7 OSBORNE - BUILDING INSPECTION MN The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
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; Building official:
SECTION 1:LOCATION(Please indicate Block#and Lot N for locations for which a street address is not available)
gas SNIP !26jcj
No.and Street. City/Town Zip Coale Name of Budding(if applicable)
SECTION 2:PROPOSED W RK
Edition of MA State Cute used_ If New Construction check here❑or check all that aPP Y I inthe two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ I Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Sec
P ifyf
Are building plans-anal/or construction documents being supplied as part of this permit application? Yes ❑ Nt�7 CAIIs an Independent Structural Engineering Peer Review required? Yes ❑ N$] m
Brief Description of Proposed Work: I
rd rA101sr: - 5 3 �,
Oc
O n n taj
Ul
rn
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDI N,Oft
CHANGE IN USE OR OCCUPANCY n
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑ 4T'
Existing Use Group(s): '
Proposed UseCroup(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq,ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑
F: Facto F-I❑ F2 E: EJuwtionai ❑
❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
L' Institutional 1-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-0❑
S: Storage S-I❑ S-2❑ IU: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUC ION TYPE(Check as a licable)
[A ❑ Ill ❑ IIA ❑ IID ❑ IIIA ❑ IIIB ❑ IV VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit., Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone; or on site system❑ required❑or trench or specify:
permit is unclosed❑
Railroad right-of-way: Hazards to Air Navigation: CIA I list ri i ,ngn csnn R..ices I'ntcss:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
[dition of Code: Use Group(.$): Type of Construction: Occupant Load per Floor:
Does[lie building contain an Sprinkler System?;__ Special St ipndations
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) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit 1p lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.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
10.2TGenera9-Co ntractor
C"i N
Company Name
- 11:: ru
s-11
N:une:of Pe{sgn Responsible for Construction License No. and Type if Applicable
StreeFAddress City/Town State Zip
1V
Telephone No. business Telephone No. cell - e-mail address
SECTION 11:wOR EKs'COMI'EN.SAIION INSURANCE AFFIDAVI I' 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 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Rem Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Budding $ - Building Permit Fee-Total Construction Cost x_(Insert here
2 Electrical $ appropriate municipal factor)_$
3. Plumbing 5.
4. Mechanical (HVAC) $ Nute:Minimum fee=S (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ aO D" (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.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Dalc
n
11
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 NVASHINGTON S ITtEET,3"D FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THONtAS STTIERRE
DIRECTOR OF PUBLIC PROPE RTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location �20S)l-,r 4-1c I.,n_cS dtS7r
Home Owner Address / OS 15.0 r ✓1 -2
Present Mailing Address S I.q
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.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING IN ECTOR ��
QTY OF SALEM, MASSAaR SEM
ter I BUILDING DEPARTMENT
120 WASHINGTON STREET,3m FLOOR
TEL. (978)745-9595
KIMBERLEY DRISQOLL FAX(978) 740-9846
MAYOR THomAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMSSIONER
Construction Debris ff
Disposal Affidavit
p
(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:
0w�IP o
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Kature of applicant
Date
f° Q-1-Y OF SALEM, NWSACHL:SETI-S
t BUILDING DEPART>t&vT
120 %V.ISHLNGTON STREET, 3'FLOOR
•I'EL (978) 745-9595
F.vr(978) 740-9846
K1-IgEjt[HY DRI IL SCO
t'J LYOR THollw ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/Bmrir\G COmISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblit�� k�1;1111C(Ilusituss,Organiratian,'Individual): � !J/�v .�_
Address: �10-&Ps o!'-q P Safi c-
City/State/Zip: S*12� lgrei<i OLSz& Phonelf: Lf
Arc you un employer?Check the appropriate box: 'rype of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ [.am a sole proprietor or Partner- listed on the attached sheet. t �• El Remodeling
,hip and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'camp. insurance. 9. Q Building addition
workers'comp. insurance 5. El We are a corporation and itsrequired,] officers have exercised their 10.0 Electrical repairs or additions
3.9 lam a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'camp. C. 152, §1(4),and we have no 12.0 Roof rupairs
insurance required) t employees.[No workers' 13.0 Other
cump. imsurancerequircd.)
•Any npplicanT rim chchs but rl most also fill out ore section Wowahewing their worker'oumpemadoe policy h3ru natfon.
'1 fomeowncn who submit this atnrtnvit indicating they am doing(all work and Than hire outride camncron most submit a new alndavit indicating such.
:<\u.IMIUM shut rhcrk ibis boa most anchcd an addidural.hoot showing rho name or the subavnincion and their workers'camp,put Icy information.
funs art eurpluyer tbut is providing workers'cuntpensadon inturuncajor my employees Below Is the pol/cy undjob sire
inforntation.
Insurance Company Name:
Policy it or Self-im. Lie.d: Expiration Date:
Job Site address: City/State/Zip:
Attach a copy of the worlceW compensutloo pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of JIGL c. 152 can lead to the imposition of criminal penalties ufa
tine up to S1,500.00 and/or one-year imprisonmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a tine
orup m S-'50.00 a day against The violator. Ile advised that a copy of this statement may be furwarded to the Office of
Investigations oft lie D[A for insurance coverage veri licaliun. -
l du hereby certify raider the putts mad penalties of perfury that Ilse hi/armulron provided ubuve is true and correct.
Sien.uurr. Date:
Phone 'h
Official use only. Do nor write in this area,to be completed by city at town o/Jlriu[
Ciry or l'urrn:
Issuing Authority (circle one): --
1. Board of Ileallh 2. Building Department .1.Citylrnrsu Clerk J. Electrical luspeclur 5. Plumbing Lupeetor
6. Other
CunUd I'crion:.__..----- I hone !l: