28 NORMAN ST - BUILDING INSPECTION (7) CK 2l8 22o
� The Commonwealth of Massachusetts
r Q``������'' Department of Public SREOEI VED
yu, MassachuseltsState Buil MdOUIX&J1$ERVICES
Building Permit Application for any Building other than a One-or Two-Family Dwelling
.(This Section For Official Use
Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
2g NOrmth st- C0/7M 41f�-
(-?� No.and Street City/Town Zip Code Name of Building(if applicable)
I SECTION2.PROPOSED WORK
I r� Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
\� Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Er
Is an Independent Structural Engineering Peer Review re bf ? Yes ❑ No 53�
Brief Desttiption of Proposed Work: Q.eAh i h51r b!f�h Ill N r
Qfrtilr ,P,,r,l Sh`In �,Vnir filar r�utrrr
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 Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) (/oef
Total Area(sq.ft.)and Total Height(ft.) I s000 I /O
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ If: High Hazard H-1❑. H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ Ile\ ❑ [1110 . IIIA ❑ IIIB ❑ 1 IV ❑ I VA ❑ VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public Er Check if outside Flood Zone❑ Indicate municipal❑
A trench will not be Licensed Disposal Site
required l�r trench or specify:
Private❑ or indemity Zone: or on site systemlia` permit is enclosed❑
Railroad right-of-way: I Wards to Air Navigation: yl,-\ li.,n>ri..-lnnm,i�sim Iftwicw I'roi,•94:
Not Applicable Pf Is Structure within airport roach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No® Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Glitiun u(Code: Use Group(s): Typeof Construction: . Occupant Load per Hoor:
Uues the building, lain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of•Property Owner,., .. . _ - f
ydf-c, � fjofmati S�l�cn rYl
Name(Print) No.and Street City/Town Zip
Property Owner Contact
Information: ��
0VjV(Q {Rat rIlre * -V3J- � ��'-L_
Title __ , Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Paul l_roorl �2 -PQrL PLt� (/�f' (Wlt/ Ali 01� d
Name �-t 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)
!f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check hem❑and skip Section 10.1
10.1 Registered Professional Responsible for Constmction Control
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Name(Registr t) Telephone No. a-mail address Registration Nwpbcr /
I �@rla_ ad Wt AfileGS'ref- � �O dinrtsY ictts
Street Address City/Town State Zip Discipline Expiration Date
i
10.2 General Contractor
L V C NO %Stru1C*(00 khC
Company Name
+1Qul LPp>��t Cs -0Z-713 Constr-mtt do S'wpeyvlso(
Name of Person Responsible for Construction License No. and Type if Applicable
IZ 'Oark IM9- 1) 1,949
Street Address City/Town State Zip
-kf - V 0 -( A -M -&YV- E743 L2cco�stn.ct�ow:nc a yM4f/,rorL+
Telephone No. business Telephone No. cell e-mail address
SECTION 11:bV0RREF9 Cot ll'l.NSA I ION INSURAN(T AFFIUAVCI' 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 nuance 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)_$
1. Building $ Building Permit Fee—Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality
S. Mechanical Other $ Enclose check payable to
6.Total Cost $ 8��.d 0 (wntact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby uttest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the b t of y knowledge anal understanding.
l �Q 15(� oldNi%�2l
Please print and si n name Title Telephone No. Date
J-z '�`� —
Street Address City/Town Stale Zip
I h S r
Municipal Inspector to fill out this section upon application approval:
Name Dale
QTYOF SALEM, MASSAaiLISETIS
BUILDING DEPAR7WNT
120 WA9m rGTcNS7mT,3'DFLooR
AL(978)745-9395
PAX(978)740-9846
KIlv]BERLEYDRISQ7LL
MAYOR THCMAS ST.PIERRE
DMECrO-ROFPLMIJCPROPERTY/BUWMODMMMONn
Construction De
bris Disposal Affidavit
idavi t
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 MR, 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:
M( T ruick
(name of hauler)
The debris will be disposed of in:
j✓JN'N %/qws���' $hthoh
(name of facility)
C`bnnMr�Ctic ��' L.yNu
(address of facility)
Signature of ap licant
Date
The Commonwealth of Massachusetts
Department oflndustrfalAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Vworkers'Compensation Insurance Affidavit:Builders/Contractors/Elects icians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lettibly
Name(Business/Organization/Individuxl): CoS Oh
4r4o'H 74e
Address: 1 Z 2 r k V Gt'
City/State/Zip: Vi v M PS t`l f Phone M I R( Z I 0 Ly9
Are you an employer?Check the appropriate box: Type of project(required):
I.[!(lam a employer with employees(full and/or part-time).• 7. ❑New construction
2.Q I am a,sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required]
9. El Demolition
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
4.�I am a homeowner and will be hiring contractors to conduct all work an my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.F�I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.�Loof repairs
These sub-contractors have employees and have workers'comp.insurance?
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�the7
152,§1(4),and we have no employees.[No workers comp.insurance required.] - -
*Any applicant that checks box#1 must also fill out 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 contractors must submit a new affidavit indicating such.
lContmctors that check this box must attached an additional sheet showing the name of the sub-contrac?ors and state whether or not those entities have
employees. If the subcontracrors have employees,they must provide then workers'-comp.policy number..
lam an employer that is providing workers'compensation insurance for my employees. BeJow is the policy and jobsite
information.Insurance Company Name: 14 j NI IV)
_/^�IA N44 -l""'U✓61 J7Lf CO
Policy#or Self-ins.Lie.#: VWC -1db - &0t 5C7{--2014 R Expiration Date: r- 2Z -14
Job Site Address: .Z�. �DCrAmy% S`Y City/State/Zip: 601'( UA
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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Signature' / Y Date: �l Z
Phone 7$i ? z/—o 4 6-51 7�1 V14 F70 I
Official 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 arid,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(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 date the affidavit. The affidavit should
be returned to the city or town that the application for the pemrit 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 permit/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 bum 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
1 Congress Street, Suite 100
Boston,MA 02 1 1 4-20 1 7
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia