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28 NORMAN ST - BUILDING INSPECTION (6) The Commonwealth of Massachusetts 6— W Department of Public Safety MassachusetlsState Building Code(730CIofR) Building Permit Application for any Building other than a One-or TV 04amily Dwelling . (This Section For Official Use Only) 'n Building Permit Number., Date Applied: Building Official: U J SECTION 1:LOCATION(Please indicate Block k and Lot 1!for locations for which a street address is notmrrailab � PJOV-MAN 5T �SAl-15-VA MA c`�/ )o " =m i No.and Street City/Town Zip Code Name of Budding(if appAgable)Drout — SECTION Z PROPOSED WORK rri Edition of MA State Code used If New Construction check here❑or check all that apply in the Isv�.rows ow Existing Building❑ Repair❑ Alteration Addition❑ Demolition ❑ (Pletse fiR out and submit�ypem(ttr,t) Change of Use ❑ 1 Change of Occupancy ❑ Other Cl Specify: rn Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑/ Is an independent Structural Engineering Peer Review remred? Yes ❑ No fl�l Brief Description of Proposed Work: ✓�`fJ�4NG Ywr�Tio�� y a5'//✓�`•.SCEnr�n� 's� A /.VljtE/x- //0r,1To c rcr A 7A-7 rc,— r51-0ll o SECTION 3.COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE'OR OCCUPANCY jbIyA k here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ ing Use Group(s): Proposed Use Group(s): SECTION4:BUILDING HEIGHT AND AREA Existing Proposed f Floors/Stories(include basement levels)&Area Per Floor.(sq. ft.) Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a licable) sembly A-t❑ A-2❑ Nightclub ❑ A-3❑ A-4❑ A-5❑ B. I usiness O E. Educational ❑ to F-I❑ F2❑ H: Hi h Hazard H-1 O. H-2❑ H-3 ❑ H-4❑ H-5❑ titutional I-1 O 1-2❑ 1-3❑ 1-4❑ M: Mercantile R: Residential R-10 R-2❑ R-3❑ R-4❑ rage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: l Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) IBO HA ❑ 11BO IIIA ❑ 11180 IV ❑ VA ❑ VB ❑SECTION 7-SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) SuppI Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:blic Check if outside Flood Zone❑ Indicate municipal A trench will nut be Licensed Disposal5ite❑required rtrench or specify:ate❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: 4L\t lisngi.Cpnmu,7lon.uce_li"'I'nxg,C Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Budd enclosed❑ 1 Yes❑ or NO❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: . Occupant Load per l:lour: Does the building,contain an Sprinkler System?: Special Stipulations: __ SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street - City/Town Zip Property Owner Contact Information: C!?r-s 8607 qO- 7a10 Title - Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this budding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) - If building is less than 35,000 cu.R.of enclosed space and/or not under Construction Control thencheck here O and ski Stetion 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 10.2General Contractor - - � 2 7P,261t 0-ONT Co any Name .,bin-2 Cs--022-j 7 Name of Person Responsible for Construction License No. and Type if Applicable '��) � LLL��iQ� til/ln I,ul�els _ Street Address City/Town _ State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:4V0PKFKS'C0MPFNSA I[ON INSURANCE AFFIUAVII M.C.L.c.152. 25C 6 A Workers'Compensation Insurance Affidavit from the NIA 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 E3 No O SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ I. Building $ // O'JO Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ ,3 ' appropriate municipal factor)_$ 3. Plumbing S OQ�>•'-- 4.Mechanical (HVAC) S Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ 1� Enclose check payable to e.. 6.Total Cost $ 0 / ,-�- ("'tact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERhIIT 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 accurate to the best of my knowledge and understanding. r7 02- <5t7 FL017`1 Ple.ue rint and sign name Title Telephone No. u e Z�I IZb6�S wt Md_ 0/270 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval• - �LBZL7 " Name Date Y The Commonwealth of Massachusetts Department oflndustrialAceidents I Congress Street,Suite 100 Boston,MA 02114-1017 www.massgov/dia rworkers'Compensation Insurance Affidavit:Builders/Contractors/E►ectiicians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information r n Please Print LeObiv Name(Business/Orrgganization/Individual)�J-r=rd/, UTM` or 19r�N C (Dy-r Address: rQ-9 2-44L, �Q City/State/Zip: t c Lbd • d f 76 Phone#:97f Are yoo employer?Check the appropriate box: Type of project(reQaired): 1. 1 am a employer with .3 employees(full and/or part-time).' 7. ❑N COnstNChOn 2.❑1 am a sole proprietor or partnership and have no employees working for me m _ 8. Odeling my capacity.(No workers'comp.insmanee required) - 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9: El Demolition 10❑Building addition. 4.❑I am a bomeowner and will be hiring contractors in conduct all work(many property. I wrlt ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with an employees. - 12.❑Plumbing repairs or additions 5. I sat a general comraclor and d I h hired the subcontractors on listed the attached sheet. ❑ 13.❑RooOther repairs, These sub-contractors have employees and have workers'comp.insivancet 6.❑We am a corporation and its officers have exercised their right of exemption MGL c. 14.❑Other - lk emPn per 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box pl must also fill our the section below showing their workers'compensation policy information. - t Homeowners who submit this affidavit indicating they are doing all work and than hire outside comractors must submit a new-affidavit indicating such. tCmnacmn that check this box must attached an additional sheet showing the rove of the sub-contractors and state whether or not those monies have employees. If the subcontractors have employees,they must provide their workers'pomp.policy number, I am an employer that is providing workers'compensation insurance for my employees.-Below is the policy and jobsite Information. y - Insurance Company Name: Policy#or Self-ins.Lic.#: UJ C -'IY5�5-� 3 Expiration Date: d Job Site Address: /I��(1 N 1 6 h/ �� City/Stete/Zip: (M Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 _ and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify r th pen ies ofperjury that the information provided above is true and correct. Si afore: Date: 1719115 Phone M OJreW use only. Do not write in this area,to be completed by city or town official City or Town: Permit(License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(ILC)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 date 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 Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pemtit/license 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 the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dqg license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: - The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02 1 14-201 7. Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CrTY OF SALEA MASSAGiUSE M Bui DngGDEPARTA ENT 120 WAsHmToNS7REET,3,DFWOR nL.(978)745-9595 KAMERLEYDRISODU FAX(978)740-9846 MAYOR TlHMW ST.PMM DIRECTOR of PUBLTCPROPERTY/BLa DmG oDmmmoNER Construction Debris Disposa/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 c40, 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 deposit 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: (name of facility) (address of facility) Signature of applicant Date I £l RIVATE TATTOO BOOTH 3 TATTOO BOOTHS INKS NTERIOR DIVIDER WALLS TILITY ROOM!STORAGE � 10'i" 3 T.�.. 22 17'7 " 22 3 . T NTRANCE TO CORE BATHROOM/ iSECONDARY EGRESS AIN ENTRANCE CONSTRUCTION NOTES -ALL VINYL FLOORING AND BASE BOARD THROUGHOUT -INTERIOR DIVIDER WALLS FOR TATTOO BOOTHS TO BE 8'TALL LEAVING SMALL GAP FOR AIR VENTILATION SCALE: 1/8"=1' -SINKS IN EVERY BOOTH 15' -CORE BATHROOM LOCATED IN SHARED SPACE DATE: 5/6/2015 CLIENT: KELLY DOTY GOLD DUST GALLERY oL II STROUT CONSTRUCTION DRAWN BY: MC - - - CONSTRUCTION PETER STROUT - LOCATION: 28 NORMAN STREET SHEET NUMBER SCALE: 1/8"=1' SALEM, MA i_ MICHAEL STROUT 01970 C1.01 TRAV[S STROUT CHECKED:TS w .StroutConstmc8on.com M APPROVED: PS NORTH �4