42 PARK ST - BUILDING INSPECTION �� C�Y•
The Commonwealth of Massachusetts
Department of Public Safety
\la.wtchti'01.State Budding Code(790 C SIR)Seventh Edition
/V/► /// City of Salem
BuildingPermit Application for an Buildingother than a 1- or 2-Family Dwellin
(This Section For Official Use Onlv)
\ _molding Permit Number: Date Applied: Building Inspector:
/ SECTION I: LOCATION (Please indicate Block N and Lot 0 for locations for which a street address is not available)
eA,s_, 0197 O
)..Ind titrert City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ I Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: I
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review req}}j�tred?
-
Yes El No ❑
roposedWork: V;—> (P— 5,e-aA0y of- tWlA1A1W�BZ4 p � A- c ' A Q (Tik A SJ W, U(1•Lr. LS'O
v—•
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): r
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 applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-I ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
L• Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ a
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA too IIA ❑ 1180 IIIA ❑ IIIB ❑ IV VA ❑ Vol
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 it outNide•Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site O
required ❑or trench ur Npeci A:
• ►'orate Cl or milcntik Zone: or un Nrtr Nc.tem ❑ permit is encluned ❑
Railroad right-of-way: Hazards to Air Navigation:
\nt Apphc.ddv❑ I.�Irui lure��ohm airport.tppm,tch area.' 1* their review cannpleted'
,r(*.m,cttt (.. Budd yndovd ❑ Ya•N❑ or No❑ Yen O \u ❑
SECTION 8: CONTENT OF CERTIFICA rE OF OCCUPANCY
I dili,m of ( �alr: L.e( roup(%): r%pe of Construction: l)ccupanl Load per Ploor: .
1)oc, lha•buildup;cont.unan Sprinkler`s%Nlem.': SpaC1,11Sipulauons:
2c( J-ew n 1 nt(s C0166<
pE,rioovrt eyo. all&a
SECTION 9: PROPERTY OWNER AUTHORIZATION '
.Vame,vai A I tress o1 Pro tcriv Owner
/I �rPN�i�r I. -Ko M A4- �P lki r
Name(Print) No. and Street - City/Town 'Lip
* _ t
Pniperty lhcnrr le
InlormeGun:
owNee q2a�277- -I,;S-L - -
Title Telephone No. (business) Telephone No. (cell) a-mail address,
If applicable, the property owner hereby authorizes
t
Name Street Address City/Town State Lip
to act on the property owners behalf, in all matters relative to work authorized by this buildin g permit a t tbcation.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It buildin•is less than 35,000 cu.it.at endovd s ace and/or not under Construction Control then check here 0 and kip Sectiun I0.1)
10.1 Registered Professional Responsible for Construction Control
IL4 �led lf-- �54 3�i2 1142.03 .
elephon Nu a-mail a dr O I
s Registration Numb to ),
Nti�, d�- YD
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
G �iUCA�` 0 pA-TE7
Nam m t e:
p' y�ra 11eww-t C� 2z ,7 6 -06 2oI2.
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:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$
1. Building S Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)_$
3. Plumbing S
4. Mechanical -(HVAC) S Note: Minimum fee=S (contact municipality)
L5. Mechanical (Other) S Enclose check payable to
6. Total Cost S j Q^ (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
ap Iication is true and accurate to the best of my knowledge and understanding.
t
1 I K
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'1 ri one i t �1�Y1�'( 4f M Tel r or7 Z-N�V8q;; /
.c( addns City/ own tit rZ(' /yam
.Municipal Inspector to fill out this section upon application approval:
N.,'4 I). to
CITY OF SALEM
i a PUBLIC PROPRERTY
' �`—% DEPARTMENT
�'
.NIIf{N!I'Y:)µli(:,ll1.
I.1^�WMHIN(:IONSIXEEa' • SALI'M.MASS.x(.1II ii:11%3197C,
:V8.743-9595 s FAX: 978-74^--9840
Workers' Compensation Insurance Afriidavit: builders/Contractors/Electricians/Plumbers
ili�ant Information l .Y 1r Please Print Leeibly
60 V Bfrlu lnusnnasfOrBanivatinNlnJlvlduull: - -"b Vey y )6 0) tLeA
V
A(klressq 18 L S A �? ^7
City'Stacc//..ip: buk"e� �^Q WA p1Q40 Mone %:-7 7-S T— 4ER /
ire you an employer'.' Check the appropriate box: 'Type of project(required):
4. ❑ 1 am a general contractor and 1
1. I :can a employer with 2- 6. New construction
employees(full and/ur part-time).' have hired the sub-contractors 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. :
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
l No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.) officers have exercised their
right of exert P'r exemption o MGL I I.❑ Plumbing repairs or additions
3.❑ I um a homeowner doing all work S P .
myself. [No workers comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. LNo workers' 13.❑ Other
comp. insurance required,]
-Ally.1ill,lll'allt Ilia CNCek6 box OI mUtn a6a ill out then.-chult wua,SIWWIIIg iwir workus eumpen"ion policy intilrnxltion.
'I Wmeuwnen who albmirthis affidavit indicating They am doing all work and Then him outside culumetors must.ubmll a new affidavit indicating wlch.
C'omm�a,n That check this box most mtaehcxt an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l soot can employer that is pruviditkq Ivurkers'cuutpensatinn insurance fur sty eutplait ees. Belaty is the policy and job site
iuforinatimit
Insurance Company None: 1 —�w_ Gt"U_`V...-----
I'ulicy is or Self-ins. Lgicn. 1?: 1�RQ��/ ,,�� ��nr.0 '.,A (`�
Job Site Address: C, h/'<u�ce� � CilyiSlate/Zip:M p�"
Attach it copy of the workers' compensation policy declaration pulse (showing the policy number and expiration date).
failure to secure coverage as required under Section 25A ui'1IGL c. 152 can lead to the imposition of criminal penalties of a
tint up al S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it Jay against the violator. Be advised that a copy of this statement may be Iurwarded to the Office of
1;1% gaunns ul'thc DIA for imurance covcrage,crification.
l do here cc i y un, •r i pm s oil )eua! 'es of perjury that the infunnution provided above is true and correct.
S i, :I at"i Data 3(st - iCOI C)
Null:•:I: —48Q
D(licial use wily. Do itnt sprite its this area,to be cuntpleled by city or town ajjicial.
City or Mown: _.. _ Permit/License 0_-..--
Issuing.ituthorhy(circle one):
1. hoard of IIvalih 2. Iluildiny DcParuneut 3. Ciiyi fo,s it Clerk 4. Electrical Inspector 5. Plumbing; luspector I
6. 01tier
Contact Pursuu; _ _ --- Phone 0:
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplane is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An emplu),er is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more
l the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of:m 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 or 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 number(s)along with their certificate(s)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 continuation of insurance coverage. Also be sure to sign and dote the affidavit. The affidavit should
be retumed 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 question regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at tine number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. in addition,an applicant
that most submit multiple pennitilicetse 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The 0Ilice of favestigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call.
The DepuroncrWs address, telephone and fax number
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
acv;sed 5-26-05
Fax #617-727-7749
www.mass.gov/dia
\lassachusctt. - UcparUucnt of Public �,:dct�
Buacd if Building Ret-,ulatiuns and Standards
t Construction Supervisor License
License: CS 22287
Restricted to: 00 -
ANTHONYJ VENUTI
918 SALEM ST
LYNNFIELD, MA 01940
Expiration: 602012
(' nunissioner Tr#: 26554
,,. CITY OF SALEM
y� 4
PUBLIC PROPRERTY
n ;
DEPAR"I'v1ENT
\\ 51 i11:1 r 01.\I I m. \I.\.i\k .1, 1 . :1') -
Construction Debris Disposal Affidavit
(re(juired litr all demolition and renovation work)
In accordance \�ith the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Quilling Permit tt is issued with the condition that the debris resulting from
this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
Umme of hauler)
I he debris will be disposed of in
f aZol'tacility)
(ad(iress ol'Iacility)
�i na me >t a nit .y�plicant
date