10 ROPES ST - BUILDING INSPECTION A
The Commonwealth of Massachusetts
Department of Public Safety
VyV Mn55dchusetts State Building Code(780 CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
N (This Section For Official Use Only)
O Building Permit Number: Date Applied: Building Official
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations forwhich a street address is not available)
1 �
(n No.and Street City/Town Zip Code Name of Building(if applicMle) m
J SECTION 2:PROPOSED WORK
Edition of NIA State Code used zo s If New Construction check here❑or check all that apply in the two rdAs bcl Tvrn
Existing Building Repair 01 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix lam
Change of Use ❑ 1 ChangeofOccupancy ❑ Other ❑ Specify: m
Are building plans and/or construction documents being supplied is part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ Nirtl/m
Brief Description of Proposed Work: ��+'�a�-�-� /7T�>K���✓s r , .4,'40 N
/�/ z�r+v✓2_ G7,v '` &�A 4e' ,f-o C c/,....6'1, e /",4 L.�c'
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 CNIR 34) El
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.) v
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ 12❑ ' FI: Hi h Hazard H-1❑ H-2❑ H-3 ❑ FI-a❑ H-5❑
1: Institutional 1 ❑ !-2❑ t-3❑ 14❑ M: Mercantile❑ R: Residential R-l❑ 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 ❑ lB ❑ IL\ ❑ FIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Selvage Permit: Debris Removal:ge Disposal: Licensed Disposal d Site❑
Public A trench will nut be p s
Check i(outside Flood Zone tH hniicate oumicipal
required�r trench or specify:r�w„h�
Private❑ or indentify Zane: or on site system❑ permit is enclosed❑ �_'.5 S>e C
Railroad right-of-way: 1-lazards to Air Navigation: MA-I 1. t u -qn,,,I o t .,io,y t ,�
Not Applicable®� Is Structure within airport approach area? Is their review Completed?
or Consent to Build enclosed❑ Yes❑ or No 11>___� Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE
,O,FFOOCCUPANCY
Edition of Code: Use Group(s):_ Type of Construction: -rs,{o�Omipant Load per Floor:-
Does the building,contain an Sprinkler System?: _ A-�=Special Stipulations:.
(hntt_� z
i
,C/,eZ-- 1117
i
SECTION9: PROPERTYOWNERAUTHORIZATION
Name and Address of Property Owner /,
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: _
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the pro-vertyywner hereby thorizes
tiffs< a �' f!s Yz Sa�,,. /r�r�— cse9zo
Name Street Address City/Town State Zip
to act on the' ro er 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 s ace and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
i�imeARegistrant)) 1 Tc!phone No. a-mail address NC Registration Number
�, sow t�•eZ S` s . jw/lf- -) 3 1a
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
Company Name_//
Name of Person Responsible for Construction License No. and Type if Applicable
v'_.o , A.i"- Yf7-7- ��. �i.9 0 /`3 70
Street i ddress / City/Town State Zip
�1� S dZ!Z �n'/�L'�s- ys/3 E�r�C.✓�/•P�v pe a-t y. co,c�_
Telephone No. business Telephone No. cell e-mail address
SECTION 11:woRhEts CONIFENSA I[ON 1N511RAsNCE Af+1DAvff 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 thg isAdnce of the building permit.
Is a signed Affidavit submitted with this application? Yes No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and hlatcrials) Total Construction Cost(from Item 6)_$
I. Building 5 Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing S
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
Fi.Total Cost $ l3 LL-r/ (contact mmticipality)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 Est of my k e and u Landing.
P ue ri n�U name Title Telephone No. DateY�YZ
Street Address City/Town Sta Zip
Municipal Inspector to fill out this section upon application approval• 17(�
Name Da e
CCI'Y OF Si1LEM, l'L-1SS:ICHL;SETTS
BL•iwwt;DEPAR-IMEINT
i
� ) • � r�l I20 1'IIASH1IVGTON STREET, 3'°FLOOR
.ea TEL (978) 745-9595
Etta(978) 740-9846
K1.NBFRf FYDRISCOLL THolt sST.PIERIM
s;1'LAYOR
DIRECTOR OF PUBLIC PROPERTY/BUILD I.,,lG CO',LMISS[ONER
1Vorkers' Compensation Insurance AlTidavit: Builders/Contractors/Electricians/Plumbers
•lnniicant information Please Print Leeibly
N 31TI L'(nminuss,Organirali°Nlndividual): "� n e�"r^ Z 4 S ///ram.�' ✓�'�4 Z" L z
Address: /
City/State/Zip: � u�n r . �1 D197° Phone Il:l �72)
Arc you employer?Check the appropriate boa: Type or project(required):
I. am a cmpIoyer with 4, ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub contractors
2.❑ 1 am a sole proprietor or partner-
listed on the attachcci sheet, t 7• Q-11lemodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'camp. insurance. 9. ❑Building addition
I No workers*camp. insurance 5. ❑ We are a corporation and its
officers have exercised their l0.❑Electrical repairs or additions
required.)
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.INo workers'comp. C. 152, q 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees.INo workers'
• comp. insurance required.) I3.❑Other
•Any applic:un oeu checks bux ri must also rill.,[the sediun below showing(heir wmken'eompensadon polity,infsnnmlon.
'I1..eowmo who whmit this uTldnvit indicating they am doing all work and then hire outside contracron mml submil a new anWavil indicating such.
4fentmurun but check this bus most attached on addiliurul A.1 showing the narne of the subaontncton and their workers'comp.pulley infurmolion.
I unt an eurpluyer that is providing Iverkers'cuntriensadon insurance for my employers. Below is the policy andJab rile
lufrrfmotion.
Insurance Company Name: :•V,l✓'L'S r� / f
Policy it or Sclf-ilu. Lie.th V✓ W t�3 0 9�_` �� Expiration Date''-2
Job SiteAJdress: �V � y2U9•t?S' StP-' City/State/Zip: �,a�:st �i3— Ott 970
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expintlon date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition ofcriminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and aline
Of up to 5250,00 a Jay against the violator. Ile advised that i copy of this statement may tie: rurwarded to the Ofllwe of
Inii•stigatiunr ahhc DIA for insurance coverage verification.
/do hereby certify rue p ad pen ul .qfperiug that the inforotutlon provided ubuvo is true a rd correct
lo'n I C' � 1):lid:
Phonc,l: y�B 7r
Official use onty. Do not write in this urea, to be completed by city or town offh•/ul
City nr I'nwa: _... Permlt1Llevnsc q__.
Issuing Authority (circle one): --
1. Board of Ileallh 2. Building Bepartlnent .1.Cilyfrown Clerk 1. Electrical hupeclur 5. Plumbing Inspector
6. Other
Coolact Person: Pho ne :t:
QTY OF SALEM, MASSACHUSE M
F pe BUILDING DEPARTMENT
120 WASHINGTON STREET,3AD FLOOR
ThL.(978)745-9595
KREERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COWESSIONER
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:
(name of hauler)
The debris will be disposed of in:
(name of facility)
1�ieX4? r-1— /017 A 7Z
(address of facility)
Signature of applicant
Date