34 SETTLERS WAY - BUILDING INSPECTION (2) I
365 - lq
The Commonwealth of Massachusetts
Department of Public Safety
(Y° t4assachusetts State Building Code(780 CNIR)
Building Permit Application for any Building other than a One-or Two-Fa ;Dwelling
("rhis Section For Official Use Ord )
Building Permit Number. Date Applied: Building Official:
SECTION •LOCATION(Please nu cate Block#and Lot#for locations for which a street address is a t available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION2 PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply In the two rows below
eC
Existing Building pa Repair r\Iteration ❑ I Addition❑ . Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No e
Is an Independent Structural Engineering Peer Review re lured? Yes ❑ No Q'
S Brief Descri it n of P posed Work:
J!,
SECTION 3:COMPLETE T 115 SECTION IF EXISTING B L ING UNDE OING REN VATION,ADDITIq Nap
CHANGE IN USE OR OCCUPANCY 2.Air uiL�.L�rAfy/ %?f
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 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(sy, ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as ap licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-3❑ F B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ I H. High Hazard H-1❑ H-2❑ H-3 ❑ HA❑ H-5❑
L• Institutional I-t❑ 1-2❑ I-3❑ 1-4❑ NI: Mercantile❑ R: Residential R-111 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ 5-2❑ IU: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION'fYPE(Check asap licable)
Ir\ ❑ IB ❑ HA ❑ If6 ❑ IIL\ ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CN1R 111.0 for details on each item)
Water supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
PublicH Check if otnside Flood Lone ludicate .... pal A trench w I not be Licensed Disposal Site
Private❑ or indentify Zone or on site system❑ required or trench or specify:
permit is enclnseal❑
RailroadfApplht-of-wa Hazards ithina vvavapproac ? Is
rl it reviwco �t� Ir �rs:
6
Not:\ licable� Is Structure within air ort a r roach area, fs them review ann Icted7 ������
or Consent to Build unclosed❑
es 0 No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): 1'ypu of Construction: Occupant Loud per Floor
Does the building contain,m Sprinkler System?: Special Stipulations:_ —_
i
SEC"TION 9: 111101'EIYTY OVVNER AU'rItORIZA'rION
Nanne,uu�l�pert Owner �
Name(Print) No.and Street —� City/'rows /ZAP
Property Owner Contact information: - _> G�f
Title Telephone No. (business) Telephone No. (cell) lgae-mail address
If applicable, the property owner hereby authorizes
7;5iir -
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 ennit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,O00 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
Y2�
Name R sum❑ 'Tole Awl
No. e-mail all re s W-9 f Registration Number J J
Street Address City/Town State Zip Discipline Expiration Dale
10.2 General Contractor (`
Company Name
Name of Person Res nsible for onstruction Li-rose No. and Typed Applicable -_
Street Address City/Town State Zip
"reie (tone No.(bitsiness 'rele hone Nu. cell -mail address
SECTION11:wi-INK ls N'COnu'c�s,�r10N1 ul:nNch_tfru?;\Vll M.G.L.e.152.§ 25C6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provid
e this affidavit will result in the denial of the issuance of the building permit.
Is a si ned Affidavit submitted with this a lication? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)=S
1. Building S1 On' Quilling Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ 7 r pD 1 appropriate ntwticipal factor)='S
3. Plumbing $ Note: Mininiu n fee=S (contact munici tl
Y)
I. Mechanical (FIVAC) $ �
5. Mechanical Other S Enclose check payable to
6.Tuhd cost "� ?d (contact municipality)and write check number here
SECTION If 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 Tetephone No. Date
Street Address City/Town State Zip
i
Municipal Inspector to fill nut this section upon application approval• !i
Name Date
I f
t
CITY OF S.1I.EM, NAXSSACHUSETTS
BUILDING DEPART7,10NT
120 WASHINGTON STREET, 3BD FLOOR
TEL. (978) 745-9595
FA-X(978) 7.80-9M
KI\fBERLEY DRSSCOLL THOMAS ST,PIEMM
N AYOR
DIRECTOR OF PCBLICPROPERTY/BCLLDL\G CONCIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractorc/Electricians/Pfumhers
Applicant Information Please Print Le ibl
Name (13usinesa'Organization Individual):
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and l 6. ❑New construction
- tployees(full and/or part-time).* have hired the subcontractors
1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling
,hip and have no employees These sub-contractors have 8. ❑ Demolition
working foi me in any capacity. workers'comp.insurance. 9• -Building addition
(No workeri comp. insurance 5. ❑ We are a corporation and its
officers have-exercised their 10.❑ Electrical repass or additions
required.] of
3. 1 am a honw6wncr doing all work right of exemption per MGL I I.[] Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12,❑ Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp.insurance required.l
*Any upplic:mr that dtaks box kt most also fill uuuhe section below showing their worken'compensation policy noin-mation.
'I lomeowneru who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new aftidavii indicating such.
:cmomewn that chcvk this box most atachcd an additional sheer showing the nave of the sub-contractors and their workers'comp,policy information.
f aru an employer that is providing workers'compeusadon in.surancejor my employees. Below is the policy and job site
injoraration.
Insurance Company Name:
Policy 4 or Self-ins. Lic. 0: O ..__ Expiration Date: i�.0 7
Job Site Address: � City/State/Zip:
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 25A of 4IGL c. 152 can lead to the imposition of criminal penalties of
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S250.00 a day against The violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigwions of die DIA For insurance coverage verification.
!do hereby c•erti inn�deerr the ppaQins and teaaltles jperjury that the information provided above is true and correct.
Si •oanhrt' ^Gl� %; ��G/`2%2 Data:
Phn e 1:
Official use only. Do oat curia in this area,to be caurplead by city or town official
City or Town: —_—,--- Permit/l.lccnse#---.-`--------__—_. _.._
Issuing,%ulhorily(circle one):
I. Board of Health 2. Building Department 3.Citylfmvn Clerk d. Flectrical Inspector 5. Plumbing Inspector
6.Olher.__...___
Contact Person: __ ... .._ _... Phone#:
CITY OF SALEM iNLkSSACHUSETTS
13t i=NG DEP.�Rnl&NT
t! r 120%V.A5HLNGTON STREET, 3" FLOOR
\�
" TEL (978) 745-9595
F.L,K(978) 740-9846
KIJIBERL.EY DRISCOLL
1>rr4YOX Tuo.%w ST.PmRRH
DIRECTOR OF PUBLIC PROPERTY/BUILDING CMWISSIONER
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 t 11.5
Debris, and the provisions of NIGL c 40, 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 disposal facility as defined by NIGL c
l 11, S 150A.
l'he debris wi It be transported by:
y�/t%/rI ✓//Il�/f
(name of hauler)
The debris will be disposed of in
106
(name of facility)
-----(address of facility)
signature of permit applicant
date
dbni:iT.,Iw