17 NORTH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts Slate Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Famil Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: •0 Building Inspector:
SECTION 1: LOCATION (Please indicate Block R and Lot S for Io tions for which a street address is not available)
f 7 R., ,�RLem O I G r7U [_�,�'��
:No. and Street Citv /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below - f
Existing Building 191 Repair❑ Alteration Fdr j Addition ISI' Demolition ❑ (Please fill out and submit Appendix 1)
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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ - n
Brief Description of Proposed Work: e m O e, 1 +l h t d>-.Sp oyt r vlar
iLftdl 7 if-d u3r 0 O i I f,r (it yryiuoa—
AiAi Fla -tkan.S LtcO u
{/— 2 4 per"5Ap ti
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 Group(s): 4 2Y Proposed Use Group(s): IZ-
Existing Hazard Index 780 CMR 34: S Proposed Hazard Index 780 CMR 34: �f
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) 1 3 aS rp 4 F 1,_ ate° F"oe
Total Area (sq.ft.)and Total Height(ft.) l6q4ri 12 3fs Sa"
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E. Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2 ❑ - H-3 ❑ H-4 ❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-10 R-2 &K R-3❑ R-4 ❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA &-' 111130 IV 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:
f(:d Public A trench will not be . Licensed Disposal Site
Check it outside 1=1uud Zone❑ Indicate municipal
required ❑or trench or specify:
Private❑ o r indentifv Zone: _.or on site vstem ❑
- permit is enclosed ❑
Railroad right-of-waay: Hazards to Air Navigation: \L\ I li,ilm, (wormri m Rc%it%c Pror,—:
.:\itt \pplicable 07 I*StruUure within airport,pp i:ach area? Is their rem ice, completed?
it C nnant Gi Bnild enclosed ❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Fdition of Code: Use Group(.a): Type of Construction: Occupant Load per Fluoe
Does the building contain an Sprinkler System?: Special Stipulations:
evl_%p 7 Z 2 may/ e.
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name.,Nameand
,sol� Prt S G qIS
Name(Print) No.and Street City/Town Zip
Pro c Ow'ner Con act Informa
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicabl the p�of�erly owner heret thorizes
Name Street Address Citv/Town State Zip
to act on the property owner's behalf, in all matters relatike to work authorized by this building permit application.
SEC'CION`to:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed s Lace and/or not under Construction Control then check here 0 and skip Section 10.I)
10.1 Registered Professional Res onsible for Construction Control
l ec' , c"1�3 1 vZ $-1 q `l
Na^�Regi}qpn[)kJolfG� � fepne�N „ A e-mail�ad�dr�esps Registlatiop er
Street City/Town W\ ^y te{ Zip Discipline Expiration Date
10.2 General Contractor
Oza
r�O Res
U1l..)(��yrty�b yt
(itLftu� rttt�-C �l Lar( a if A. pplicable6\ 9
Stre&t Ad es lZ City/Town 1 (SSttaatee Zip
Telephone No. (business)' 1 Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ 3 S- 8 O b
Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ 5 Q b�0 appropriate municipal factor)_$
3. Plumbing $ 6 b '
4. Mechanical (HVAC) $ t � D Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6. Tot I 21 Cost $ Q o (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained i this
application is true and accurate to the best of my knowledge and understanding. --t V
` + (a--U
Please pool and aign n e r---� Title Telephone No. Date
—�Z �S�'oo Cis ( 4r-c'� C.s2, S�J Q w��'S�-� � •�9L9�7
street Addfesv Cih/Tm%n Sate Zip �f
Municipal Inspector to fill out this section upon application approval: t r+
'ame I . to
CITY OF S.UX.,NI, �L-�SSACHLSETTS
BL'DDLYG DEPARTNIEdiT
• 120 WAS14INGTON sTREE r, 3m FLOOR
TEL (978) 745-9595
FAx(978) 740-91M
KI-tgFAi E D Y RISCOLL
Y DR THOMAS ST.PtEItim
�(
DIRECfoR OF PLBLIC PROPERTY/gl•IIDLNG CO%MUSSICINER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r licant Information 1 Please Print Leiribly
Name (ausim�organi:ati uat
`� io
ominthvid ): / r \ C+✓ G�
Address: ' b - �`� � SS�O
Cily/stafeizip:4,J AQ S�� y�l.� rho n ff
\r you as employer?Check the appropriate box: Type of project(required):
I. I am a employer with 4. ❑ 1 am a general ctmtnctor and 1 6. New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : 7. Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers'comp. insurance. 9. building addition
iNo workeri comp. insurance 5. ❑ We are a corporation and its
required.]
otricen have exercised their 10. Elt -rtC. repairs or additions
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 employces. [NO workers' 13 ❑Otha
comp. insurance required.]
'Any applicant thin checks has 01 must alai fill was the 3Ktim below showing their worker'contamination policy infurmatlom
'I l.vneumnen,who submit this affidavit indicating they ars doing all work and these hiss outside contmetes must submit a new affidavit indicating such.
{',mtraeton that cheek this bax mud amachod an additiswol Awat showing the name of the ati eaeantmore and their workers'comp.policy intermission.
l am an employer that b providlnir workers'compensadon lnsarome for ray employees Below is the policy and job rile
information.
Insurance Company Name:
Policy a or Self-ins. Lie.p: Expiration Date:
Job Site Address: City/State/zip:
,lttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the Corm of a STOP WORK ORDER and a file
of up to S250.00 i day against the violator. lk advised that a copy of this statement maybe forwarded to the Office of
Inreshgmionx al'thc DIA for insurance coverage veri tication.
l do hereby c rrify i,11dripirst pain{ nd t ties of perjury that the hrfonnmlon provided above is true and carreca
,;Ior t u Dole: '-Zb ^D
Phonc �: \ O `�
0fruial use only. Do not write in this area, to be completed by city or town ofJk'imi
City or ruwn: _ Pcrmi0.lccnse M
hsuing Authuniy (circle one):
1. Board of Health 2. Building Department 3. C'ilyffown Clerk 4. Electrical Inspector 5. Plumbing Inppector
6. Other
lunlact Person: _ _ Phone Ih
I
L
CITY OF SALLM
ry PUBLIC PROPRERTY
° .., • DEPARTMENT
Construction Debris Disposal Affidavit
(rciluired liir all demolition and renovation work)
In accordance wth the sixth edition of the State Building Code, 780 CAIR section HI 5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting front
this work shall he disposed of in :t pruperly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will he hansportcd by:
S 0A
tname of hauler)
I he debris will be disposed of in
(nalnr of I'aultty)
(address .4 Iunlity)
aplatulc p:rn ut .y+phc Jnt