104 PROCTOR ST - BUILDING INSPECTION r�
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The Commonwealth of Massachusetts
Department of Public Safety
yr Massachusetts State Building Code(780 CMR)
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 p and Lot N for locations for which a street address is not available)
O 1'r s . l_ i4 G
No.and Street City/Town Zip Code Name of Budding(if applicable)
SECTION2.PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply 1 inthe two rows below
Existing Building❑ Repair❑ r1lhruion ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes,31t,-No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No•�
Brief Description of ProosetlT rk: A 2 _
�K M
\ Octe Q
i S^I'M
bar w.P s c
SECTION 3:COMPLETE THIS SECTION IF EXISTING UNDERGOING RENOVATION,AD o
CHANCE IN USE ORBUILDING OCCUPANCY cION,
Check here if an Existing Building Investigation and Evaluation is enclosed(See 760 LAIR 34) ❑ nl
Existing Use Group(s):
Proposed Use Group(s):—
SECTION 4:BUILDING HEIGHT AND AREA
Existing - P .pose
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
n
Total Area(sq.ft.)and Total Height(ft.) yr
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-I❑ A-5❑ I B: Business ❑
F..Facto F-I❑ F2 E: Educational ❑
❑ 1 Ii: Hi h Iiazud H-1❑ I-2❑ H-3 ❑" FI-•1❑ H-5❑
'I:.Institutional 1-f❑ 1-2❑. 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-I ❑' S-2❑ U: Utility❑ Special Use Cl and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA IB ❑ IIA ❑ IIB ❑ ILIA ❑ 11160 IV VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 C61R 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench permit: Debris Removal:
Public Cl Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ retuired ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: W\I h na t ,?tun s, _y I'r y-r•s:
Not Applicable O 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 Group(s): type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?. Special Stipulations: —
S-Q.Yr
` SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
j00$\a%) kKAN (`os,�lsk; Gov PocJ s� Ss�IP vnA o �47a
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Mr oe — 9�S_ X'oK- 8- G
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
?a/,w Oa,vTA�l� � &' e-a C* OVA � rah} C)19G
Name . Street Address City/ own State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
_ M
U'oklIV PA44TAPA P ��8-` - 7RU� y �.�T aa����o I � C5 b'7003
Name(R•gistmn TelleY _hon es
e No. a-mail address Registration Number
a i_/ou QE + v m /1 _dlS1,o L•fV /0-16 7 i1 —
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
" pAit-r4 P A f
ompany Name
•-r�_ .ti P�r17'A�/�i him /ylS'SZ EX= y .2G ��
N merof Person3Responsible for Construction License No. and Type if Applicable
y07 �cweq 5J • PE\�)(�,Joy v---\ ,,) nl96a
Street AddressD - City/Tow nn T State Zi/p�
Telephone No.business - Telephone No. cell e-mail address
[t SECTION 11t FYOI:KERS'COPY ENSAl10N INSURANC1i:V:PIUi\Vff M.G.L.c.152. 25C 6
A Workers:Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with-this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes D No ❑
` - - SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building ` $ g00 Building Permit Fee=Total Construction Cost x_(Insert here -
2. Electrical - $ appropriate municipal factor)=$
3.Plumbing $ .
4.Mechanical (HVAC) $ ,Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable r able to
6.Total Cost $ S'00 4G (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERIDIIT APPLICANT
By entering my name below, 1 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 my knowledge and understanding.
Please print and si n name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
-,,ter
° a CITY OF SiU EM, NL\SSACHCSETTS
BUILDING DEPARTMr—NT
120 WASHIINGTON STREET, 3w FLOOR
1. TEL (978) 7 i5-9595
F.tox(978) 730-9W
IU,%IBERI FY DRISCOLL
yl�LAYOR THoMAs ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNISSIONER
W'nrlcers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information_ ,, 11 A f Pfease Print l e iblY
Name(Bu.ti(niass Orga(nii;aatti1o`,m'Indi ViidJuall:J o- Gl 1 Y PAN' PA Jr
Address: 1 •0 f- (` Oy,. 1o& V p
City/State/Zip:M(AQtlL)\./, VV%A 01%1 Phone hi:
Are you an employer'!Check the appropriate box: 'Type of project(required):
I.Q 1 am a employer with 4. Q I am a general contractor and 1 6. ❑New construction
y{ employees(full and/or pan-time)"' have hired the sub-contractors �y
2,�'l listed on the attached nhect. t 7. MILLRemodeIing
t I mn a sole proprietor or pariner-
t ship and have no employees Thiess:sub-contractors have 8. Q Demolition
working for me in any capacity. workers'comp. insurance. 9. Q Building addition
[No workers'camp. insurance 5. Q We are a corporation and its
required.]
officers have exercised their 10.Q Electrical repairs or additions
3.0 1 ant a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers'camp. c. 152, §1(4),and we have no 12.Q Roof repairs
insurancc required.) t employees, LINO workers' 13.❑ Bibs,
cunip. insurance required.)
'Any uplihowit Owl check,box 01 mutt atao NI out the section belaw,howing their woden'eumpensmion pulicy tolomatiun.
'I I,nmeowtwn oho,uhniif this of iclavir indicating they an doing all work mad then hire outside contractors m,at submit a new JMdavit indicating ouch.
$'•nnrmnn that chstk this bus mtut mtachal an udditiuwl ahrat showing the mmrie ofthe aubaamnetun and their wnrtten•camp.policy information.
I ant an employer that is providing workers'compen.radua insurance for my employees. Behou Is dhe pollcy marl fob Nile
information.
Insurance Company
Policy if or Self-ins. Lie. th .__._ Expiration Date: !
is
lub Site Address: City/State/Zip; - -
Attach a copy of the workers'compensation policy declaration page(showing the pulley number and expiration date).
Failure to secure cuvenige as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a`• --
fine up to S 1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
OF up to S250.00 a day against I]ta violator. 13e advised that a copy of this.ctatament may Ix runvarded to file 011ice of
Investigations of'the MA For insurance coverage verification.
/do hereby certify uu v the pair ud ,tooth's of perjury fiat the iujunnutlun pruviduJ u�r1 true aril correct
Phone J
Offie'ial use ordy. Ou not ivrife ire this area,to be completed by city ur to ova off iciat
• 7. 11111,
City or foo'n: PermitiLicense.,4Issuing Authority(circle one):1. Board u(Ile-Ah 2. Buildlnq Dcpaitiorot .i.Ciiylronu Clerlth;lcctrial luspcdnr 5. Pinmhing In
6. Other
Cuufuet Person:_ _ Phone !t:
QTY OF SALEM, MASSACHUSETTS
a ftf' I
BUILDING DEPARTMENT
120 WASHINGTON STREET,3"D FLOOR
TEL. (978) 745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR TY-omAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
T n Pecs L-i Lce N I gac� CD�J o �.3
(na a of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
ignature of app icant
Date