12 SCHOOL ST - BUILDING INSPECTION (2) e
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The Commonwealth of Massa 9 dN9l SERVICE,
CEIVED ~
Department of Public Safety
yp Massachusetts State Building Code(780 Civil -
Building Permit Application for any Building other than a On �" j y�r{)tily�s�Ilt�t�
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block k and Lot H for locations for which a street address is not available)
No.and Street City/Torun Zip Code Name of Buildi (if applicable)
SECTION 2•PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below.
Existing Building❑ 1 Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit AppendilN I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
A ,building plans and/or construction documents being supplied as part of this permit application? Yes ❑
Is an Independent Structo rnl Engineering Peer Review require es- No ❑
Brief Description of Proposed Work:
SECTION 3:COMPLETE THIS SECTION IF EXISTING B ILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑
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.) '
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 Cl A-4❑ r\-5❑ B: Business ❑ 77[7TEducational ❑
F: Facto F-I ❑ F2❑ 11: High Hazard FI-I ❑ H-2❑ H-3 ❑ FI-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14 Cl NL• Mercantile❑ R: Residential R-I❑ 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 a plicable)
IA Ill Cl IIA ❑ 1100 IIIrA ❑ IIIB ❑ I. IV ❑ TVA ❑ VB ❑
ECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) �
Water Sup ly Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood "Lune❑ bnlicate municipal Cy A trench will not be Licensed Disposal Site❑
required ❑or trench or specify:
Private❑ or indentify Zone or on site system❑ permit is enclosed❑
Railroad right-of-way: hazards to Air Navigation: MA I li t,ri,:_r," .. ......io n.l ,. I_oy c.0
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Ycs❑ Or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: A&C Occupant Load per Floor:.
Does the building contain au Sprinkler System?: --Special Stipulations: ___
SECTION 4t PROPERTY OWNER AUTIIORIZATION
Name and Address of Pro arty O men
Nanie.(Print)._ac (r,L ;Ii t]-i�UYNo.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all natters 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❑and skip Section 10.1
.11.1 Registered Profer<ional Responsible for Cunstruction Control
Na ne(Re aistr int) " Tele hone Nu. e-mail address Registration Number
/121 ��c-,�1�
Street Address City/Town hate' Zip Discipline Expiration Dote
10.2 General Contractor
pe
Company Name / Q ,
�la 'mil yUL /7-S l V�PCS6&4 • f/ 5: y/
Name of Pers n Responsible for Construction License No. and Type if Applicable
Street Address -/ City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11: w0WK1,:RS'COMI1FNS,A I ION INSURA:NC'H AITFAVIT M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from tine NIA 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 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs: (Labor
and Ntaterials) Total Construction Cost(from Item 6)=$
L Building 5 Building Permit Fee—Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing 5
4. Mechanical (HVAC) $ Note: Nlininium fee=5 (contact municipality)
S. Mechanical Other $ Enclose Bieck payable to
6.Total Cost --- 5 (contact municipality)and write check number here
SECTIOa 13:SIGNATURE or BUILDING PERMIT APPLICANT
By entering my n n y eby attest wider the pains and penalties of perjury that all of the information contained in this
application i' rue an - r. to the best of n y know)• ge and understanding.
d6e
Please print and sign name 'rifle Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approva
Nam Date
of
. `-12\ Ofrice:of Consumer Affmis, Busi essReguo grr
' Wx
ME IMPROVEMENT CONTRAC
TORgiStration 135734piration 5d2016 - �`A f
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PATRICKA CHASS�
f?C SASH Y'"aiY{F
'PATRICK-CHASE
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14;CLEVELAND ST. T- ` "'��•'
_ }m SALEM, MA 01970 ' �"- ''' fir•".
t _ .UodersecretaWiy ,
Massachusetts Department of PU61ic Satefy' '
loard of Building Regulationsand.Stabdarft T
x Cgntilru twn Super};isnr "^�+-.-
G .• Licens; CS-085041�`I
PATRICK A CHA
14;CLEVELANDST +1%(►`� t `
SALEM MA 019a0 / x
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Nyrs 'G t 16}{I t
x' Expiratroq
�+ M1 Commissioner - _ ,-' „" '.• 11/2 74
CITY OF S U EN1, NL-1SSACHUSE-1-rS ~
4 - BUILDING DEPARTMEINT
120 Cif.\SI ILNGTON STREET, ace FLOOR
TEL (978) 745-9595
F.kx(978) 740-9846
K1-tBFRt Y DRISCOLI
RL-E YOR THonks ST.PIE.MW
DIRECTOR OF PUBLIC PROPERTY/BI:ILDrNG COMMISSIONER
\Yori(ers' Compensation Insurance Affidavit: I)uilders/Contractor.5/Electricians/Plumhera
\ r ilicant information Please Print Le ibl
Name (Rusinass Orgtnirutiom'Individual l: f J�
Address: �cd L �
City/State/zip: �?VV Phone /f:
Are you in employer?Check (he appropriate box: Type of project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor and 1
employees(full and/or pan-time).' have hired the sub-contractors 6. El New clanswction
2.M I nm a sole proprietor or partner- lived on the attached sheet. • 7. ❑ Remodeling
,hip and have no employees These sub-contractors have N. C] Demolition
working'fix me in any capacity. workers' comp. insurance. y. Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I i.❑ Plumbing repairs or additions
myself. (,No workers' clamp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) r employees. (No workers' 13.0 Other
comp. insurance required.)
•A.Iy applicant due clwclo box sl meat also fill law the sautlun below shawing their workeri cumpensmiun policy inlummtion.
'I lom<uwnen,vho wl,mit this aOldnvir indicating they arc doing all work and then hire wasido cunimctom moat sohmit anew aMdavil indicating such-
:(\:ntmotura thul chak this box must anachul can additiurul.hr•t showing the mmnc of the mbtonrravon and their warners'camp,pulley information.
I ant an employer that is pruvfdiug workers'compeasatlon in.ru`once for my employees. Lteloly is tho poi ey and job slid
injornrurian. //�'i/��,
Insurance Company Name:A .`—J_.___��
Policy 4 or Self-ins. Lie. it: Expiration Date:
lob Site Address: City/State/zip:
Atlach a copy of the tvorlrers' compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Reckon 23A of.MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in(he torn of a STOP WORK ORDER and aline
nr up m S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the 011ice of
Incntigmiuns cal the DIA For' v• c vur - at' n. -
/do hereby certify it rr the pain u per tit' perju t rut the hifunnat an pro sided above r:r true laud correct.
S1110 t re' Date:
Official use only. Oo not write in thiv area, to be coarpleted by city or torus nfjiVhtL
City or Pcrmit/Llccnsc#
Issuing Authurity (circle one): --_ — - �_- --- - --
1. 0oard of Ile-Ah 1. Building Ilcpartutent J. Citylrnwn Clerk 1. Electrical luspector 5. Plnntbing Inspecror
0. Other
Cu nlucr I'urm n: _ Phone 3:
QTY OF SALEM, MASSAQHUSEM
BUILDING DEPARTMENT
120 WASFHNGTON STREET,3R FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING MNMSSIONER
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 bX:
�l/tom ox,
(name of hauler)
The debris will be disposed of in:
v���
(name of facility)
y '--5G1(e�rvz �—
(address of facility)
Signature of applicant
Date
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