9-11 OCEAN TER - BUILDING INSPECTION 3,10 The Commonwealth of Massachusetts
Department of Public Safety
Xtass tchu.elts State Budding Code(780 CNIR),ecenlh Edition
City of Salem
Building Permit Application for any Building 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 N and Lot N for locations for which a street address is not available)
Nu.•Ind Street C itv /Town Zip Code Name 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 6 Alteration ❑ 1 Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No l9—
Is an Independent Structural Engineering Peer Review required? /' Yes ❑ No a
Bri�ef�j/criptiun of Proposed Work: nn �-/,fG p f S� .2N� N� " �ok I rQ ar jl OI(�7RA2�,
v a (�
I
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 a Iicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B. Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ hi❑ 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 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 111013 1 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 if oulside Flood Zone❑ Indicate municipal ❑ A trench will not be Lice•med Disposal Site❑
required❑or trench or.pc0h:
I'ncata•❑ or mdent,ty Zune: or un srtr sv.tem ❑ permit is unclosed ❑
Railroad right-of-way: Hazards to Air Navigation: ....m It,•.„•.. Pn
\ot Apldic.l•Ie ❑ 1.titructane%colon aupnrt api•rnech ores)' 1,their re\ v%% c„mpleted.'
I. a llm.cnt o, Rudd vndnrd ❑ 1'c.❑ w No❑ 1'es❑ \u ❑
SECTION B:CONTENT OF CERTIFICATE OF OCCUPANCY
L.v Croui,(.). ra pe of(.,un,trmtwn: Occupant Load per Plnor:
I)oe. 0II'I'u111il1g nmtain,,n Sprinkler tiupulattons:
I
-- 0
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Idy(rr..��1 Pro mrty Owner _/
d Ale y A-n/61n t L 0C1e N�✓ Tc?,r iye' S,� �nra M,9- 01�7,
Name(Print) No.and Street Cih'/rown Lip
Pruperh Oaa ner Contact Information:
Title Telephone No. (business) Telephone.No. (cell) r-mad address
If applicable, the property owner hereby authorizer
Name Street Address City/Town State Zip
lu.act on the pro pert\'opener's behalf, in all matters relative to work authorized by this building permit a p plieHion.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
lit buildin•is laps than 35,01XI cu.it.of enclose i s pace and/or not under Construction Conlrol then check here O and slup Section 10-1)
10.1 Registered Professional Responsible for Construction Control
tv
vN
jocep6, �3.aallh 9� �s d 7oG ?/
Name(RegistrantJ Telepgqone Nu. e-mail.ddress Registration Number
41 J�P_ 8ta ,,7,0.4C,-_ _�./ell2 VUL 00 L o/
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
oaf b!e; 6 &,*x
Company y Name: r
I a 3(ta 0.01/2 l//Y1'/° lion/1
Name of Person Responsible fur Construction License No. and Type if Applicable
Street Address City/Town State Zip
8v� 1GrlG
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. 2SC(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 O No O
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 mum ipal factor)=$ .
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee= ee2 (contact municipality)
5. Mechanical (Other) $ ^ - Enclose check payable to - -
6.Total Cost S O` Q(J. oel (contact munici alit )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 inharmation contained in this
application is true and accurate to the best of my knowledge and Understanding.
I'Iva,v grin a d sign n, ritle relephone No. Date
4�
titrcet :\dd L, Citt/Town r Zip
.Municipal Inspector to fill out this section upon application approval: I 1 s I
Name Dote
2
t�
2
CITY OF S.1LEa`1, ,NLvLkSSAC1iL SETTS
BL D.DIING DEP.stant&NT
120 WA3NLNGTON STREET. )'a FLOOR
TEL (978) 745-9595
FAx(9711) 740-95"
KI,IBE> E� D
Y RISCOLL
Y DR THO&W ST.PIEM
�
DIRECTOR OF FL OLIC PROPERTY/{L'1rDLNG CO-%L%0SSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectrlcisaWPlumbers
antellcant Information Plesm Print LMblr
Naind (gusirveva.Oryaurahorvindevn
Address. 11 n 1 ¢ a T�i�O�GG
City/State/Zip: f4 6A t ssop - o/-7>a Phoney: I7R 45S
Are you as employs'Cheek the appropriate box: Type of project(required):
1.❑ 1 am a employer with U— e. Q I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).• have hired the subcontractors
2.Q I am a sole proprietor It Palmer- listed on the attached sheet: 7. ❑Remodeling
+hip and have no employees Thee sub-contreerors have 11. ❑Demolition
%vorkin for me in an capacity. workers'comp.inwnooa
{ Y Ps tY• 9. Q DuiWing addition
I No workers'comp. insurance S. Q We are a corporation and its
ookers have exercised their I0.❑Electrical repairs ar additions
requital.'
1.Q 1 am a homeowner doing all work right of exemption per MOL I I.Q Plumbing repairs or additions
myself.[Na workers'comp. c. 132,11(4),and we have no 12.0 Roof repairs
insurance requital)► .mployema.LNo work=.
comp.insurance required j I3.0 Other
-Art appose ihr chicle ban et nasal alwr ass uW tlr seceia Ealose ahrwiy their wertua'mnye.radow policy utfumsado L
't bm,eowt.e.who su6art this anldevie indltadna they as some all work art dwo hue comb can"am"mtw atlhna anew amdavie indi rains Wort
:r.mraton shot cheek tNo Ara toned amachod an a Mikooll dirt showily on natae of dte ak.eaamosms and their wosion -cmnp.policy i.Am woo
l sae an eaeproyer that/s pnvldlas workers'cowpetstadotr btsunnnjor oar emplttireesr Below/s McPN/q awd/o1 sib
injortntdlota
Insurance Company Name:
Policy M ur Self-ins. Lie.p Expiration Data,
lob Site Addrers: City/State/Zip:
Attach a copy of the workers'compensation policy declaration pep(showing the policy number and expiration dnlo),
Failure to secure coverage a•required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to S 1.300.00 and/or one-year imprisonment,as well as civil penalties in the form of*STOP WORK ORDER and a tine
Of up to S210.00 a day against the violator. Ile advistal that a copy of this statement may be forwarded to the OIY1ce of
Invcsngatiuna nl the MA for insurance covcrap verifwatiuo.
l do hereby certify candor the pain.►and penaldrs of perjury that the injoratatian provided above is true and earreeL
,;o_n sure: I)ato:
Phone 4
D/fleial We only. Do nor wan in rh&near to be carnp/rted by city or Town,q/kiat �
I
City or ruwn: _ Yermit/IJcenseM__. _
Issuing Auihurity (circle oney
1. lluard of Ilrallh 2. Ruihlinil Department J. Cilytrown Clerk 1. Electrical inspector S. Plumbing Inspector
6. Other
L-,niacl Person: _ ._ __ Phone e•
CITY OF SALEM
; I PUBLIC PROPRERTY
DEPARTMENT
1'JI: MIDI "Mlv 1-II
I.0 W.,d II\L.,IV 51 at1'T To)•111\I, �1.N�11 I It J I'`-11
to•'I%t-NS'r3Ys �P\r:Y7/.NS7/Jh
Construction Debris Disposal AMdavit
(required tur all demolition aild rcnovatiun work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.3
provisions of MGL c 4U, 54;
Debris, and the
� Building Permit p__�- . _ iss issued with the condition that the debris resulting from
this dirk shall he dislwscd of in a properly Licensed disposal facility as defined by MGL c
111. S 130A.
The debris will be transpoortcd by:
Jo i,
i I name ut•haultr)
The debris will be disposed of in :
i d f'4-a-1
(n,une ul act Ity
t < 4ZeebQ®-'I —
I uJJras l 1 1lyl
.1/131ure of Iwrmit,IpplicaM
date