19 NORTH ST - BUILDING INSPECTION (3) t The Commonwealth of Massachusetts
Department of Public Safety
q x ,
\las.adni..rtt.State Building Code(780 GN1R)Seventh Edition
City of Salem
Building Permit Application for any Buil ing other than a 1- or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
/9 zy ih st Sc em M-4ry
T
\'u. and Street CihY /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
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition ❑ 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 Ar
Is an Independent Structural Engineering Peer Review required? Yes ❑ No R-
Brief Description of Proposed Work:
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): Proposed Use Group(s): P
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hi h Hazard H-1 ❑ H-2 ❑ H-3 ❑ H-4❑ H-5❑ -
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ 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 ❑ 1110 HA IIB ❑ IIIA ❑ IIIB ❑ 1 IV 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
+ Debris Removal:
Water S m Supply: Flood Zone Information: Sewage Disposal: Trench Permit:-
Public ❑ Check if outside Flood Zone ❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site ❑
required ❑or trench or-pecih:
Private❑ or unientifv Zunc:_ nr on site yvstem ❑ permit is enclosed ❑.
Railroad right-of-way: Hazards to Air Navigation: \I:\ I h,tn,ri,( -mini—ion Ro.h•„
\ot \pplicable❑ I.�trIICWIC�'lthln airport approach area' Is their rec ie,c completed'
or C nment to Budd cndn-ed ❑ 1'c-❑ or No❑ Yes Cl \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code. U-c• T_c pe of Construction: Ocaipanl Load per I Ivor.
Doc- the building conl,iin an Sprinkler S\stem.': Special Stipulations:
..
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and A idress of PropertY Owner -
-Te a oo ppC /� ��� s� Srr�Pm s�
Name(Prit—�- tt) r Nu.and Street City/Town Zip
Pntperth 0%%ner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
1(applicable, th)e prop rt_y owner hereby authorizes
�r ��ri^if 7 /S i0e e')Q
Name Street Address Citv/Town Stale Zip
to act on the pro pert% owner's behalf, in all matters relative to work authorized by this build in g permit a p pl ica Lion.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,(Xk)Co. It.of enclosed s pace and/or not under Cunstructian Control then check here O and skip Section 10.0
10.1 Registered Professional Responsible for Construction Control
A/M Dx, krz rl.4 S2 rL- -ram /yn 7f
pm (Re istranp Telephone No. e-mail address Rey4stration Number
Street Address City State Zip Discipline Expiration Date
10.2 General alt2yl-
�Contractor
Wm / KiaR nn r Z/)!
ClA/./"7 y Ne/Ytf)T 14912
YC /�
Name of Person Responsible for Construction License No. and Type if Applicable
all; ✓Pltn
Street Address - ity/Town State Zip
Telephone No.(business) 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 0 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ 6400e r O s.D Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $
Enclose check payable to
6. Total Cost $ &0e,40 ,0 Ga` (contact municipality)and write chec c number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby apt t under the pains and penalties of perjury that all of the information contained in this
appplication is true and accurate to the be tit my knowledge and understanding.
1 Ve
Please print and Title Telephone No. 12, e
rA(1 d /57
Street Addles. City/Town tita Zip
.Municipal Inspector to fill out this section upon application approval:
\a Date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
-
'f rl:4711-743:)i95 1°.\x:978•740-9946
Construction Debris Disposal Affidavit
(required lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 11 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p . _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
Inamt of haultr)
The debris will be disposed of in
(nameor�aul— ty�
(1 ddress or faclluy) _
J _ V
Signature of Ixnnit a/pplicant
la)-7 ai
date
CITY OF &U.&M, NLASSACHUSETTS
BI:MDLNG DEPART]fEVT
120 WASHINIGTON STREET, 310 FLOOR
TEL (978) 745-9595
FAX(978) 74069846
Ito\BERRY DIUSCOLL T HObUS ST.PMAAis
MAYOR
DIRECTOR OF PC gL(C PROPERTY/gl'¢DCIG CONM155(ONF1
Workers' Compensation Insurance Affidavit: Builders/Contractor!/Electrfcians/Plombers
al)plIc2nt Information Please Print Leviblr
Naine(Bu �OOrtam,ationlndowdual):4/r✓I
Address:sD_ -! ��U&e6 n(A
City/State/Zip: Phone M:
,%re you as employer'Check Rho appropriate box: Type of project(required).
1.Warn a employer with 1ST 4. ❑ 1 am a general contractor and 1
6. ❑New construction
nnployces(full and/or pan-time)." have hired the wbcantracmrs
2.❑ 1 am a sole proprietor ar partner- listed on the attached sheet : 7. ❑Remodeling
These sub-contractors have I. Demolition
:hip and have Iw employees ❑
working for me in any capacity. workers'comp.insuralroa. 9. ❑Building addition
[No workers'comp. insurance S. ❑ We area corporation and its I0.❑Electrical repairs or additions
required.] odicers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,$1(4),and we have no 12.❑Roof teppai-rs
insurance requited.)t employees.LNG workers' 13.0 Other "704
comp, insurance required.]
-Any applicant this chMk*box el must aW rig 0111 Ins Mlia Rtalaw,showing their workea'c0 nprnpdnn policy inewinalloo.
'I h neuwn is who submit this snldsvis indicting eley am doing all work and thta him onside eestmoem mml mheh a rare IMJasis indiailq noels.
<',vm:vn Oho cheek Ibis box man aruchee an aldaoxwl Jos showing us none of tow atb4enrmalem low Ihek wer hill a'comp.policy intimation.
/ate as employer that ir providing workers'cextpersrmloe Inadroree for My raep/rytnes, Below IS tM pe/fap NO If sins
irtforrndfioa.
Inwrance Company Name: ^-�
Policy 4 or Self•ins. Lic.p:.7d cJ J 7�60/Z o O /q
Expiration Date: /_ ,.
Job Site Address: / 6(IA S City/StatrJZip:. LEA,"
Ansch a copy of The workers'compensation policy deelaralloe pogo(showing the policy oumbor and explrsdon data).
Failure to secure coverage as required under Section 25A of MOIL c. 152 can lead to the imposition of criminal penalties of
tine up to S 1,500.00 and/or one-year imprisonmcnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250,00 u day against the violator. Ile adviwl chats copy of this statement may be forwarded to the Of lice of
Invc,tigationa of the DIA for insurance coverage veritication.
I da hereby 1014molder the prima and pemrlt/es of perfdry char the informodon provided above is true annd.correct
�ry r t r Date:
Official we only. Do not write in rhir area, to be cumpleid by dry or roes,)/flciol
Cityar fuwn:
Lsuing Awhuray (circle one): — - —
I. Ituard of Ilr:rllb 2. AuihlingDepartment 3.Cityfrown Clerk J. Electrical tinpector 5. Plumbing Intpeetor
6. Other
l„nlactPenon: _ _ ._. _.. PhoneM•