt he afrtdavil tur you to till out in rho avant the Cwhic of ill be i ell a.4 hex to cuntaet you reVor ng
given year, need only submit one atlldavit indicating c`rien'
I'I:ua be :ure w till in the pannit/licanxa nwnllor ins in any which will W uaed�t'1";teh1lulJromcc lwrite'Odl IacuJu snip n ap (' Y
ilr,it,neat aibmit multiple Penni) and tinder Address"the aP0 be rovidad to the
policy iut'm mulion I if necessary) vJ or marked by iha city or town isy P
wwnl•'. \ copy of Iha u17Wavit that has bean officially sump
¢trait+err licensor. A now a111Juvit must be filled mW ere
ennit not related to any business err commareinl venture
applicant as proof that a valid affidavit is on fiie for i"n p
em ll is NOT reyuired ro camPleto Ihis affidavit.
y e:tr. \ohcra+home owner or citizen is)braining a license or uastlaiis.
a. a .lay Iicellte of permit to burn loaves ate.)said p you halo any 4
I Ile I)Ili:e UI (11�hflyatlanx wJuld 11Aa IJ thioll yltu in aJv{it1CV Iut yout:oeparal11111 a11J ehuuld
I,Ica,e Jo not hesitate to ylve us a call.
e L)cp•,runent's addra+s, tulephune am
rail number
th C ypJnonWae1t11 of Massachusetts
DaP ORfee of Investigations
600 Washington Street
Boston, MA 02111
Pal, M 617.727fv00 Cat 406 of 1-877•MASSAf Ec
< LI s ',vWW,Mass.gov/diet
CITY OF S,Vc &Nf, NLASS.ICffUSETTS
BLaMCYG DEPARTNIE,VT
110 W-UHNGTON STREET, J40 FLOCA
' T1L (978) 745-9595
KIMBERLEY DRWOLL FU(978) 740.9846
,MAYOR T)io.+w ST.PMAA2
DIAFCTOA OP PL auc PItOPEATY/9"DLVG CONOUSSIONEA
Construction Debris Disposal Aft7davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.S
Debris, and the provisions of MGL c 40, S 54;
Building Permit ff 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
III, S ISOA.
The debris will be transported by:
Jamc—.5 t fltirel S
(name of hauler)
The debris will be disposed of in
a: m-e-[L 2
//(name of tcIIity)
- (address or Facility)
elynamre ofpermtt applicant
' h/I JI�Iti'