1 SEWALL ST - BPA-13-572 A/C ROOFTOP UNITS The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(78 MR
!lIJJJ Building Permit Application for any Building other than On o tly Dwelling
'(Tliis Section For Official Use Only)
Building Permit Number Date Applied •" Budding 0 ci
SECTIONII:LOCATIO�N'+(Please indicate.Block#and tiot#for locahons'for`w i street add ss.is'notavailable)
No.and Street City/Town Zip Code Name of Building(if applicable)
.: -.
'SECTION 2:PROPOSED WORK-
Edition of MA State Code used Je) If New Construction check here❑or check all that apply in the two rows below
Existing Building r6 Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition ❑ (lease fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: w 1
Are building plans and/or construction documents being supplied as part of this permit application? Yes ® No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Descriptof Pro osed Work:
s U
�+ c
SECTION 3:COMPLETE THIS SECTION,IF EXISTING..BUILDING.UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USEOR 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.) 'I
SECTION 5:USE.GROUP(Check a§applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational
F: Facto F-1 ❑ F2❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑
1: Institutional 1-1 ❑ 1-2❑ I-3❑ I-4 E3M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 13 111 FIA (3 1113 13 IIIA ❑ 11113 13 IV 13 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'wilrnot be Licensed Disposal Site ❑
Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA Historic Commission Review Pra:rss:
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 Floor:
Does the building contain an Sprinkler System?: Special Stipulations•
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>-.. _ OWN.
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SECTION 9:=PROPERTY O ER AUTI-IDRIZAT �lIOs '-
N/Ia'me and Address offProperty Owner p "
zy
Name(Print) No.and Street City/To vn Zip
Property Owner Contact
tIInformation:
Ya-
Ti ea
tle Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby auth'o'rizes I I II
1aI IJ?"ICox c+ ,W. �utv»�os L� 11 A rr c1 � o lAr.Z
Name Street Address City/TowA 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 bmtdin is less than 35,000 c6.eft.of enclosed s ace add�or n6tvndei Coiistruction,ConUol Hien check here crand ski` Sechon 1o,1 -
10.1 Registered Professional`Res onsible 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 < - -
� � LLC-
Company
Name
1�9t I:lt�tN, Jet�v,l c �22�1 l,�
Name of PersonRe o ible for onstruction License No. and Type if pplicable
e�-I t� S-l- s �v.e.
Street Addresspp����y.. City/Town State Zip
�q`2- 222,pl --L-221. 16 \ ty o..,. da v
Telephone No. business - Telephone No. cell mail address
SECTION-11::WORKEP.S'CO\IRENSATION.IN.SUPANCE�AFFIDAViT M.a.L.c.-152:. 25C6 `.
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
and Materials) Total Construction Cost(from Item 6)_$ q_ l�
1. Building $ 4'0Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ O appropriate municipal factor)_$
3. Plumbing - $
4. Mechanical (HVAC) $ Q/ QO
Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ 000 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDINGPERMIT APPLICANT T _`
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 owled and understanding.
Please pr' t and 'gn na I Title Telephone No. ate
Street Address City/Town State Zip
MunicipafInspector to fill out this section upon applicationapprovah
- _ Name.. . Date
I
"r CITY OF SALEM,, NLUSACHUSETTS �
l BL'tLDL\G DEPAR'nMNT
` r• 120 WASHINGTON STREET, 3' FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
Kl�(Baar EY DRISCOLL
MAYOR THo.%w ST.PIER s
DIRECTOR OF PUBLIC PROPERTY/13UUMING CONINUSSIONER
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 I l l.5
Debris, and the provisions of MGL 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 MGL c
111, S 150A.
The debris will be transported by:
iVyI.c-A- G41-4 CLV" W1tV tw d�b�'l$
(name of hauler)
The debris will be disposed of in :
(name of facility)
_ --(address of facility)
signature of permit applicant
date
dcbri>o0.dx
t CITY OF S.UYaI, \/L-kSSACHUSETTS
• BUILDMG DEPART\IEAIT
Y• 120 WASHINGTON STREET, Ya FLOOR
orf TEL (978)745-9595
FAX(978) 710-9846
KINIBFRi EY DRISCOL
THOMAS ST.PtERR&
1INUYOR
DIRECTOR OF PUBLIC PROPERTY/BL'IIDLNG CONMaSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 f / Please Print Leeibly
Name(Business Organizationilndividual):
Address: t; `l pa,,.�J S�
City/State/Zip: o 1AC.7 Phone #: 7-4 1 91j2 2m.?Z,3
Are you an employer?Cheek the appropriate box: Type of project(required):
1. 1 am a employer with_� 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time).
• have hired the sub-contractors 6. El Now construction
2_❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ® Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑ Building addition
[No workers comp. insurance 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL l l.❑ Plumbing repairs or additions
myself. [No workers' comp. C. 152,§1(4),and we have no 12.❑hoof repairs
insurance required.)t employees. [No workers' 13.®Other //yAe zAcL fL
comp.insurance required.]
•Any applicant that checks box 9I most also fill out the section below showing they workers'compensation policy infutmation.
'l lomeowneta who submit this affidavit indicating they alt doing all work and thea hire outside commeton must submit a new affidavit indicating such.
=(:ontnarun that cheek this box must attached nn additiorW shoet showing the nama of the nubcomrusams and(heir workers'romp.policy infomwioo.
I am an employer that Is providing workers'compensadon Insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Lt 6cr�tJrt�r et.�
Policy Nor Self-ins.Lic.fl: [t/e -3/5— 38345. --oi2 Expiration Date:_l1-25—,03
Job Site Address: Mt—,4 .SaIe-w City/State/Zip:
Attack 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 MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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 fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Otlice of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify a der the pains and penalties of perjury that the lnformallon provided above is true and correct.
5i6n lure: 111 Date, I —1 Q-1
Phone rt: ? ,I 4112 277-SzS
njrcial use only. Do not write in this area,to be completed by city or town ojjrclal
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ Phone#: