2 SAUNDERS ST - BUILDING INSPECTION 0 " ► The Commonwealth of Massachusetts
Department of Public Safety
>c, �lassadntsatts State Building Code(780 CMR)Serenlh Edition
City of Salem
Building Permit Aeplication for.any Building other than a 1- or 2-Family Dwellin
(This Section F rr O ficial Use Only)
Building Permit Number: Date Applied: Building Inspector-
SECTION 1: LOCATION (Pie i dicate Block M jAd Lot N for locations for which treet addre is not available)
l�—
No. and Street City /Town Zip Code Name of Buil ing (if applicable)
SECTION 2:PROPOSED WORK
,14 New Cons uction check here❑or check all that apply in the two rows below "
Existing Building Repair Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Revie ei uired? 1 c Yes ❑ No
Brief Description of Proposed Work: //"' � � �i�•
SECTION 3:COMPLETE THIS SECTION IF EXISTI
NG BUILDING UNDERGOING RENOVA
TION,ADDITION,OR
CHANGE IN USE OR OCCUPANC
Y
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use
Existing 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)-4Area 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 ❑ A-2nc❑ A-3 ❑ A4 ❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-I ❑ H-2 ❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3-0 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 ❑ R-4
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
FINFORMATION
:CONSTRUCTION TYPE (Check as applicable)
IA ❑ IBRSECTION
1111 ❑ IIIA ❑ 111110 IV VA ❑ VB ❑
ON 7RMATION (referto 780 CMR 111.0 fordetailson each item)
Water Supply: Zonen: Sewage Disposal: Trench Permit: Debris Removal:
Public f}R outsie Indiaitr municipal ❑ A trench mm ill not be Licensed Di.pusal tiitr❑
I'ri1 ate ❑ tifc Znrun site"'tem ❑ required ❑ur trench nr 1pecifv:
permit is enclosed ❑
Railroad r : Hazards to Air.Navigation: \lA I li,t,,n,Niture �nlhin airport apPruach dra'•m, I. their fenemc completed'
��r(\m,cnl Io Bed ❑ Yc-,❑ nr.N'o❑ 1'c•.❑ Nn ❑
SECTION 8: CONTENT OF CERTIFICA-FE OF OCCUPANCY
I-ain,m i C,air- _ C.e Gn:u pi.0 fcpc of Con�lnlcli+in: lmcalpant Ladd per I lo"I --
0"C' 111e budding;ront.undn Sprinkler Sm,tem': '�pvcial}lipulationsr -
VK� A Cam,fi-ce /�
SECTION 9: PROPERTY OWNER AUTHORIZATION,i ,iiid Address of Pr urtv zner .® /, �/� �)1.�� �� q "7D
Name(I rint) Nu.and Street Cit%-//Tuwn f! Zip
Prtlpyrhv lhy ner Contact Inform i lion: L
Title _f, Te ephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner herebv authorizes
Name Street Address City/Town State Zip
to art on the property owner's behalf, in all matters relative to work authorized by this building permit a p plicatiun.
SECTION 10:CONSTRUCTION CONTROL (Please fill'out Appendix 2)
(If building is less than 35,000 cu.It of enclo d space and/or not under Construction Control then check here O and skip SLOW[' 10.1)
10.1 Re istered Profess' nal Res onsible for Construction Control
i5z
Name(Registranq Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
�10.2 Contras r
Company a e: �� � ��/ T �
Name of Person Respon�for struction License No. and Type if Applicable
Street dress City/Town State Zip
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor �U�
and Materials) Total Construction Cost(from Item 6)_$
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) I $ Enclose check payable to �
6.Total Cost $ (contact municipality)and write check mlrnbeAere
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 best of my knowledge and understanding.
Please print and sign name Title - Telephone No. hate
titreet Address Citc/T,n%n State Zip
Municipal Inspector to till out this section upon application approval:
Name Date
r F s t
' CITY OF SALLM
PUBLIC PROPRERTY
DEPARTMENT
Construction Debris Disposal At'lid.nit
(rcyuired li)r all demolition mid rcno\anon work)
in accurdancc \\ith the sixth edition of the Slate Building Code, 7S0 CAIR section I 115
Debris, and the provisiuns of..NIGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
this work shall he dkl)oscd of in a pruperly licensed waste disposal facility as defined by V1GL c
I 11. S 150A.
The debris will be transported by:
�X rf/w4 (I-eo
t name of hauler)
I he debris will be disposed ofin
tome w fau ny)
LiJJrer. of I]nhly)
a�nalurc f p:unn .iplrhi Jnl
I�Ir
: . CITY OF S.U.E.`I, ',%L-kSS.XCHUSE-ITS
BI:ILDING DEPARTMENT
." 120 W.kSHINGTON STREET; 31d ftOOR
TEL (978) 745-9595
FAx(978) 740-9846
K .NfBFRIEY DIUSCOIl
MAYOR DIRECTOR
ST.P�ItRIi
DIRECTOR OF PLBLIC PROPERTY/RLRDLVG COSL\DSSIO%ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers
41)pllcant Informatlott Please Print Legibly
Nalnclduairw�aOrtvsrariorolndavtlual):
Address: v r
City/State/Zip: Phone
Are yo ■employer'Cheek the appropriate boa: Type of project(required):1. am a employer with SI__ 4. ❑ I am a general contactor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contraction;
2.El am a sole proprietor or partner- listed on the attached shell :
7. ❑ Remodeling
ship and have trot employees These sub-contractor have n. ❑ Demolition
workingfor me in an capacity. workers'comp.insurance
y p ry. 9. ❑ Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its 10.❑Electrical repairs or additions
"Tuired) officers have exercised their
3.❑ 1 am:a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.f 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employed.INo worker'
comp. insurance required.) I3.❑Other
-Any applicant the dtoeb has II meat alwr no wl tat ass"m hot"attention their workers'consi snsatiew policy in/umrsaoa
r I idnmwners who subosn this affidavit indicating they am doing all work and than him outside contries"Mons mhtnil a new arndsvil indicating suet
<'..ntr:yen that.hock this lief tnW aeached an additiaed short showing da m of fife A&S Or W%n and their workers'corny,policy into ..am,
/raw ew rrwp/oyer rhea b prwvidln�workers'rorwperwtbe/nrnrswee jot aq emp/trynnx edow b rat pollry owd/oI iltY
Inwranca Company Name:
Pal icy Nor Self-ins. Lie. N:_ Expiration Date:
Job SiteAddresa:.,�_ City/Staie/Tip:
,snack a copy of The workers'compensation policy declaration pop(showing the polk7 number and expiration date).
Failure to sat:urc coverage as required under Seclion 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 well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lit adviwxl that a copy of this stalcment maybe forwarded to the Office of
Inccsngations of ilia MA for insurance covcrago verification.
I do hereby certify rorJ the priws wad penaties ofosi that the injormarlow provided above is true and curreK
Win• r t r Dole:
P or A:
O Icial use Only. Do nor write in this drew, to be cumpletd by wiry or town o/lc'iuj
i
City or fuwn: _ - . _ ecrmiO.1cense 0 _
1.suinr.%uihunly (circleunc): - - _- - ----
I. Iluard of Iltallh 2. Ruilding Ucparlmcnf ). Citytrown Clerk 4. Electrical Nipector 5. Plumbing Inspector
6. Other _
L„noel Person: