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60 PERKINS ST - BUILDING INSPECTION (3) t.; C � /On 3 Z— 1 t)('Lto The Commonwealth of Massachusetts n Department of Public Safety Massachusetts 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: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) vl 5+ e.vl 019-) (7 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK. Edition of MA State COLIC used_ If New Construction check here❑or check all that apply in the two rows below Existing BuildinN Repair❑ I Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No-9 Is an Independent Structural Engineering Peer ReKnew reQurred? Yes ❑ No 19, Brief Description of Propos d Work: t"'1U Q'Q( j Utir S 1 R \tC1.9�5 ,_� insuw� d 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(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sy ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) - A: Assembly A-1 Cl A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-L❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4 ElH-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R. Residential R-I❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) - IA ❑ IB ❑ IIA ❑ 1113 ❑ 1 IIIA ❑ IIIB ❑ 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: "French Permit: Debris Removal: A trench will not be Licensed Disposal Site❑ Publicmg. Check if outside Flood Zone❑ Indicate municipalNJ 1 .'Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify:M v fn 14A permit is enclosed❑ Sol ul to Railroad right-of-way: Hazards to Air Navigation: V)I lit is-_ wi-nitis,ui 7�.c�, I r,o�is: 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 Edition of Code: Use Gruup(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: } ColTnrc{z,�/. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner nn n ?jt'I ep Roc �e5 ICI Name(Print) No.and Street City/'town Zip Property Owner Contact Information: r q)%- �SZ 'i�b� �� `6S� y�b� br(g>1�,ac�e5 @crn4(� co Title Telephone No.(business) Telephone No. (cell) e-mail address 7 If applicable, the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this budding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) r If build in 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 10.2 General Contractor - Coas�l►�,� Gy,)!A�� 4) o. � Company Name Name of Person Responsible for Construction License No. and Type if Applicable I� n�z� Rz �� 01 � Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:VV'Of IKHRS'CONIPF,ISA'I[ON INSUIf ANCH. Af HDAVI I' M.G.L.c.152. 25C 6 A Workers'Compensation Insurance Affidavit from the NIA 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 $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ i. 3. Plumbing $ C r7. nt d. Mechanical (HVAC) $ Note:Nlinonum fee=$ (contact municipality) S. Mechanical Other $ Enclose check to 6.Totd Cost $ payable Z (7 O 'Q (contact municipality)and write check number here SECTION 13:SI NATURE 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 a best of my wledge and um erstanding. Please print and sign name Title Telephone No. Date �CI P _ _a R� � ���-I Iq nmyt Street Address City/"rown State Zip Municipal Inspector to fill out this section upon application approval: Name Date CITY OF SakLEN1, 1,'L-�SS.ICHUSETTS BUILDING DEPARTNMNT + N< 120 WASHINGTON STREET, 3aa FLOOR ono TEL (978) 735-9595 FmX(978) 740.9846 KIN EBERLF-Y DRISCOLL THOMAS ST.PIEPM MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LNIISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A t ilicant Information Please Print Le ibl 1 )no- ;line (Busioessorgannizanom'Individual): v� a, 06s �,�yvCT Address: I q City/State/Zip: ` Phone #: F ou an employer?Check the appropriate box: 'type of project(requited): 1 am a employer with� 4• ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or pan-tine).° have hired the sub-contractorsI am a sole proprietor or partner- listed on the attached sheet.; 7. -Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity* workers' comp. insurance. 9. Q Building addition No workers' coat insurance 5. ❑ We are a corporation and its r P• 10.Q Electrical repairs or additions required.] officers have exercised thew 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ 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' 13.❑Other cutup. insurance required.] -Any opplicam dot dtccks box HI moat also GII aul the sccaon below showing their workea'compensmiun policy infinmation. 'I lomcownerx who submit this affidavit indicating they arc doing all work and then hit;outside contractors matt submit anew a(fidavil indicating such. Cuwrwwa shut check this box must anachcd an additional shout showing IN,name of the sub-eantnctoa and their workers'comp.policy infommtion. I am an employer that is providing workers'eumpensaton insurance for my employees. Below is the policy and fob site information. _ /� Insurance Company Name: Y—.` Policy U or Self-ins. Lic. h: (wA )1e Expiration Date: Job Site Address: Cityistate/Zip: ,knach a copy of the workers'compensation Polley declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of VIOL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a Tine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigutions of the DIA for insurance coverage verification. I do hereby certify under the paints mud pet a perjury that the information provide abovf is true and correct. Date �3 Phone y- 6n Official use only. Do not write in this area,to be completed by city or town official City or Tuwa: __...._.. Permitil.lcense#---�----,------._..._-._.—.— Issuing Authority(circle one): 1. Board of tlealth 2.Building Department 3.City(fown Clerk 3. Electrical Inspector 5. Plumbing Inspector 6. ...--_.._-.__...... Contact Person: ..._....-._. . _ .------_ Phone#: } 4, CITY OF S.1C.E\t, tiL1SSACHUSETTS t . BLmDDx DEPARTMENT 120 WASHNGTON STREET, 3'FLOOR T EL (978) 745-9595 FA.X(978) 740-9846 KimBERLEY DRISCOLL ,NLA,YOR THOSL1s ST.PtERRB DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMISSIONER 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 c 40, 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 disposal facility as defined by NIGL c t 11, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in -- - (name of faeility) (address dt facility) I i nature of permit applicant d to Z �1 2" z Z- G.V" 12-7 12, 2rP�c� 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 Offici0 Useonly) Building Permit Number: Date Applied: O Y212-011 uilding Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a skeet address is not available) Wv Perkjo5 Srik'm r114 01Ci-10 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 Build ng'A Repair❑ 1 Alteration ❑ I Addition❑ Demolition C3 (Please fill out and submit Appendix l) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No In Is an Independent Structural Engineering Peer R5'view required? Yes ❑ No ❑ Brief Description of Proposed Work 111 R 3 I(t�C ens, t,s + l.rw R�n�, vent Ivnf 4- 1. 4115 £ ec el 4' V-) !n CoC 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) Cl 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. fL) - Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-L❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑ F: Facto F-L❑ F2❑ 1 H: Fli h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ I-2❑ 1-3❑ 14❑ M: Mercantlle❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ 16 ❑ IIA ❑ IIB ❑ IiIA ❑ BIB 1 IV ❑ 1 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: A trench will not be Licensed Disposal Site 4� Public Check if outside Flood Zone❑ Indicate municipal�] PG required ❑or trench ors ecify:!'� En hCI Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ ,Sp�) Railroad right-of-way: Hazards to Air Navigation: V,\I h,u ri, nnm- yi n It of^ iwv r cu,,: 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 &li[iun of Cede: Use Group(s): Type of Construction: Occupant Load per Floor: Does the Guilding contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner r bf i c>1 �c�e S 1 i y(fZzla led "/✓a Ji � l S _ elL4'n� U i Name(Print) No.and Street 'City/Town Zip Property Owner Contact Information: Ouyv, C11b - g�, yq6� brf`q��oc S IVO r 010 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 building permit application. 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 10.2 General Contractor Brl0h &C�PS C1� (0(151tIne Co Ira , 0h Company Name - jq ) wr. & o /SS76 Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip -- ate- 8SZ_ yg6�7 s Telephone No. business - I Telephone No. cell e-mail address SECTION 11:W0RKF'IS'C0NlPFNSA I ON 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❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ L Building $ 1 0 -0 D Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ j Z d 0 O appropriate municipal factor)_$ 3. Plumbing $ { r 1. Mechanical (HVAC) $ Note:Nlinin urn fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost S Z39000 1 (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.md accurate to the best of my knowledge and understanding. n Onah Ij OoJe5 V) &cQi owv-(n �V 55'2- V117 Please print and sign none Title Telepl No. t e {�, Rezzla ,�to _j.1 l�l o i is Street Address City/' own a/L7, State Zip Municipal Inspector to fill out this section upon application approval: •, D'7r`-' Name Date CITY OF SALEM. NL�SSACHLSBTI'S' BUILDING DEPARTMENT V 'cJ i 120 WASHINGTON STREET, ace FLOOR I TEL (978) 745-9595 FAx(978) 7.10-9W KI\tBERLEY DRISCOLL MAYOR THO\IAS ST.PIERKE DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\NISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Fnq Please Print Legibly V;1117C (OusincsOrgan�niration;lndividualhI : GAY, (A Address: I �1 VlP2Z1Q aU <' �} ) City/State/Zip: 2- Ili,A V1 01 "I 1 S Phone #: � d Are you an employer?Check the appropriate box: 'Type of project(required): 1. I am a employer with t- 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 ana a sole proprietor or partner- listed on the attached sheet.: 7• aRemodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity, workers'comp. insurance. y ❑ Building addition [No workers'camp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.[No workers' comp. C. 152, S 1(4),and we have no 12.❑ Roof repairs insurance required.)t employees.[No workers' comp. insurance required;] 13.❑ Other •Any applicant nut checks box BI most also rill out the section below showing their worked compensmion policy inlbnnation. 'I Luncowtxn who submit this 01davit indicating they arc doing oil work and then hire outside cuntrocion mica submit a new affidavit indicting such. ;C"mtmcion thus chuck this box mrut attached an addidural.heat showing nhe mmne of the s ib.eontracton and lheir workero'comp,policy information. I ant an enipluyer that is providing workers'compensation fnsurancefor my employees. Below is the poltey and job.tire (reformation. Insurance Company Name: r6 I/l1 Policy N or M Self-ins. ILic. tl:_J V) ( �Q -__,.__. Expiration Dale: Jub Site Address: b�� ety—IC�Vr 5 J� City/Slate/Zip: SGt e f/1 1 / 1 A 0010 •plash a copy of the workers'compensation policy declaration page(showing the pulley number and expiration date). Failure to secure coverage as required under Section 25A ot'`1GL 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(he form of a STOP WORK ORDER and aline of up to S250.00 a day against the violator. Be advised that a copy of this statement may Ix:forwarded to (tic Office of hnrstigwions oi'Ihe DIA for insurance coverage verification. I du/tereby c•er ' under the putt and penalt/es of perjury d m that elm infuratlun sur provided above is true d c'orrecL Si-•niture' !14 {T�D JU_, Data: L P_fiimc,,l °+l� BSz.y961 Official use aedy. Do nor write in this area,to be completed by city ue lown ofjfciaL City nr Town: Permit/License N , Issuing Authurily (circle one): I. Board of Ilealih 2. Building neparlutcut 3.Citylrowu Clerk 3. Electrical Inspector 5. Plumbing Inspector 6.Other Phone Y:_ [ i CITY OF SM-EM) iANSSACHUSETIS BUIMIING DEP.%a-II,LErT 130 WASHLYGTON STREET 1'°F2 TEL (978) 745-9595 FLOOR Rux(978) 7404845 KIIBERLEY DRISCOLL NLAYO:t Tt-IOStAS ST.PIERRE DumacR OF PUBLIC PROPERTY/BUUMLNG CONNISSIONER Construction Debris (Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CM section I t 1.5 Debris, and the provisions of NfOL c 40, S 54; Building Permit k is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by ,MGL c l 11, S 150A. The debris will be transported by: Sob d wg;k (name ofhauler) The debris will be disposed ot'in ..------- (n.vne of faal/ty) -- (nddres.s ot'tucility) i signature of permit applicmu — .