158 NORTH ST - BUILDING INSPECTION y
"
^,► The Commonwealth of Massachusetts
' 1 Department of Public Safety 7 \lussachusclts tilate Building Curie 17S0 CA1R)Seventh Edition
l City of Salem
Building Permit Application for an Building other than a 1- or2-Famil Dwellin
(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 avail e)
Nu.and Street '!L� City /Tux n Zip Code ® Name of Building(if applicable)
SECTION 2:PROPOSED WOR _
If New Construction check here❑or check all that apply in the two rows below
Existing Building Cd-- Repair Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 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
Brief Description of Proposed Wurk: �
- s
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): r
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❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ *" H: Hi h Hazard H-1 ❑ H-2 ❑ H-3 ❑ H-4❑ H-5 ❑
I: Institutional 1-1 ❑ I-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: /
ECTION 6:CONSTRUCTION TYP (Check as applicable)
IA ❑ 1110 IIA ❑ IIB ❑ IIIA ❑ 111B ❑ 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:
Public ❑ Check it outside Flood Zone ❑ lodicate municipal ❑ A trench will not be Licemed Di*posal Site ❑
Pei c,i le ❑ or indentita Zone: nr on site at:Stem ❑ required Clot trench or..pccitN:
permit is cnHosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I:\ I h,t, rut
\ol,:\p[,hi,iHv ❑ I.tit ru Cliue wuhrn uirpnrl aF+prua Ch orea' Is lheu'recmry Completed'
sir Crn"lit t Btirld cnCln`cd ❑ " t
SECTION 8:CONTENT OF CERTIFICATE OF O CUPANCY
1nr ,Edittr+n.d C rnir L v
Co :: f Pl fvpc rri Coast nicurrn: Uaupant 1,14111 per Moor
l),o. the buildmg Cont.un an Sprinkler Sv,tem:' Special Stipulation,� � F . .
�Gb
r
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Prup�,erSSt�yI JO,/AAw
Naner /
m�e�—�—
Name(print) No.and Street City/Town Zip
Pro,erly lhcner Contact nlurmaliun: W
Title Telephone No. (business) Telephone No. (cell) e-mail address
If aF�j1k'� 'le, th'., r er o�'ner hereby authorizes ���� u� F ,/;—t�
`�t-� t a ORN S) ran —.L1. 7
Name - Street Address City/Town State Zip
to act on the *roeerty on%ner's behalf, igall matters relative to work authorized by this building permit a >>licatiun.
,SECTIONQO:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It building is less than i"ot)6cu.ft.of enclosed s pace and/or not under Construction Control then check here O and skip Section 10 1)
10.1 Registered Professional Responsible for Construction Control (y
lC 6 ? r J L— 1S oti� O
Name Registrant) Telephone No. a-mail address Q��� Reg®t�ratiunNumber.
��11� 1 nr1 �r— � I law .
Street Address City/Town State Zip Discipline 9xporation Date
10.2 General Contractor i--n
Cu,Anpan Ir — 0-1
Nart�e o Person Respunsib a for Construction �bce�se No. and Type if Applicable
�L a Jtk �h *k-
Street Address .sc;�Q .�d] �r,��,Q City/Town State Zi
7� ss-; R A300 - btu rL �T abTnl it
Telephone No.( usiness) 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 application7 Yes❑ No 9f
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6) _$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $- - appropriate municipal
3. Plumbing $ Note: Minimum fee=$-3 D (contact municipality)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ (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 in this
application is true and accurate to the best of my knowledge and understanding.
I'Irnt and •n nor r Title Telephone No. Uate
e
�t ra•r1 :\.i.iriss City/Town State Lip
Municipal Inspector to fill out this section upon application approval:
Name Pate
CITY OF S.U.EN1, ,NLLkSSACHi;SEM
BL'1LDLNG DEPARTMENT w
120 WASHINGTON STREET, )rot FLOOR
TEL (978) 74S-9595
FAX(978) 740.9&M
w.,iBF1tIEY DRISCOLL
VSAYOII I�ioaus ST.P[Elutt
DIRECTOR OF PLOLIC PROPERTY/gCItDC4G C01ODUSSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information � �� wi Please Print Legibly
Name (dusinas.Orpn,zarrion,Inhvldrul): ��^y^�rr�,�p,PAV\
City/State/Zip- C�Lem M� Phone M: -1 il4 363
,%re you an employer?Cheek the appropriate box: Type of project(required):
1.ElI am a employer with 4. ElI am a gm,-ral contractor and I 6. ❑New construction
,,..��
employees(full and/or part-time)." have hired the subcontractors
2.d I am a sole proprietor or partner- listed on the attached shceL 7. ❑ Remodeling
,hip and have no employees These subcontractors have g. ❑ Demolition
working for me in any capacity. worker'comp.insumom 9. D Building addition
I No workers' comp, insurance 5. D We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
J.D 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself (No workers'comp. c. 152,41(4),and we have no 12.❑ Roof repairs
insurance required.] r employees. iNo workers, I;,❑Other
comp. insurance required.)
-Any applicant that cheeps tot At mull alwt fill wt the srclioa belor showing their worked'cmnp gioidsn pulley mtarn daa
'I I.vneOnvtwas who sula nit this aRldsrk indicting they are doing all work and than him outside controcbn must submit a neat alrldavit indicating such.
T,,mmun that chock Ohio boot mud anwhod an addiliurrl shod-hawing due name of this sub o fractom and their wwkem'comp,pal icy intormouan.
f um an employer that tat providing workers'compensation inanratace for my employee Bdow fi the pdffry and Jot tfar
information
Imurance Company Name: tv ViO� ,...[l�rllt/.E6A(pst.
Policy 4 or Self-its. Lie. `-e:m aft A019 - Expiration Date: C77 i C>
Job Sire Address: 1 J% City/Stale/Zip,(�AIou , 14 koiq-76
,mach a copy of the worken'compessatlos pogtgn dectantbs pagg(showing flu polky number and explodes date}
Failure to wcure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
f ne up to S 1,500.00 and/or one-year imprisonmenc.as well as civil penalties in the form of a STOP WORK ORDER and a fine .
of up to$250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Ofrice of.
In%catigatiuns ul dw nIA for insurance coverage verification.
[do hereby certify
yuujndde�r�the pa1linns`und penaides of perjury that the information provided above is true and correct
tut
�IL•11'tf life: ��-r—G�'"X 1�/1�
Phone d `2 /O 7 �LI
i0117ciaf use d,dy. Do lot write in this area, to be catrrp/eted by city or town ojfciai
iCity orruwn: __ Permit/lJccmeN__.
!.suing Authurily (circle(jne): j
I. Iluard of Ileuilk 2. 9uilding Department J. C'ilylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. OI her
C�nttacl Person: _ __. _. Phone It:
CITY OF SALEM
< 3 PUBLIC PROPRERTY
DEPARTMENT
:nlc: Ell 011
120 WAMIING'tONSMUT 1 S.\I r\1, NiAsi,\( II tit.I is�1'1
TEf:978.14 9 95 ♦ 1:.%X:978.74(}9846
Construction Debris Disposal Affidavit
(retluired 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 c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall he disposcd of in a properly licensed waste disposal 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
(tiame of faci ity)
(address of facility)
. gnamre porn nt
date
ncnn;,rrr.,k
i
,.
,,
l