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13 PARADISE RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts V Department of Public Safety Massac I�y1j husetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This$ectibrrFor,::Official,Use Building Permit Number. Date Applied Bmkling Ofhctal SECTION 1:LOCATION (Please indicate.Block#and Lot N for lotions for which a street address:is' .l.not ail 1-3PARFIDiSE RD -58L- /`', .. locations Q/c170 W*fN No.and Street City/Town Zip Code Name of Building(if applicable) "SECTION 2 PROPOSED WORK *"" Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building 0 1 Repair❑ Atteration'o I Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes X No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No )l Brief Description of Proposed Work: gPCu-r3 " ,4fK S',}A-oN Al F /b�n/o Pt All f� PAPr-rt-rl ,v c14A,vaG5 rIWM 4&, P'ND Et. EC:orfZlcAL- SECTION 3i 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(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 applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M. Mercantile❑ R: Residential R-1❑ R-Z❑ 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 u applicable) IA ❑ Ill ❑ IIA ❑ IIB ❑ 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 enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Pmsss: Not Applicable❑ 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 Sp^rinnkkller System?: Special Stipulations: //'��Q / SECTION 9: PROPERTY OWNER AUTHORIZATION 7 Name and Address of Property Owner NFw C KEF k U C UnlS 7-a .fir 621a Name (Print) No. and Street City/Town Zip Property Owner Contact Information: 'Citle 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 building permit application. O SECTION 10 CONSTRUCT'IN CONTROL(Pleasee fill out A`ppendtx 2) - If buirdiir �s less than 35,000 co.tt.of enclosel s ace`arid%6i not under Coi truetion Contr6l then check Here EYa`nd'ski Section 10.1 10.1 Re 'stared'Professional-Res'onsible foi Constri ction Contiol`.. Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date -10.2 General Contractor M s coNs��t���aN Company Name M1}aCoC&I sM1 �:U4 C S (p f+7 1 Name of Person Responsible for Construction License No. and Type if Applicable /0 �0 Ot9-K 5T- M�Bc E1�o2€�(1c�(� I Street Address - City/Town State Zip ✓t c PsT tit �h o& Telephone No. business Telephone No. cell e-mail address SECTION II:WORKERS CUNIFENSATION INSURANCE:AFFIDAVIT M.G.L.C.152.9'25C 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) Total Construction Cost(from Item 6)_$ 1. Building $ 4,9030 ` 06 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ 535 b ` O o appropriate municipal factor)=$ 3. Plumbing $ 33 50 ` ,615 4. Mechanical (HVAC) $ Note:Nlinimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ 3 P 73©` m C` (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 in owled a and understanding. M Ae-coum sM f'(N 60 Please riot and sign name Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approvals Name - Date APPROVAL DATE: Certificate of approval is hereby granted, on approved plans or submittal of project details, by the SALEM FIRE DEPARTMENT. All plans are approved solely for identification of type and location of fire protection devices and equipment All plans are subject to approval of any other authority having jurisdiction. Upon completion, the applicant or installer(s) shall request an inspection and/or test of the fire protection devices and equipment. (ADDITTIONAL REQUIREMENTS, SEE REVERSE SIDE ***) - E2J NEW CONSTRUCTION. PROPERTY LOCATION HAS NO COMPLIANCE WITH IHE PROVISIONS OF CHAPTER 148, SECTION 26 C/E, M.G.L. , RELATIVE TO THE INSTALA- TION OF APPROVED FIRE ALARM DEVICES. THE OWNER OF THIS PRO- PERTY IS REQUIRED TO OBTAIN COMPLIANCE AS A CONDITION OF OBTAINING A BUILDING PERMIT. ED PROPERTY LOCATION IS I.N COHT-LIACNE U1111 T'HE PROVISION OF CUA.PT4:R 148, SECTION 26 C/5, M,C_L. EXPIRATION DATE: czciiA> qr I ... UNDER 7,500 sq. 1�7. - 8'S u4}J ! P. ',5O0 Sl;. F"?'. nR LAl:G7=R � _ 3^�z AHE K \ f • i CITY OF SiU.EA,I, AXSS:ICHUSETTS Bu IMING DEPARTSIMNT 120 WASHINGTON STREET, 3aa FLOOR TEL (978) 745-9595 F.mX(978) 740-9846 K]JfBERLEY ORISCOLL MAYOR THohtAS St xa PlEx DIRECTOR OF PUBLIC PROPERTY/BCII.DING CM12MISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aliolleant information y� �q I n� Please Print Leeibly Name(Business�OrgtniratiomIndividual): MI'11-WtM .5k( 1-�t't Address: ID4, OA1 c ST City/State/Zip: M IMP+ ado 4023" Phone N: J t9 Tti`) o2r1 Are on an employer?Check the appropriate boxt Type of project(required): II am a employer with 1 4. 0 I am a gcncral contractor and I 111111 . have hired the subcontractors fi. ❑New construction employees(tLll and/or part-rime). 2.0 1 am is sole proprietor or purtner. listed on the attached sheet t 7. ❑Remodeling ship and have no employees These subcontractors have S. (]Demolition working for me in any capacity. workers'comp. insurance. 9, 0 Building addition (No workers'comp.insurance 5. 0 We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 1 I.[I Plumbing repairs or additions myself.(No workers'cutup. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.)t employees.[No workers' comp.insurance required.) 1J•QOther •Any appllc:un that chocks box el must aim nil out the aches tcloW showing their worker'componudoo policy inlurmation. t I hrneowncn who suhmit this aiBdavis indicating ihcy am doing call work and then him uunidscantrcton muss submill a new amdavil indicating Such. :Cuntnotor that chuck ihb tux the Manor!of the alreontrador and their worker'comp.policy information. I am an employer,that/s providing ivorkers'compensadon insurance jor my C.,oployeea Below/a the polley and fob site injormallon. ' 7 , / .. Insurance Company Name: {r�^bvv t'1TFfMj')/f-f� �i/1'I QLcJ`I R!t (1J$' f v ,r Policy 4l or Self-itu. Lis d:.�[n��t-mac "l'Q 00Sf(7 0 Expiration Date: o — 2 L4 [ ' Job Site Address: /3 LAP-- i a u City/statdzip: Sit--EM MA 0(47V attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Faiium to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a line of up to 5230.00 a Jay against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations el•the DtA f)rillsura coverage verification. 1 du hereby certify under the and penal er ary Aral the,injunnadon provided ab ve 77rue and c o"ret. Data! 2 (3 Phoricr! I0)jirial use mdy. Do aof write in f/rls areal to be completed by city at town n/Jlelat i City or Town: Permit/f.lcense As Issuing Aulhorily(circle ono): 1. Board of I lea ItIs 2. Building Departumnt 3.Cilyirown Clerk 4. Clectrica) dtspector S. Vitt in timpector 6.0ther _._ -------- Contact Person: __._ ._ Phone tie CITY OF &U ENM) - Lu&kcHUSETTS BL:ILDL\G DFPAR'il.L&NT V#�.•. 120 WASHINGTON STREE 'D T, 3 FLOOR lo TEL (978) 745-9595 KIMBERL.EY DRISCOLL FAX(978) 744D-9846 NLkYOR THO.Nus ST.PIERRg DIRECTOR OF PCBLIC PROPERTY/BUHMN'G CONNISSIONER 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 tNIGL e 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposcd of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: gpw 0 V A-L_ (name of hauler) The debris will be disposed of in C T P-4M- csI A (name of facility) _ Ml�P20 M 'A (address of facility) signature of permit applicant �Z` S labm:�l�d•x