73 NORTH ST - BUILDING INSPECTION xv
The Commonwealth of Massachusetts
Department of Public Safety
�� F �i��;% \la.•arhu•ells State Building Cade 1,JUG.\IR)Sa•u'rnlh Edition !
City of Salem
Buildins Permit Application for any Building other than a I or 2-Family Dwelling
I Ihts Section For Official U,e Onlv).
iBuilding Permit Number: Dale Applied: Budding Insprchrr: �
SEC-TION 1: LOCATION (Please indicate Block Y and Lot a for Iota l ions for which a street address is not+v+i l+b 10
Street C nc /Town Zip Cade Name ut.Budding bt opp0aable)
�" - �T• SECTION 2: PROPOSED WORK
If New Construction check here❑ur check all thal apply in the two rows below
Exising Budding Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
/n Changeuf Use ❑ Changeuf Occupancy ❑ Other ❑ Specify:
rl Are building plans and/ur curstructiun ducuments bring supplied as part of this permit application? Yes ❑ Nu
yVl / Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
"I ^ft-tV eX A- " 0 P ..ate•
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): i•
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CNIR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) + -
Toral Area(stl.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❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-S❑
1: Institutional I.1 ❑ 1-2 ❑ 1.3❑ 1-4❑ Mi Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-) ❑ U: Utility❑ Special Use❑and lease describe below
:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ ISO IIA ❑ [ISO IIIA ❑ HIS ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 far details on each item) _
W+ter Supply: Flood Zone Information: Sewage Disposal: French Permit: Debris RemovSite❑al:
I'uhuc❑ Chcd d u trtde ILw .I Gnte❑ InJlu le mumcteal❑ \ trench will not be Llirmed Unlit�al
j required ❑or trench .,r .pcatc._
I'n yeti❑ ,r utJcnb A- Zone._ nr ran .dr•r•Irm ❑ permm r•cnclu•rJ ❑
j Riilru+d rightof-way: H+tards to Air Navigation: \I\ I h•i.•n, a .. r�nn--o...
\ 1 \pph,.tPlc❑ L �Irutlum„ilhut eirl• rtl.tpl•tndih.tn�a' I•thvu rct ic„ nanldrlrJ'
..il •n•cnl nllwl.l cnJr.cJ ❑ I la•❑ .,r\,-❑ N" O \�� ❑
SECTION 8:CONTENT OF CER"rIFICA rE OF OCCUPANCY
I .Ilion , I lJc . .__� �'cl•n ap•i•I _ I,l`c q l.mJni.lu n ____ ltiiul•enl ln.t.l l•rrl L ,n __.____.___._
1)'.. 1hv t•...Llw';u,ntl.mt.In shnnAlcr?u -Icm` _ `p,v let sllpul.tllnn• ______._.__—____
�Sa I 40
Cc, stok"
73 kJor7t
SECTION 9: PROPERTY OWN ER AUTHORIZATION
NJ we.ur.l Add rvnt5I n'l+crlc Owner
\anm 11 nnU Nu. .vx1 }(reef lit. , r,nvn
I'rnl+erlc U..ovr Contact Information:
rrtlr rrlrphune No.(busmr>n) rrlephone No. Ice14 r mall Iddr,"
If.rpplic.tbly, the pr.+)•rrH os.ner hereby.utlhontrs
Nome Nrvel Address cite/ru.vn }late Zip
tn,rct+m the +ru •erly .n.•ner'%behalf, m,dl rnatter9 rvlauce to.vork.ndhurttc•d by this building rrnnt a + dtcnn m.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(II bud.hn•is cos than 3i,(M)Ucu. It.of enckw,l< acc and/or not wovr C.in:trucbon Cuutrul then check here Cl and.ki +S•.b�io 10 1)
10.1 Re istered Professional Responsible r�� for Corotruction Control
®CYO' _ _ .s•� 1PY'lll'1�}fl Cr✓ U.�.
.Vatr�7/( gistranl) r rF e No. a-mall tadd�d/r�ess Registration Numberr.
Strret_Addrrss City/Town State Lip Discipline Ea tea lion Date -
10.2 General Contractor
SwA
C any Nam SAL
� ^ I
Na e r erssm Res ns161e for nslructiun �Li nsseotN•o.aannddd Type if'�A plicable
�l0 w �N t-1� O
Street dress City/Town Stat Zi
- 73oa - MChet'fhNT/afc @ At�31 , M•
Telephone No.(business) Telephone No.(cell) email address
SECTION 11:WORKERS'CONWENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =5,
I. Building f / t
Building Perini[Fee =Total Construction Cost x_ (Insert here
2. Electrical 5 appropriate municipal factor) =5
3. Plumbing f
�. Mechanical (HVAC) f Note:Minimum fee=f (contact municipality)
S. ,,l hanicJl (Other) 5 Enclose check payable to
6. Total cnet $ G p&p p y
(contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
liy entering my name below, I herebv altrsl tinder the pains and penalties of perlury that all of the m(orm.uwn n intmned 'n thl,
..pplicahun I,true and accurate to the beef crf my knowledge and undrrslandtng.
I't.•.i.r f not1 mQ1J-_p. en9`.nro�tm�c- �y�. fn�lr
_- �, "'l�,~Y"'" , L"f\ v.1•� /j� .•Icl•hl�`• \ i I!.�Ic
h
I' Municipal Inspector to fill out this section upon application approvN�71J1al: __
\.line _I cite
l /�
i
CITY OF SALEM
PUBLIC 13ROPRERTY
*� DEPARTMENT
.lam: a:fY:)a lfla�I1
\I grist
12:WASHOW l 11.X its ELT 0S.0 I+.W, M.t>V�.u.ut a l rs Jl97�
978.713-9395 •P ill 9711-74C•1316
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
%imlicant Infurtnation Pleme Print Legibly
Villne 0. VIA �1 yyQ�
Address: .�� � )thn7xn S1
City,Slamzip: ��_ Phonei!:
Are I yeu an culploycr?Check the appropriate box: I'ype of proiect(required):I:❑ I ant a employer with 4. M I :un a gcocral ctatractor and 1
employees(full indlur punt-time).• have hired the suh-contractors ft' New construction
2.❑ 1 tilt a iole proprietor or partner- listed on the anachcd sheet. : 7• ❑Remodeling
ship and have no employer s These subcontractors have S. Demolition
working lilt me in any capacity. workers' camp. Insurance___-_-9._❑_DuilJing-;nlJitiun- -----------
-- -- - iKn workers'comp.iusuranca S.-Q Wa arc a rnlpor tl and itx
mquircd.J otYicers have exercised their IO.Q Electrical repairs of additions
J.❑ 1 am t homeowner doing all work right of exemption per bfCL 11. Plumbing repairs or additions
myself. [No t�orkcrs'comp. c. 152.¢1(4).and we havo no 12. Rtwf re rtn
insurrncu rcyuired.J l - unpluyecs. iKo workers' P .
comp. insurailm ruyuircd.J 13.Q 011lcr
•any.yipbewa ihW chccka boa al mwl also rill wl the wellan below Imwinx their wwhvi cumpvmmiwt policy inli,rmuliun.
'I Im,nunwmm whu u bmil this anldavie indiuiinx obey ara dains all work aid ibcn Ain:Wlnidn c,atunergf mwr auhrnil an"ai'ndavit indiaannx mock.
•C.monclun iha cMxk this boa mraa anached an addiliuml ahwl ahuwinx the nano of rho sutrsonlraclom and their wuhon'comp,pdky infmman.us.
lilaamill
d am on rarpluyrr that lr pruriding rvurhers'cmnpenrntlon inrarnnee for my amp/uytea. Below/s the puNicy and job site
hiforlioutiatr.
Insurance Company Valne:
Policy A or Sclf-ins. Lic.to: -._ .. ..- Expiration Date:
Job Silo-\ddrees: Cilyislute/Zip:
Attach it copy of Ihd workers'cumpeniatlun policy declaration page(showing the policy number and expiration date).
Failure to secure cu\eruge as required under Sccliun 23A uf.'IGL c. 152 can lead to the imposition of criminal penalties of a
rive up at 31.5110.00 and/or une-year imprisonment, ar wull is civil penalties in the lorm of a STOP WORK ORDER and a fine
oftip fit i250.00 a Jay against file violalnr. lie advi.icd that a copy ufthis slutcmcnt may be lurwarded lu the Office uC
Im C.,twillmis ul the 01A lar tlsurallec c,Ivcragc tcrilicauun.
/da hereby certify am/er the pains,ai Id pena/Nev of perjury that the in/braratlon pruvided above it rrae and correct f
<nraauoe - L- �r ) \ 0� 1
1'I.w: •a D D
U//laiud use Do not uv/te in rhir unto, ru be rump/rrtd by airy ur rmvn o/Jit.•iaL
i
City or Dime: Pcrinitrl.lcensc 41 .. I
Issuing.\ulhurily(circle tine):
I. IA,urJ of Ilctlth 2. Iluildinq Ikpartactt 1.l:ityr'Ibna Clerk J. Electrical Inspector 5.
b. O11er PlumbingIuypcctor I
l',nuua 1'cnun: Phone d:
t
Information and Instructions
,,\I:usaCltosens Ucricral Laws Chapter 132 tcquires all employers to provide workers' compensation fix their cnlpoyees.
1'ur.uatn to this statute,an emplut•ee is defined as"...every person in the service of another under any confirl of hire.
express or implied, oral or written."
.fin vinplupar is defined as"an individual, partnership.:IssOclatWn,corporation ti other Icde entity,or any two r t more
,It the loregoing engaged in a joint enterprise,and including the legal reQresentatives of a deceased employer,or the
rceervcr or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than to Jo nr apartments
enun and
unalructoo or repair work on such dwellcupant Of ing haute
.Iwelling house of another who employs persons
or on the.,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.'
SIt,L chapter 152, p25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or per to operate a business or to construct buildings In the commonwealth for any
:Ipplicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally �IGL chapter 15?, a?3C(7)states"Neither the commonwealth nor any of its political subdivisions shall
corer into any contract for the prrfomwnce ul'public work until acceptable evidence ofconlQliance with the insurance
requirements of this chapter have been presented to the contracting authority."
-AppApplicants
lies"(out-the.-workcra.'_compensation affidavit completely,by checking the boxes that apply to your situation and,if
pi.-- — - - necessary,supply sub-contractor(s)name(s),adlihess(es)and phone-nurnber(s)along with-chair c employee
e(,of
insurance. Limited Liability Companies(LLCworLimitedjbility o Partnerships
(If an)with
o o p does employees other than the
members or partners,are not required to carrycompensation
employees. is.policy is required. Se advised that this affidavit only,be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the atttdavIL The atlitlavit should
he retooled to the city or town that the application for the permit or In:
is being requested, not the Department of
. as regarding
law or if you are required to
a workers'
Industrial Accidents. Shoo call the you have nny Vestlict at the number list d below. Self•irnsurad companisisttshould enter their
compensation policy,pDepartment
self-insurance license number on the appropriate line.
City or'rown Ofticlals
e sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom
Picric be
for you to fill out in the event the Oliice of Investigations has to contact you regarding the applicant.
of the a
be used as a reference number. In addition,
1'I:use be sure to till in the permit>license nulnbx which will er. i applicant
s
that mwt submit multiple pennitllicerrse applications in any given year,need only submit one atiidnvi[ indicating current
policy infomation(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 ilia city or town Inay be provided to the
id affidavit is on file for future permits or licenses. A new affidavit must be filled out each
applicant as proot'that a val
r citizen is obtaining a license or permit not related to any business or commercial venture
year. Where a hone owner o
(i.e. a dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
111c 1)1 iel' ,it I live sti gatlons would like to thank you In advance fur your Cooperation and should you hate:any gUC5110114,
pleuse do nut hesitate to give us a call.
The O.paruncrn's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
0Mce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.mws.gov/dia
° CITY OF S.U.&M, ILL-SS.kCHUSETI'S
• BUILDING DEPARTMENT
' 120 WmHL1IGTON STREHT, 3 °Rom
TLL (978) 74S-9595
PAX(978) 740-9846
xlatBE UEY DR=Ou
MAYOR THowsSi.PtPSRa
DIRECTOit OP PuBtic PROPERTY/81:9M YG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit At 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
1 11, S 150A.
The debris will be transported by:
(name of haule )
The debris will be disposed of in :
O _
(name of facility
C�1.t,1 i
^` (ad ss of facility)
Uzi
sl ature of permit applicant
data
1[bnatf ba