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16 OLIVER ST - BUILDING INSPECTION lZ(p (, The Commonwealth of Massachusetts Department of Public Safety 11assachusetts State Building Code(780 CNIR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: I Building Officiate rs SECTION 1:LOCATION(Please indicate Block R and Lot q for locations for which a street address is notwailab /G X r- ©/*7Yd No.and Street City/Town Zip Coc a Name of Building(if appllrle) Zrn SECTION2.PROPOSED WORK r< Edition of MA State Code used_ If New Construction check here O or check all that apply in the two 311"begs Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit ApF adix P,5 Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: N rn 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: .fir s2../i,r� .c'sUr/trq TiO.rs� YY` 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 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(%): 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 licable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ H: Hi Hazud H-1❑ H-2❑ H-3 ❑ H-4 H-5❑ h Institutional I-t ❑ 1-2❑ 1.3 Cl1-4❑ M: Merh cantile ❑❑ R: Residential R-l❑ R-2❑ R-3 Cl 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 ❑ Ill ❑ IIA Cl IIB ❑ IIIA Cl IIIB Cl I IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone required O or trench or specify:or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: \Ir\I N't ii, l nn"mi"i m 1 viv" Not Applicable Cl Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction:_ Occupant Load per Floor. Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) a-mad address If applicable, the property owner hereby authorizes s ry �+ r; Name Street Address City/Town State Zip to act on the rei er owners behalf, in all matters relative to work authorized bV this building permit application, i - SECFION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) "(if bit ildin�is less than 35,0W co.R.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:W0RKFRS COnu'6NSA 11ON INSURANCE AITI )AVII 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 application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) 'iohil Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical S appropriate municipal factor)=S 3. Plumbing $ 4. Mechanical (HVAC) $ Note:Mininwm fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable a rble to Y; 6.Total Cost $ j��b (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERNI 17 APPLICANT ing my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this pplicati r is r e, d accurate to a best of my knowledge and understanding. Please print and sign name J Title Telephone No. Date Street Add - City/Town tale Zip Municipal Inspector to fill out this section upon application approval: —4ruw .3)' lkl Name Date CITY OF SALEM, MASSAC iUSETTS >. ,V BUILDING DEPARTNIENT WSJ' 120 WASHINGTONSTREET, 3"0 FLOOR TEL. (978) 745-9595 F,vx(978) 740-9846 KINIBERLEY DRISCOLL MAYOR THiom S STTIERRE DIncroROF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: XDate Job Location /4 Home Owner Address— 5*W__4�i_ Present Mailing Address S 12— The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire that does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she be responsible for all such work performed,under the Building Permit. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. \'X,\ HOMEOWNER'S SIGNATUREOn _ APPROVAL OF BUILDING INSPECTOR / rf CITY OF SALEM MASSACHUSEM BUILDING DEPARTMENT 120 WASHNGTON STREET,3" FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KIMBERLEY DRISCOLL MAYOR TrIOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING 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 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: r (name of facility) ,Y;f/£� (address of facility) r e Signature of applicant EVate