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4 PROCTOR ST - BUILDING INSPECTION ; . The Commonwealth of Massachusetts \'. I Department of Public Safety \lasaahuwlIN Male Liuj1dmg Code I780 C\IR)Seventh Edition City of Salem BuildinILPermit Application for any Building other than a I-or 2-Family Dwellin I Phis Section For Official Use l3nly) limiding Pvrmt Number: Dauv Applied: IBuilding Inspector: SECTION 1: LOCATION (Please indicate Block a and Lot a for locations for which a street address is not available) ©C '(y,\ un No. and Street C ih• /Town Zip Code Name ut Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here O or check all that apply in the two rows below Existing Building 0 Repair O Alteratiun O Addition O Demolition 0 (Please fill out and submit Appendix 1) ASC angeufUse 0 Change of Occupancy O Other 0 Specify: Are building plans and/ur construction documents being supplied as part of this permit application? Yes 0 No 0 Is an Independent Structural Enginrrrin Pee Rev' reyui cd7 Yes ❑ No O Brief ptiun of Pro a Work- l e� t� ee r r^ l 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) 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 Fluurs/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION S:USE GROUP(Check as a Ucable) A: Assembly A-1 ❑ A-2r 0 A-2nc❑ A-3 O A4 O A-5 0 B: Husineu O E: Educational 0 F: Facto F-1 0 F213 H: Hish Hazard H-I 0 H-2 0 H-3 0 H-4❑ H-5 0 I: Institutional f-1 0 1.2 0 1-3 0 14 0 M: Mercantile❑ FR. Residential R-10 R-2❑ R-3 0 R4 S: Stora a S•1 0 S-2 0 U: Utility 0 Special Use D and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicablol IA 0 IB O IIA 0 Fle O IIIA 0 IIIB O IV O VA O VB 0 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 8Y Check II nut>tde 19o,'J Luna•❑ Indicate mumc:pal ld A Irench avlll nut be Licen.ea1 Disp.nal Site 0 I'm ate❑ or tn,lenuA' Zone: or on.ite,v,tem 0 raqulrad 0 or trench ur.peclfv: permit is vnclovaf ❑ Railroad right-of-way: Hazards to Air.Navigation: xla lino,n. O.,n+,n,..n,„I<a+iraa Not \I')d1v.1H • I.their re%ieav onn)dcted.' .a'1 ,nt-cot I„ 11u,i.l coal,a.avl ❑ 1L•,❑ or Noll le>❑ \u ❑ SECTION 8:CONTENT OF CERTIFICA IE OF OCCUPANCY I ,huao ,a (".Jv. L.v(:rooi•l.l. rapca,! llvnlnlCUon: Occupant Load pvr I I,u,r Ihy., the['u11diog mi.unanSprinklerm,tvm': �lax'ial?Upulaoun.: SECTION 9: PROPERTY OWNER AUTHORIZATION .V.tmy,.,)n.l \. . re-..�l Prnl�r Q svnrr Name(Print) .No. andStrrrt •7 •yCil�•/ r�u wn Ltp Pro urt� .l?�: rr('fr�tady f+umr ln.n: — g7&D69_ !/�A 7 Title - - Telephone Nu. (business) rrlephone No. (cell) a-mad address If, +bcable. the ruprrty owner hereby au o ..Name / StrrrtAd.ir'd..r City/Town State Zip to act on the +ro +arty owner's behalf, in all matters-relaticr its work authorized by this building +ermit a + +hcauon. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (It building is less Ihan 34.0W cue Mot enclosed• ace and/ur not under Construction Cuntrul then check here Candlup Sevltun Ilf 1) 10.1 Registered Professional Responsible for Construction Control V Ir" ' C_.k"J1�41 ,/ L2 SSGTO 0 Name(Regislrantt) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor C p n ,Name: i � i r ,� Li ofzlj . . ��1(�`a(p C'_SS:L Namv, e n U p��Crr�3struction -&✓C-\�License No. and Type i A plica heo ' i Street Address City/T wn State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WO (M.G.L.c. 152 2SC(6)) A Workrn'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 si ned Affidavit submitted with this application? Yes O No O SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item and Materials) Total Construction Cost(from Item 6)=f JetJ d«7 1. Building f 1Building Permit Fee-Total Construction Cost x`Q(Insert here 2. Electrical f appropriate municipal factor)= 3. Plumbing f 4. Mechanical (HVAC) f Note: Minimum fee=f5(contact municipality) 5. Mechanical (Other) f Enclose check payable to 6. Total Lest f (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Its• entering my name below, I hvrvby altesl 7n11 lr the pains and penalties of perjury that all of the inl+rmahon conhuned in this .1pplicaIisrn is true and accurate to the brst of my 1kni P%vled and undvrstanding. S�PD C7,� �e1� f<' Ma Cs C ._ ( � 010 I'le.nv Fin in+t`i);n n me i rifle rclepNnn No. , Dale 11 ` C L \ VC.r^\\-9 0 Slrvvf .\d.lre.. C rty/Town Municipal Inspector to fill out this section upon application approval: TAVAO Name- Date CITY OF SALEM PUBLIC PROPRERTY DEP ART'�tENT H\' 'd 'I: I'; \\ ,C1li<I:I'r • �.\I I \I, "I.\"\1 ♦ I\5: 9,-8.'4- 'I,i4., Construction Debris Disposal Affidavit (required lbr all denwlitioil and renovation work) In accordance With the sixth edition ofthe State Building Code, 780 CMR section 111.5 Debris, and the provisions of.NlGL c 40, S 54; Building Permit 9 is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal Facility as defined by MGL c I 11. S 150A. The debris will be transported by: (name tit I\atder) The debris will be disposed ot"in (uaine ul lacdny) (address ul'facility) . _nature ut prnnit applicant 11 010/0 date CITY OF SALEM ��,. __ a,, ;rj PUBLIC PROPRERTY DEPARTMENT "I\I I;:RI I:Y URISORL \I% IR 12C WASHING IONSTg ELT • SAtL.M,MASSMA ICSL1 l%OI97-^ lla.:1778-745-9595 or, 1-:\x: 978-740.9346 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A 3nlicant Information Please Print Leeihly Nalne ll3ucincss/Oro3nizatinlJlndividuub: U �� S Address: V Cityi'Slatci%ip: �l 1 Phone".: � Are you an employer?Check the appropriate box: 'Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a.eneral contractor and I 6. ❑ New construction eta to ees full and/or art-time).` have hired the sub-contractors t-y P Y ( P' 7. ❑ Remodeling 2-q/� 1 am a sole proprietor or partner- listed on the attached shave ship and have no employees These sub-contractors have S. ❑ Demoliriun working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition 'No workers'cum insurance 5. ❑ We are a corporation and its I P• ME] Electrical repairs or additions required.] officers have exercised their I am a homeowner doing all work S P right of exemption per MGL I I.[] Plumbing repairs or additions 3-❑ myself. LNo workers' comp. c. 152, y 1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.&Olher R4_rr»__.^� comp. insurance rcquired.] -Any applicant that chucks box 9l must also till out the union bcouw showing Ihcir wwrkurs cumpcnsatiun policy infurmatium - ' I Iomeuwnen who submit Ihis atYdavit indicating Ihcy are doing all work and then him Outside cwumaore must vhmil a new al'rdavit indicating such. -C,Ira,a lrs ne,check this box must anachcd tin additional sheet aI uwing the name of the subcontractors and their workers'comp.policy information. l non un employer that i.v providing)vorkers'c•oorpensarion iasurnrree for aty employees. Below is the policy and job site iufonnurion. Insurance Company Name:--- policy i!or Self-ins. Lic.>i: ___...._ Expiration Date: Job Site Address: City/Slalei2:ip: Attach it Copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ul �IGL 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 a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Ilc advised That a copy of this statement may be forwarded to the Office of Invrstiglations cal the DIA ('or insur:u:cC coverage vcritication. l ilo herehy cart' ande the pains tin /tenalticc ofperjury that the information provided ubo •e is true and correct. /4010 Ih1 77t'S 0 o Ofjiciol use only. Do not Icrite in this area, to be completed by city or town official C'iry or flown: Permit/License d__—. _ Issuing Authority (circle one): I. Iluard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact I'ersou: _ Phone H: Information and Instructions \lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an empfgree is defined as"...every person in the service of another under any contract of hire, express or implicit, oral or written." An employer is defined as"an individual, partnership,association, corporation or other legal entity,or any two or more of the toreeoing engaged in a joint 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." AIGL 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, bIGL chapter 152, 325C(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 nwnber(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 contimmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be 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 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 nurnber which will be used as a reference number. In addition,an applicant that must 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 of 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 burn leaves etc.)said person is NOT required to complete this affidavit. I he 01fice 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. The Department's 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 Fax # 617-727-7749 tict'iscd 5-16-05 WwW.maSS.gOV/dIH