12 SCHOOL ST - BUILDING INSPECTION lot
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The Commonwealth of Massachusetts
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Department of Public Safety
Massachusetts State Building Code(780 CMR)
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: o
SECTION 1:LOCATION(Please indicate Block k and Lot N for locations for which a street address is noyvallalftu)
/Z Sc 'lbA1 Si SAlz,�A D! V-0
No.and Street City/Town Zip Code Name of Building(if app6gable)3ar^
SECTION 2:PROPOSED WORK tom
Edition of MA State Code used If New Construction check here O or check all that apply in the two lows f M)w
Existing Building O Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit AlzpendiFi)
Change of Use ❑ ChangebfOccupancy ❑ Other ❑ Specify: — rA
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an IndependentStrucnuml Engineering Peer Review required? �. Yes ❑ No ❑
Brief Description of Proposed Work; �e 1W 0v.�_� �/� i9-+�a J,ea .SAC�Ti�O^0
oS-e-
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) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)do Area Per Fluor(sq. ft.)
Total Area(sq.ft.),nd Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I Cl F2❑ Iif: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional M ❑ 1-2❑ 1-3❑ 1-4❑ NI: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ R-4❑
S: Storage Sl ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
fA ❑ Ill ❑ IIA Cl If8 Cl IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on sitesystem❑ required❑or trench or specify:permit is enclosed CI
Railroad right-of-way: Iids to Air Navigation: �I,-�lli I I ll 1_plllllll\Sl ul I cil•ly i pn.c.5:
Not Applicable❑ Is Structureazu
within airport approach area? Is their review completed? _
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): 'type of Construction:. Oenlpant Load per Floor:
Uaes the building contain an Sprinkler System?: _ Special Stipulations:
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SECTION9: PROPERTY OWNERAUTHORIZATION
Name and Address of Property Owner
VoW IS cJa-li-itz 3V L/iIt T11A5 I- L;ywl mar 0/ 40
Name(Print) No.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
A�7Z s$�Ji�n s jD0 (jMM;AcS C7-✓( 3 C rf'- 40 D /S
Name Street Address City/Town State Zip
to act on the pr6perty owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
SEiZ1/1c � S LC�L
Company Name
Lnv1S TA
Name of Person Responsible for Construction License No. and Type if Applicable
L// 4 M��lalj� � /C�t/�! 2_ J1Y n71��
Street cAddress City/Town
_ State Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:WORKel:5'COnu'ENSA I ION INSURANCE AITIUAVII M.G.L.c.152.§25C 6
A Workers Compensation Insurance Affidavit from the NIA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the ce of the building permit.
Is a signed Affidavit submitted with this application? Yesf' No 0
SECTION 72 CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ a�
Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=S
3. Plumbing S
1. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $
Enclose check payable to
6.Total Cost S 'LZ Qe 0 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 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 ky9wledge and understanding.
Please print and sign name Title Telephone No. Date
CTK
Street Address —Z C City/Tok n /f date Zip
Municipal Inspector to fill out this section upon application approval:
Name
CITY OF SALEM, MASSACHUSEM
a
BUILDING DEPARTMENT
\ 120 WASHINGTON STREET,31D FLOOR
\�+� TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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:
G �7ocJ(`'�G X ,6 7-1 U(k/7--,�
(name of haul r)
The debris will be disposed of in:
Le
(name of facility)
(address of facility)
Signature of applicant
Date
a CITY OF ScU.ENI, A-kss,ICHL;SETTS
4
I)U'1IDNG DEPdRTxt&\T
120 WASHIINGTON STREET, 3"'FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
KI\IBERLF-Y DRISCOLL
"tiLAYOR T HOMAs ST.PIE1k R9
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electrlcians/Plumbers
Applicant Information Plcase Print Leitiblv
Vafnt: (HminassOrgmtiratiomindividual): / / TU � � � ,` �iA�1
3 3 -?C
City/State/Zip: 2evrr/0� /t14 - U/7/S Phone It: 7 ',5'- ' ( �5�3
A,�r7c�you on employer'!Check the appropriate box: F10CH
ject(required):
I�I am a employer with 4• ❑ 1 am a general contractor and 1onstruction
employees(full and/or pan-time).• have hired the sub-contracterx
2.❑ I ant a sale proprietor or partner- listed on the attached sheet. t deling
P ship and have no employees These sub-contractors have lition
working for me in any capacity. workers'comp. insurance, ng addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) oAicers have exercised their cal repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. (No workers' sump. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' 13.0 Other
cutup. insurance required.j
•,1ny gI.liana tlwt checks bux sl mars,also Fit uut the we tiun bclowshowing their w,,k,,'camPemmnun Pulivy initam a Our.
'I fomauwtwns who uhnsit This a1iit indicating they am doing all work and then hire outside cuntmcmn most suhmit a new aaldaviI indicating such.
K'unmctun thus check this box m¢vt attachal an additional xheet showing the none or the 1ubCenlrscWn and their workers'comp.put Icy in runn tti on.
f ant an emptuyer that is providing workers'compensation insurance for my errtpluyees. Bd/ulv/s die poBcy and fob slur
infitnirutinn. j� n
Insurance Co 1pany Vame: �-7�V L ��"�-£_— 1 Q y
Policy 4 orkSelf-ins. /(Lic. N: �/ �J y/Q ��v . �/p�� Ekpiration Date: /V—/�
Job SiteAddr(:ss: /r� JC140Q'! S� Cily/State/Zip:.STI�m
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition oferiminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may 1x funvarded to the OI'lice of
Invatigmioos ut'the Dirt for insurance coverage verification.
/du hdreb -errify sander point n peualries of perjury that the infurawrlmr provided above i.v true an[d`corrret
Data:
I'hunu y
Official use only. Du nor write in this area, to be curupleted by city ur faiva o//Icial
City or fawn: _ __ I'ermit/l.icemc p
Issuing Authority (circle one): . __--
I. Baird of Ileal(h 2. Iluildinq Deparnnent I.Cily/fwwu Clerk J. Rlectrical lulpcdur 5. Plumbing Inspector
0. Other _. -. . ...
Cnn(aR l4rsn): _ Mine !t: