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12 SCHOOL ST - BUILDING INSPECTION (3) I - 1 I — I 5 RECEIVED TInNAI SERVICES The Commonwealth of Massachusetts "Department of Public Safety ' IOIU NOV 2b P I: 3b VIVA Massachusetts State Building Code(780 CNIR) 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#and Lot#for locations for which a street address is not available) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration O Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as of this permit application? Yes No ❑ Is an Independent Structural Engineering Peer Review required? ,[ Yes 0 No ❑ Brief Description of Proposed Work: S J f. psi SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here Ilan Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): I 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 ❑ A4❑ A-5❑ 1 Bi-Ousine;s'.❑ E: Educational ❑ F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ 'H-3 ❑ H-4❑ H-5❑ 1: Institutional M ❑ 1-2❑ 1-3❑ I-4 O NI: Mercantile❑ FR. Residential R-113 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 licable) IA ❑ IB ❑ 11A ❑ 11613 ILIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item),", Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: A trench will not be Licensed Disposal Site❑ Publiw Check if outside Flood Zone❑ Indicate numicipa required O or trench or specify: Private O or indentify Zone: or on site system❑ permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: y i I. u ri., m m, i q,i;, Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed ❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code Use Group(s): type of Construction' . Occupant Load per Flour:. Does the building contain an Sprinkler System?: Special Stipulations:, — c-!a l,f�-r-) 118 L4 �,� . SECTION 9: PROPERTY OWNER AUTHORIZATION Nameand2l ddr}}•'ssofPropertyOwner ✓1 CA IfFIPf ZC5 :�y wfi jfrru 5f t In m¢ 0/9 %u one(Print) 4 No. and Stree ity/Town Zip S Property Owner Contact Information: �(Whrl khj4v4ZtS M-abr 39Y4V00 Title Telephone No.(business) Telephone No. (cell) a-ntad address If applija.5b, tl a property nvner 1 •reby authorizes .y /> t AGi'l'��de% Name Street Address City/Town 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 O and skip Section 10.1 10.1 Re istered ProfessionatRes onsible for Construction Control game(Registrant) 1 Telep one No. e-mail address Registration Number ZZeVAv�� g/ SZJ Al ��7d r, Street Address - City/Town State Zip Discipline E phr ion Date 10.2 General Contractor - - Contp Name of Person Responsible fo on�structtiun License No. and Type if Applicable Street Address City/Tow;n ,// )State Zipa // Telephone No. business Telephone No. cell e-mail address SECTION 11:1V'0RFF:IS'C0NIFI-,NSA'IION INSURANCE AFFIDAVIT 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 the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE' Item�� ts: (Labor d' ri,t Total Construction Cost(from lien 6)_$ L Building $ Building Permit Fee=Total Construction Cost x_(Insert Isere 2. Electrical $ ,?� a appropriate municipal factor)=$ 1. Plumbing $ E it. Mechanical (HVAC) $ �© Note: Minimum fee=$ (contact municipality) 5. Mechanical Other $ XZ2 Enclose pay check v able to 6.Total Cost $ (conttct nmicipality)and write check number here S��3:SI NATURE OF BUILDING PERMIT APPLICANT By entering my nanuf 6elow, I hereby attest under the pains and penalties of perjury that all of the information contained in this appl' t n us rue and tccura to tot a best of my knowledge and understanding. - - Please print utJ sign na ne Title /,�,� Telephone No. ate Z527 c-D Street Address City/Town State Zip / Municipal Inspector to fill out this section upon application approval: 's / �7 Name Da QTY OF SALEM, MASSAQHUSEM BUILDING DEPARTMENT ' 120 WASaNGTON STREET,3" FLooR TEL. (978)745-9595 KIMBERLEY DRISCOLL FAX(978)740-9846 MAYOR THoMAs ST-NERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING OCAMSSIONER 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 a transported by: name of hauler) The debris will be disposed of in: 1� (narp,dof facility) (address of facility) Signature of applicant Date n ;T e CI-I'Y OF S:U—EM, i%L-1SS:ICHI:SETTS BL'iLDLtG D E P.A RT\LEIN T i 120 \\'/.\SHNGTON STREET, 3r'FLOOR ono TEL (918) 745-9595 F.A-X(978) 740-9846 Kl\IBFRj F-Y DRISCOLL THO,\"S ST.PIFA88 t AAYOR DIREcrUR OF PUBLIC PROPERTY/BCQ.DIIG CO\L\II55(ONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plurnhers A i tlieant Information Please Print Le ibl Name lBminess Orgmtiratiom''Individual): �� Address: Cily/State/Zip: Phone F employer'.'Check the apprapria(�tox: 'type of project(raqulred): employerwith 4, 1 am a general contractor and 1 6. ❑New construction "es(full and/or part-time).• have hired the subcontractorssole proprietor or partner. listed on theattachadsheet. t -7. ❑Remodeling d have no employees These sub-contractors have 8. ❑ Demolition g for me in any capacity. workers'comp.insurance. 9• I] Building addition rkeri comp. insurance 5. ❑ We are a corporation and is 10.❑ Electrical repairs or additions required.] of have exercised their J.❑ 1 am a homeowner doing ail work right of exemption per MGL I I.[]Plumbing repairs or additions myself.(i\o workers'Gump. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. (No workers' 13.❑Olhcr comp. insurance required.) -Any applicant awl checks box el most also rrll out are section below showing rbeir wade'compeesadum Pulicy inGrrmatlon. 'I lomeuwtwns wha whmii this stTdnvit indicating they am doing all work and then hire outside contmctors anul aobmtl a new amdavil indioing such. :tlnnncton that chak this box mmr attached in additional+hul showing the name of the sub ronrmctom and Ihelr wnrk,m'comp.policy inlia malion. I ran un rurpluyrr rha7 4 pruvldlnK Ivor rr'eumpt n vurm�ce jar my empluyrrs. Belulp/r tha policy und/ab site Insurance Company Name:— G7 Policy it or Self-its. Lie.Ih __ Expiration Date: Job Site Addruss: Cily/State/zip: Atlach a copy of the woriters'compensation policy declaration page(showing the policy number and expiration date). railura to secure coverage as required under Section 25A afMGL e. 152 can lead to the imposition ofcriminal penalties of a tine up to Si•500,00 und/or one-year itn risonmcnt,as I as civil penalties in the form of n STOP WORK ORDER and a Tine of up to S23000 a Jay nst r viol r r. Ile advi d at a copy of this statement may be forwarded to the 011ice of Investigaliuns of die IA for insur rt g overage a Icaliun. /du herby cord surd It and per tlrs ujprrjary that the/njunrtut/au pruvidrJ about it trot unJ c orrreR i ,•n 1 r Data: -- Phone d: _ k Fof1kialuse only. Du our rvrilt in dais urru, m be cuurpler¢d by rity ur rorvn o/JJeiuLcvn: Permit/l.icensclburily (circle one): Ilealth 2. Building Department 1.Cilyffown Clerk J. Electrical Inspector 5. Plumbing luapeehorrtnn:..___..__.___.. ..—___._ Phone g: _ allaoVED Subject to aPP!Ovsa authority havA43-riaL�iGttom CITY 04 S TX ,�T e Fir _DlFVENTMNB jr £i CAT*aoF ?';iq;Y.AP.L APPROV DSOLELY F6R DEVICES. TYPE A@0 LOCA 11 t or FVQEEPR j .E„- TO I �" ^RCTECTI_SI iF7c COL' ST 1.No Csc'ECTIO14 FOr CO>,iP 4 FM `OTM 2M 2 'ANTS/ 5TM i alaeN uuu maa vmxAao. a lie 0 O ® O a+n O den clo O aa9n O n cncT oMTM taam��l ezxooxl it fi . an9ei aaxf O O e3 V� f�l O STMI �bMi O STMI 'U s$ V ✓ O �Y �w ow �r O SNOKE OEIFLTOR �Q uo WWN MONOXIDE OEiEOTOR ` �e. E ASEME R5 OR 5EG0 P IRD OR ILA S-1 vow vrc� 6 v+w ` other to approval by any U10107w; a<_'SALEM MASS• :ram? yF NB AU 1 ICATIONOF ONE SOLELY FOR IOE ifK'! "CLSS. TYPE A LOCAT13; GE^FIRE-P �yuJwl TO P .FTECOCo PA41M 5iA[i PMRi SiMt 5 q� 1 I I f f GILY:A' tNMSAW IJIPN NNKMG 1� r. Y. 0� O ® O wtx uo O O d zw[t wm ancT wm y p3P.KN1 DAICtlMI &Y.Ne u` anx� easxwe av�i c.�ax+e i acne min v p 111 tl 8 LM 5}MI � Y ac O SFYKE DEiFLTOR �CE Uo UM VaOM OETEGTOR 5 c F _ A5Fa1E R 5 OR P4a 5 ,SECOND IRD OR S-1