38-40 PALMER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
ALrssachusctts titutc Building Code(780GAIlt)
o,•
Building Permit Application for any Building other than a One-or Two- .1mily Dwe I It g
\� (This Section For Official Use Onlv)
�J Building Permit Number: Uate:\pplicd: _ _ BuildingOfficial:
SECTION 1:LOCA"PION('lease indicate Block It and Lot p for locations for which a street address not available)
No. and Street City/Town Zip Code Name of Building(if appli(able)
SECTION 2:PROPOSED WORK
Edition of MA Slue Code used— If New Construction check here Our check all that apph� in the two rows below —_
Existing Building❑ Repair❑ :\Iteration ❑ 1 Addition.❑ Demolition ❑ (Please fill out and submit Appendix 1)
_Change of Use ❑ Change of Orcupanq' ❑ Other ❑ Specify:-- _
Are building plans and/or amstrucliun documents being supplied aes part of this permit application? Yes ❑ No ❑--_--
Is an Independent Structural Engineering Peer Review roquircd? Yes ❑ No ❑
.-Brief Description of Proposed Work: — I.J O �_��6:R-�eYIL STiC1GLyvL�
e V— `Z'o t-.� o f -F�u LL-T>I L-4-1�,,"
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here it an Existing Building Investigation and Evaluation is enclosed(Sue 780 CMR.1-f) ❑
Existing UseGroup(s): _._ IProposed Use Group(s): --_
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sq. ft.)
Tula)Area(sq. ft).md Tohd Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A4❑ A-5❑ Bo Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: Ili h Hazard H-1 ❑ H-2❑ 1-I-3 ❑ H-1❑ 11-5❑
1: Institutional 1-1 ❑ 1-2❑ 1.3❑ 14❑ NI: Mercantile❑ R: Residential R-I❑ R-2❑ R-3❑ R-1❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use - -
SECTION 6:CONSTRUCrION TYPE(Check as applicable)
IA ❑ IB ❑ IIA0 IIB ❑ IIIA ❑ II10 ❑ 1 IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 C NIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal:
Public❑ Check it outside Hood Zane❑ Indicate municipal ❑ A trenCh will not be I.icensed Disposal Site❑
I'm ate❑ ar indontifv Zone: or on site system ❑ required ❑or trend) or spec ih':... ..
—_-- permit is me losed❑
Railroad right-,f-way: Hazards to Air Navigation: ',i i�:-.i• . . ., ...
Not:\pplicable❑ Is Slru,wre within eirport approach area? Is their roe irwv raol+lcled'
or Consant to Iludd vmlo'ed ❑ 1c,❑ or No les❑ No ❑
SFC I[ON N:CON I ENT OF('Fit"1*1FICA 11:OF OCCUPANCY
I ditwo of Cade: _ ._ Lso Group(s): . . . . I\Ile Of C1mslnn tlan: ly,updnt Loed per Einar: .
Pou,the building,00laiu on�priokler;v stem': tipecidl stipulltiansr. _ _ .
SECTION 9: 1'ROI'F.ITIY OWNIiR AUTIIOIiIZAI'ION
Museand Addres.cof Property Owner
l rs c----2A--v-z- 31 t
N'.nme(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title ---- -- telephone No, (business) Telephone No. (cull) a-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 building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
Ill buildin p is less than 35,00t1 cu.ft.of enclosed s+ace and or not under Construction Control then check here O and ski Section WA
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-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
�2a 1�1e.s4N�t�17i� <-)- �dct l VA dl`i'LG
Strout Address _ City/Town State Zip
Tole phone No. business Telephone No. cell a-mail address
SECTION 11:its_.,ititi.^_,_ei_o\iitv,.\iln\1 1g;,\.Nt.'rAri11-.t\I1, M.G.L.e.152.§ 25C6
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)-S_
1. Building S Building Permit Fur-Total Construction Cost x_(Insert here
'_. Electrical S appropriate municipal factor)-5
1. plumbing $
d. \lochanical (HVAC) S Note: \lininnon fee-.S (Contact municipality)
S. :\IcChanical Other 54NFnclose check payable to
6. roll Grst 5 (Con taC1 nuuliCipal itv)and write Check number here
SECTION 13:SIGNA"PURE OF BUILDING PERMIT APPLICANT
14v entering im name below, I hereby iltest tinder the pains mill penalties of perjury that all of the information Contained in this
application is true and JCL ura to to the best of uw know lad ge and understanding.
Please print.cod sign name I"itle rrlephone No. Date
<trect Address Citvi'rown State /i
Municipal lnspectorto fillout thissection upon applicationappruval: _.--.__-__-------_----_--_-_. . .. --
Name lime
CITY OF SiU_E,NI, l%L ss.IaiusETTS
BUILDING DEPARTMENT
120 W.\SHLNGTON STREET, Ya FLOOR
TFL (978) 745-9595
F,kx(978) 740-9846
KI,,IBERLEY DRISCOLL
AAYOR TrtOSIAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Altlillcant Information Please Print Lepibly
Na tile tllusiiwssA(ganlraiiomindividuui);
Address: ` . ,;,. 1&v}e 6�5
City/State/Zip: s phone#1 IZi�' - 741 -F60 0
Are y u an employer?Check theappropriate box: Type of project(required):
1. I am a employer with 4. 0 I am a general contractor and 1 6. 0 New construction
employees(rull and/or part-time).* have hired the sub-ccnlractorx
2.0 lain a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These subcontractors have tl. coalition
working for me in any capacity. workers'comp.insurance. 9, Building addition
[No worker?comp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 ran a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. (No workers'
comp.insurance nyuin:d.) 13.0 Other
•Any appticam our chucks box of mual also rill uul the wctiuo Wow showing their workers compenseda„Policy information.
'I1, neuwrwvs who submit this olid2vit indicating they an doing all work and then hire outside contractors most auhmit anew aMdavit indicting such.
:<lmurtuo thus chuck Chia box must anacbod un additiunai chow shuwing the mmre of the subaontnctan and their wurken'wmp.policy infomtntion.
fain art eatpluyer chat is providing warkert'cumpeasadon insurancefor my employees. Below/s rile policy and fob site
infonnaflotr.
—�
Insurvme Company Name:
I§dicy 4 or Self-ins. Lic, d: Jr00 S(o0 ��//Z p/� Expiration Date: b 6 �loL2 '
Jub Site Address: _99;1 49 -P 1�,,.kV-4,Z_
� ttylState/Zip: � �j "[ U
\ttacb a copy of the workers,compensation pulley declaratlen pigs(showing the policy number and expiration date). - -
Failure to secure coverage us required under Suction 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
Of up to S230.00 a Jay against the violator. Ile advised that a copy Of this,vlatcment may be rurwardcd to the Office of
Investlgalions oftllc DIA ror insurance coverage vcrincaitan.
/(la hereby certify under die pains mid penahles of perfury that flee itrfuroraflorr provided above iv true and correct
solll'llurc' -7 7
Ili1lJ: IZ ��
VI-
Official use anty. oa nat virile in 1114 area,lobe completed by city ur sawn affleiat
Ciry or'fown:
- -- -- Purmitfl.lcemed__.,.
Issuing Authority (circle one):
L Board Of Ilcallh 2. Ruilding I)eparlment .1.C'ityi rown Clerk 4. Electrical 6tspccfor 5. Plumbing Inspector
6.Other .. __.
Contact l'Jrwn: Phone;t:____.__-___
I
i
r "
Information and Instructions
\lassachuseits General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as".-every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL chapter 152, §25C(6)also states that"every state of local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s), address(es)and phone numbers)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure[hat the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to rill out in the event the Otf ce of Investigations has to contact you regarding the applicant
Please be sure to till in the permittlicense number which will be used as a reference number. In addition,an applicant
that most submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a call.
'rhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Iavestfgations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF SALEM, ttiLuS:ICI-iusETTS
BLILDLNG DeP.ipt-nMNr
120 WASHLNGTON STAEBT, Ye Fto00.
T)!L (978) 745-9595
K1 MER1EY DAMOLL F.\X(978) 740.9846
,tiL1Y0)t T}mW ST.F1EUA
DIPECTO11 OF PCauc PROPERTY/BUILDLNG CO.\L\I1SS10NHIt
Construction Debris Disposal Atfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section
Debris, and the provisions of MOL a 40, S 34;
Building permit #I work shall be is issued with the condition that the debris resulting from
l 11, S 1 SOA.I disposed of in a properly licensed waste disposal facility as defincd by NIGL c
The debris will be transportcd by:
��Gt,�sL �TYl�extu ca—
(name of hauler)
The debris will be disposed of in :
(name o��jy)
dates p�
(+ddref� oYfacihty) �
nynarure ofpermit Jpplicont