147-149 NORTH - BUILDING INSPECTION fit-76 zs42�
The Commonwealih'Of MzISSAS>REC ,HAL SERVICES'
AI} Department of Public Safety.
Massachusetts State Building Code-(780C7fnrT
Building Permit Application for any Building other than a Ott it�F 4 ltn p Dlw g
(This Section For Official Use Only) \
'Building Pirmit Number. to Applied: \. Building Official:
SECTION 1:LOCATION(Please indicate Block N and Lot N for locations for which a street address is not available)
]I p
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below ,
Existing Building❑ 1 Repair❑ I Alteration ❑ Addition❑ 1 Denwlition ❑ (Please fill out and submit Appendix 1) t
Chanl,e of Use ❑ Change of Occupancy ❑ 1 1 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 ❑
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 Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑
Existing Use Group(s): Proposed Use Grou p(s):
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-f❑. A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2 Cl I If: Hi h Hazard H-I❑ H-2❑ H-3 ❑ FI-4❑ H-5❑
1: Institutional [-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: i\lercantile❑ 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 a licable)
IA ❑ IB ❑ [[A ❑ [Ill ❑ I[IA ❑ 11111 ❑ 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:
"French Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate uumieipal❑
.\trench will not be Licensed Disposal Site Cl
Private❑ or indenti(y Zone: or on site system❑ required❑or trench or specify:permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: sln I li i ,k k,k i,
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s):_ type of Construction:_ Occupant Load per I looc_
Duce the building;inutoin an Sprinkler System?: _ Special Stipulations:
t.l irk F:b�
SECTION 9: I'ROPER'IY ObVNI?R AU'1't1ORIZA'FION
Mune and Address of ro erty Owner
Name(Prmt� -1 NW?.i-,�.1 No.and Street City/Town Zip
Property Owner Contact Infort Cation:
'!it e r ` - Telephone No. (business) Telephone No. (cell) a-mail address
If applir. Oh I rope t hereby author 70
t lame Street Address City/Town State Zip
to act on the property owner's behalf, in all neuters relative to work authorized by this buildingpperunitapplication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildui+is less than S,BW cu.(t.of enclosed s ace and or not tinder Construction Control then check here❑:md ski Section 10.1
10: a istered Professi nal Res onsible for Construction Control
None-(,Re tyant) )/ Telephone No. e-mail, ress Registration Number /
Street Address City/Town State Zip Discipline Es ratio Date
10.2 General Contractor
Cut parry ame
Nam e of ers n esponsible for Con rdction m e No. and Type if Ap licable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:wowm:iZS cC>Nu'[NBAI10N INSURANCE Ari'I1)AV1t M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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 $ & Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)
9. Plumbing $
41. Mechanical (HVAC) $ Note: Mininiu n fee=$payable (cont``act niu ^ip�afily)
S. Mechanical Other S Enclose check m tble to J W-v
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest under the pains and penalties of perjury that lot the information contained in this
applies 'v isJ{u�m accurate the b s of myn ledge and understandi �� -
Please,({,•rf{t/tuJLtdd sigiame l� itle Telephone NNo���!!!///�j! Date
Street Address City/Town State Zip '^
Municipal Inspector to fill out this section upon application approval: �`,,w
Name Date
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To A-A, lek �,o 4 / 5
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T° CITY OF SM EM, NIWSACHUSETI'S
i
BUILDING DEP.IRT>IE.\T
130 1Y/.iSHLNC.TON STREET, 3w FLOOR
Ya.aa> T EL (978) 745-9595
FA.x(978) 740-9846
KI.NLBEp1_FY DRISCOL L THOMASST.FIFARE
{'tiL'LYOR
DIRECTOR OF PUBLIC PROPERTY/BCQD[\G CO\L\1f5S(OV ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlcians/Plumber9
A i ilicant lnfnrmatints �r Please Print Legibly
Naine(nusiness,Organiratiorv'Individualj:
Address: / p // -•�+�
City/State/Zip::: 1 Phone N:
Are an employer!Check the appropriate box: Type of project(required):
1 am a employer with a. ❑ I am a general contractor and 1
6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2. 1 aria sole proprietor ar partner- listed on the attached sheet.t 7. El Remodeling
.hip and have no employees These sub-contmcton have N. ❑ Demolition
working'ftr me in any capacity, workers'comp.insurance. 9• ❑Building addition
i tNo workers'camp. insurance 5. ❑ We are a corporation mid its
rcquircd.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ i am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(\'o workers'comp. c. 152, §t(4),and we have no 12.❑ Roof repairs
insurance required.) t employees.(N'o workers' j},❑Other
comp. insurance required,)
-Any applicunt duct checks box el mass also fill out the section belowshewing their worked compemadu r policy iufurmailon.
'I hwneuwne's who,uhmit this atlldnvit indicating they are doing all work and then hire outside contmctan most suhmit a new affidavit indicating such.
ic". vtuo but check this box most attached an additiunut sha4showing the nine oflha sub.samnpun and their workm'wrap.policy information.
l one on enployer ileat is providing workers'eunipeusatlon lnsuratecejor my employees Below Is the policy andjub silo
injannurinn. ®'
Insurance Company Name:
Policy it or Self-its. Lie. 0: % Expiration Dole•.
Job Site Address: City/State/Zip;
Attach a copy of the workers'compensattoo pulley declaration page(showing the policy number and expiration data).
failure to secure coverage as required under Section 25A of MGL e. 132 can lead to the imposition of criminal penalties of a
line up to S1,500.00 und/or one-year imprisomncnt,as well as civil penalties in the form of it STOP WORK ORDER and a line
of up co S250.00 a day against die violator. Ile advised that a copy of this statement may(x furwarded to the OfAce of
hrvrsligariuns ol'Ihe Dlt1 far rage lion. -
/du hereby certify it ns r Ides ojperjury that the injurrnatlati provided ubuve ix true and c-urrree
�i••n r c Date:
Phone,i:
P
OJIl ial use mtly. no not write in this area,to be cuasplsted by city ur tannt njjlrlul
City nr'Fawn: - Permit/1.1eensc N_--- �
--Issuing Authority (circle one): ---- --_
1. Board cal'Ilealth 2. Buildlnq Departuteat 1('ilyffnwo Clerk J. Electrical Impecdor 5. Plninbing Inspector
b.Other
Contact Pcrsoo: ._ _ Phone ;t:
I
QTY OF SALEM, MASSAQHUSETTS
Kr� 1� BUILDING DEPARTMENT
120 WASHINGTON STREET,31D FLOOR
TEL. (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR THCmAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING ODNMUSSIONER
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 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:
(name of hauler)!/%��
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
4 �
Date