SALEM WILLOWS - BUILDING INSPECTION (2) ;e. The Commonwealth of Massachusetts
E; I, Department of Public Safety
-,�•f XI,1?Saehll]e•lt1 Slate Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Famil Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SE N 1: LOCATION (Ple se indicate Block# and Lot# for locations for which a street address is not available)
No. and Street Cit), /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
rAre
sting Building Repair ❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix I)
ngeofUse ❑ ChaneeofOcron.,, y ❑ Other ❑ Specify:
building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
n Independent Structural Engineering Peer Review required? Yes ❑ No ❑f Description of Proposed Work
p k
SECnON 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(,): Proposed Use Group(s): p
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 ClA-2nc❑ A-3 ❑ A-4❑ A-5❑ T B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2 Cl H: Hi h Hazard H-1 ❑ H-2 ❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3 ❑ R-4 ❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ 111) 0 IIIA ❑ 11100 1 IV ❑ VA VB ❑
SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for det
ails on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public ❑ C heck if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
1'ri c,t to ❑ or indCrink Zone:_ or%site,,:stem ❑ required ❑or trench or specif,:
permit is enclosed ❑
Railroad right-of-waV: Hazards to Air Navigation: \I,\ I list,",(\"mill......I Re.
Nod \p ,licable ❑ 1.SIRICtUrC ,' thin airport appn,.uh arev Is "'ell. revicmc cumFJclCd'
n C 1,cnt to Rudd rndn.cd ❑ Ye, ❑ oor.N,, ❑ lbs ❑ No ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
LJdinn eei C"Li C. l.e(gin niprsC wpc ul(.-onstruction: ocaipant Luad per.l luor:
1)ne, the huilding cont.nnan Sprinkler Sm stem': Special Sti , I fill --
�0 r�
SECTION 9: PROPERTY OWNER AUTHORIZATION
N.une and Address of Property puv er CJ A om!,��
T( r t
p
Name (Print) Nu. and Street Cih/Tow Zip
Property 0%%tier Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town Stale Zip
to actors the pro pert%owner's behalf,mall matters relative to work authorized by this buildin j permitapplication.
.SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It building is less than 35,0L)0 cu. ft.of endus d s ace and/or not under Construction Control then check here O and skip Section 10.0
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Citv/Town State Zip Discipline Expiration Date
10.2 Gene 1 Contractor
` }
Name of Per on Responsible fur Co uctiun License No. and Type if A plicable
treet City/Town State Zip
Tele hone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COIvII'ENSATION 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 f th uil i g permit.
Is a signed Affidavit submitted with this avolication7 Yes❑ No S`
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor ^�
Item and Materials) Total Construction Cost(from Item 6)_$
f
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
Note:Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv 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 >ign name Title Telepho .No, ate
ZIrcet Addlv,. City/Town State Zip
Municipal Inspector to till out this section upon application approval:
Name Dote
CITY OF SALEM
�4 „ PUBLIC PROPRERTY
DEPARTMENT
.'.I V: ,;
Construction Debris Disposal Affidavit
(Ieyuired litr all demolition and it:now al ion \voi k)
In accurtlance \\ith the sixth edition of the State Building Code, 7S0 C'h1R section 1 11.5
Dcbris, and the provisions of IGL c 40, S 54;
Building Permit K is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal I'acility as defined by MGL c
150A.
The d bris will be tr:msportc by:
hcc-> (->o
v wamcofhauler)
I he debris will be disposed of in
t name u(Ixlhty)
LldJrev.of I�rllilyl
.Iciialwc It pi nnrt .q+phcant
lalr
' CITY OF AxSSACHUSETTS
BL•tLDLYG DEPARTMENT
_ . 12O-W.%smiNGTON STREET, )a'FLOOR
TEL (979) 745-959S
FAX(978) 740-99"
lUM®ERLF_Y DRISCOLL
MAYORTlohtAs ST.PtF�tRs D IILECTO R OF PL sLIC PROPERTY/gl'aDLNG CONLNUSSION ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Plumbers
\ t licant Information Please PrintLegibly
Nalnd (ausincss.Orpn,ratiorolnJtv,duagf
Address: ? l {�— L1 N CO c-'tJ
p 2 B `' Z-
CitylStatdZip: �A�Z—�' I �\ Phone k 6 T�
x\re oe an employer?Cheek the appropriate box: Type of project(required):
I, ,am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the subcwumtors
2.❑ 1 at a sole Proprietor Or partner- listed on the attached shceL : 7. ❑
n Remodeling
:hip and have no cmploycocs Thee subcontractors have 11. ❑Demolition
workingfor me in an ca aci worker'comp.insuranoa
y p ry• 9. C] building addition
[No workers'comp. insurance S. Cl We are a corporation and its
required.)
officers have exercised their 10.❑ Electrical repair or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,¢1(4),and we have no 12.❑Roof repair
insurance required.) r - employees. [No workers'
1.❑Other
comp. insurance required.)
.Any aPPkcaN[hid dtacfa 111011101 mwl alp no ma low section Indoor shoring their worker'wnpmeadon pulk7 infunsaalooc
t t I.vrrtswr,ea who subnd this aRldwx indicting they at*doing all work and them hit*moside contractors naua sutanh anew ilQskvit indicating mock.
T.,ollmun thal cheek this has must anachod an additional shod showing the none srf the ara•eeenaeaan and their wwkna'comp.policy inranraua.
Jam an employer that b previd/n workers'compensadam insurvme jot my emp/uyms ee%w to rbe pollcp and Job alle
�
information. ( r, v .5 •
In..urdnce Company Vame: I r�� � � ,A1
Policy III or Self-ins. Lit. p: — Expiration Date: (D o
Job Sire Address: �1" B I L.l_0yJ S' City/StatdZip:
,\ttack a copy of the workers'compensation policy declaration pep(showing the policy number and expiration date).
Failure to scum coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fed
Of up to S250.00 a Jay against the violator. lit advisW that a copy of this statement maybe forwarded to the Olftce of
Invcangations od'Ilic DIA in ante coverage venticatiun.
/Jo Ire by c rat y rnrdi to, ins and penis des of perfury that the information provided alloope it rat a and correct
7 3 o b
Ptonc A
Offitird use d+r/r Do not write in this carer to be L tomplered by city or town oJJkiaA
City or futon: _ ecrmita.Iccnse
l.suing.\uthunty (circle one):
I. Ilwrd of Ilvaltk 2. Duilding Dcpurtment .). Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Impactor
6. Other
1.„matt Person: _ -_ _ -. _. . Phone.0: