141R NORTH ST - BUILDING INSPECTION R
;D The Commonwealth of Massachusetts
kDepartment of Public Safety
Massachusetts State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: D Building Inspector:
SECTION 1: LOCATION (Please indicate Block M and Lot M for locations for which a street address is not available)
No.and Street City /Town Zip Code Nome of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building ❑ Repair❑ Alteration 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 ❑
Is an Independent Structural Engineering P er Review/rep}aired/? Yes 01 No El
Brief Descr'ption of Proposed Work: mGo—'—'y /_./ /C /�Ch!!��
OH+G .�LUy/lr Gf// /o—/LSlin� G GA'ic f
-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): - a•
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 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ HA ❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-111 R-2 R-3❑ R-4❑
S: Storage S-1 ❑ S-2 ❑ �+1 z>,a U: Utility ❑ Special Use❑and please describe below:
Special Use: el&WDO
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on eacha
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: ris Removal:
Public ❑ Check if outside Flood Zone ❑ Indicate municipal ❑
A trench will not be Disposal Site
required ❑ or trench y:
Private❑ or indenlifv Zone: or on site system ❑
permit is enclosed ❑ i�.e/'1P/'
Railroad right-of-way: Hazards to Air Navigation: \IA I li'tone Cnnuni"Ion Rro ir,c
\ot Aftphcible ❑ Is}tructure within airport a3pp�roach area? Is their review completed,
r .cur<nn.ent'tii1Bi:ild enclosed ❑ ` + Yes ❑ or:No I� Yes ElNn ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Gnnip(s): T_cpe of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Speciai Stipulations:
r
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Pro perty Own r
Name(Print) No.and Street City/Town Zip
Property Owner Contact 1 f orroiti )n Al � �( [,J�PJ0 rJOL
Tile Telephone No. (business) Telephone No. (cell) e-mail address
If, pplicable, the property owner hereby authorizes
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ame Street Address - City/Town State Zip
to act on the pap pert owner's behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It building is less than 35,000 cu.ft.of enclosed space and/or nut under Construction Control then check here O and skip Section Ill.l)
10.1 Registered Professional Responsible for Constnrction Control
dame(_Rggistr t) J elephong No. e-mail address D Registration Ny�mky Z !O
Street Address City/grown State Zip Discipline Expiration Date
10.2 General Contractor
72114Pt ;F4,
Company Nap /L
e: �
,� 4- , llP..oC� /�'r-L+ (..•. /tCs
'ame of Perso Respo ible f r Construction License No. and Type if Applicable
C y/Town State Zi
/>
S e t ��IIress YY
2u// =K -L'd�j
Telephone No.(business) Telephone No. (cell) e-mail address _ �—
SECTION 11:WORKERS'CONVENSATION 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 oft e i uance of the building permit.
Is a signed Affidavit submitted with this application? Yes Er ❑
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 Cos[x_(Insert here
2. Electrical $ AV-61/ appropriate municipal factor)=$
3. Plumbing $ 4Y7,9 .
4. Mechanical (HVAC)•r! $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ r3sL (contact municipality)and write EbeFk'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 in this
application is true anted accurate to the be t of my knowledge and understanding.
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�I' ji�se�pant ani ai};n n, me• i / Title Tclephon .��.. Date
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titreet Address C c/Town e Zip ,
i
Municipal Inspector to fill out this section upon application approval C
Name I ate
CITY OF SALEM
l � PUBLIC PROPRERTY
lj:
DEPAR"I'LIENT
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Construction Debris Disposal Affidavit
(rci.luired lirr all demolition and renovation work)
I i accordance \%ith the sixth edition of the State Building Code, 7S0 C•MR section 11 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit K is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal I'acility as defined by MGL c
I11. S 150A.
The debris will be transported by: �/�' v./([.ice g �j_c� ✓S/ti)C�
C1, C.A--6(t�.rSTC- lrJ Ar CAILA P
name of hudtr)
I he debris will be disposed of in
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, ' a CITY OF S.�I.E.NI, A-kSSACHi:SETTS
BUMMING DEPART�tF.�iT .
120 WASHI NGTON STREET, 3w FLOOR
TEL (978) 745-9595
F.kx(978) 740-9&M
KIN
[BE>LLEY oRlxou
MAYOR THohtAs ST.PIEM
DIRECTOR OF PLBLIC PROPERTY/BLILDLNG CO>L\USS10NER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Plumbers
Aitnlicant Information Please Print LLeaiblr
Nalne IBusimw Ortaniizat/iorvinn/Lbvvidud)
Address: w �
city/State/Zip: e �/g� ` ��6�Phone a:
,%re you as employer?Cheek the appropriate boa: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
fir[
(full and/or part-time)." have hired the subcontractors
2.fi t am a sole proprietor err partner- listed on the attached shceL 7- ❑Remodeling
.hip and have no employe= These sub-contractors have B. ❑ Demolition
working for me in any capacity. - workers'comp.insurance. 9. ❑ Building addition
I No workers' comp. insurance S. ❑ We are a corporation and its
10.0 Electrical repairs or additions
required.) officers have exercised their
J.❑ 1 am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions
myself. [,Na workeri comp. c. 152,410),and we have no 12.❑ Roof repair
insurance required.) t employees. two workers' 13.0 Other
comp. insurance required.)
.Any applicam slur dmelts Ana sl must aim fill our the maim below wowing their workers'campanastiun polity infumraaods
'I I.mwuwtva who subim!this aflldrvit indicting they are doing all work ad their like outside cont mom must suhmil a new amdsvil indicaino such.
l.mtrs-tora tAot Owck this Ivor mud attached an addititmsl.hear showing the name of ilia aubKoidrwiors and their wwkna'camp.policy infarmab".
I am an employer that b providint workers'compensation Insurotsee for my emplayed% Below is the poiley andm site
information. �
In.urance Company Name: /21-we- L
Policy M or Self-ins. Lie.N: !9 � L Z��O Expiration Date-10/27 O —Q
Job Site Address: �7 !If `��7� SG` city/StatdZip.. -
,%ttacb a copy of the workers'compensation policy declantlon page(showing the polity number and expiration date).
Failure to secure coverage as required under Section 15A 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 form of a STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Investigations of ilia DIA for insurance coverage ventieation.
/do hereby r ify ursder the pains Ord enalt a of perjury that the information provided above is true and correct.
,w r 1 r But : e t45
Pro J: F7
iDfriol use a+dy. Do not write in this area,to be rosrspleted by trey or town o/PriaL
City or ruwn: _- _ Permit/I.IcemeN__
i
hsuinC Aulhurily (circle one):
I. Ituard of Health 2. Ruilding Department J. cityfrown Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
C"Jilaci Person: - _ -- --_ Phone n:.