27 SILVER ST - BUILDING INSPECTION (3) 3
fL Ms R VBD f3Y T44E
P• AMO GRANTED
CITY OF SALEM
No\��11 00� Dab
M I%Wmfy Lomw in Lmatioa of
M hapmly Lao"h ` /
@a0aaar WonAma? Ya�fro X
BUILDWG PERWT APPLICATION FOR: '
Pwmk tm
Of whW~apply) Roof. Reroof, Install Skflnp, CO NDW,Do* Shed, Pool,
Repel�IRepkoe, Other.• .��.�-�a_,o�c v�w�cr�>�--c._.
PLEASE FILL OUT LEGISLY&COMPLETELY TO AVOID DELAYS W PROGUNM
TO THE INSPECTOR OF BUILDINGS:
The Nprndpnad hereby applies for a permit to build aaordUp to t w speomadom
Owner's Name v I' U t-R.CeFm /k-
Ad*m A Phm ,,i S 1 4-?9-oa .
Afahlteot's Name
Ad*m& Phone ( 1
Mechanics Name
Addnee A Phone I,4. 4 •.
wnt to rM faaaaaa a- v► PDL�w J��
mmm a blitelg4 "a dwatbq,for how mmy famttaa4 QL
wr bmq aailam b two r
aalwmfad one. 5—�op umm r N A ewe uo • e.
j63
fi somure orj4~
S1014D UNDER THE P
OF PERJURY
DESCRIP110N OF WORK TO BE 09NE
.
�'" MAILPERMRTOi S
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City of Sakm,= Massachusetts .
Fire Department
n
tegYem 48La etteStreet
�f 29 Fort Ave. `
Robert W.Turner Salmi,Massachusetts 01970-3695 ire Prevention
Chief Tef 978-744-12-35 Bureau
978-744 6990 EfaX 978-74rr4646 �: , 978 745-7777
FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR A BUILDING;PERMIT
IN ACCORDANCE WITH THE PROVISIONS OF;THE. MASSACHUSETTS §'PATE BUILDING CODE
AND THE SALEM FIRE CODE, APPLICATION;IS HEREBY MADE FOR THE APPROVAL-OF PLANS +
AND THE ISSUANCE OF A CERTIFICATE OF APPROVAL FOR A BUILDING,PERMIT BY-THE
` 2
=�� r SALEM FIRE DEPARTMENT.° ( Ref.'�Section 113.3 of the. Mass. Bldg., Code) y
JOB LOCATION:
t OWNER/OCCUPANT: ll`Z LI(j rt�Sl �
,a ELECTRICAL CONTRACTOR:
n FIRE SUPPRESSION CONTRACTOR: }`
zlezSIGNATURE-0FAPPLICANT- d �ICf la s .PHONE
N
.F ADDRESS OF 7 CITY 'OT �J -�-�- sC
APPLICANT: n I4/ �f� �
TOWN � y N;
a, u
e" APPROVAL DATE: e2 p 'r R n ,<*
CeYtificate of approval is hereby granted, on approved-plans•oi,aubmittal of
'j tr F Ei r R
: > project details, by the SALEM FIRE DEPARTMENT: ,, A4--plans are approved solely
,£ fL for identification of type and location of fire protection devices and equipment
w All plans ere subject to approval ofyany-other authority,having'°jurisdiction ,
Upongcompletion, the applicant or installers) shallrrequest an inspection and/or`
test°of the fire protection devices and equipment. :(ADDITTIONAL+REQUIREMENTS, t
t o SEE.REVERSE SIDE
NEW CONSTRUCTION.
4
} PROPERTY LOCATION HAS NO COMPLIANCE- WITH. THE PROVISIONS OF, a�
CHAPTER 148, SECTION 26 CIE, M.G.L., RELATIVE TO,THE INSTALA
TION.OF APPROVED FIRE ALARM DEVICES. . THE OWNER OF THIS ,PRO . .
t , a
PERTY IS REQUIRED TO OBTAIN COMPLIANCE AS A CONDITION'bF s
OBTAINING A BUILDING PERMIT.
PROPERTY LOCATION IS IN COMPLIACNE WITH THE PROVISION OF CHAPTER a
148-, SECTION 26 CIE. M.G.L.
EXPIRATION DATE: aS �� , Je `o' .
' SIGNATURE OF FIRE OFFICIAL
e .
FEE DUE: UNDER 7,500 SQ. FT. 30 �a FORMIi 81 3/98
r_ 7,500 SQ. FT: OR LARGER $50.00
FIRE DEPARTMENT UgjlFICATE OF- .APPROVAL FGP EUILBI\G PER!tIT
In compliance with the provision .of Section 113.5 of the Massachusetts
State Building Code, and under guidelines agreed upon by the Salem Bldg.
Inspector and the Salem Fire Chief, the applicant .for a building permit
shall obtain the Certificate of Approval (see reverse side) and stamped
plan approval from the Salem Fire .Prevention Bureau.
' Said application and approval is required before a building permit may be
issued. The Massachusetts State Building Code requires compliance
approval of the Salem Fire Department, with reference ,to provisions of
.Articles d and 12 of the Building Code, the Salem Fire Code, Massachusetts
General Laws, and 527 Code of Massachusetts Regulations.
The applicant shall submit this application',with.,three (3) sets of plans,
drawn in sufficient blarity, to obtain stamped approval of the.Salem Fire '
Department. This applies for all new construction; substantial
alterations, change of use and/or occupancy, and any other approvals
required by the Massachusetts General Laws; and the Salem Fire Code.
Exception: Plans will not be required for structural work when the
Proposed work to be performed under the building permit will ' a,
not, in the opinion of the Building Inspector; require" a
plan to show the nature and character of. the work to be
performed.
Notice: Plans are normally required for fire suppression systems,
fire alarm systems, tank installations, and''Fire Cade '
+.' requirements.
Under the provisions of 22 of"the Massachusetts +
"r e' i State Build'
Code, certain iIding
..proposed projects may not require submission of plans or
complete" compliance with-new construction requirements. ' In these .
cases, provisions of Article 22, Appendix T, and 'Tables applicable `
shall apply. This section shall not, however, supersede the
provisions outlined in the Salem Fire Prevention 'Regulations Chapter
1A8; MGL, or 621 Code of.:Massachusetts Regulations. All permits, for
fire code use and/or occupancy�,shall '
. applyfcx- the.ent re,atructufor
fire alarm and/or smoke detector ,instsllat- shall apply -to the
entire structure based upon current requirements as per Laws and/or r
Codes, but the existing structure may comply with regulations . -
applicable. for existing. structures... - " -
Notice: Sub-contractors may also be required to file individual `
applications for a Fire Department Certificate .of Approval'
for toe area of' their work. Such sub-contractors shall file I
an Applleation `to Install, with the Fire Prevention Bureau 1
prior to commencing any work for those .areas applicable.
1Y
FORM #81 REV. 10/97
i� � �►/�/
qgm Commonest a o� /I f aseacai�3
� JJePcrfnaaala/9.d�,ir�f�«;�,�
sl
,IM"I Camood 02111
Cormrnstorw
Workers' Compensation Insurance Affidwpjt
1,
«1
. . with, principal plate of business at:
. . laela..r.ar
do hereby'cerzify under the pains and penalties of perjmye than
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
1 am a sole proprietor and have no one working for me in any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation polieks:
Contractor Insurance Company/Policy Number
Contractor Insurance Comparry/Faliq Number
Contractor Insurance Compasry/Policy Number
ly am a homeowner performing all the work myself.
I vneeruane wt a coot of"auaem m WE be forvarnd w tlu Once of M..sfn,ent of the DIA low eo.e*age vvA&csden ab mat wore m wcare
co•efav As reoureo under Section 2SA of MCL 15 2 can kad eo "inooacidn dl CrWr nar oe^a fin eoraaatint of a rive of tee =41.5=400 ably ON
rears'in,.oruonment W it as ei.i oaulew in the Iorrn of a $TOP WORK ORDER and a Err of S 100.00 a dsr ata:oa sK.
Signed this ., _
day of
"tuilcing Departrr.ent
eei'F tec
licensing E.oarc
Seieetmens Office
PUBLIC PROPERTY DEPARTMENT
120 W^smmaTON STREaT, aRD FLooR
SALaM,MA O t 970
TEL (978)743-9595 Err.380
FAX (676) 740-9646
STANLEY J. USOVICZ, JIL
MAYOR
DISPOSAL OF DEEM AFFIDAVIT
In accordance with the provisions of MGM c 40,534,I aclmowMedge that as a condition
of Building Permit 0_ .all delis resulting fiom the won activity
governed by, this Building Permit shall be disposed of in a pzopaly licam d soli&wsste
disPosal facility,a defined by MGL c SIM.
the debars will be disposed of at:
Location ofFacrlty
SrglmWm ofPamit AppHcaw d5
ate
FULLY complete the following kkmladm.
(PLEASE PRINT CLEARLY)
vt :2-- . Sm
Name ofP=kApplicant
Firm Nims.if ay
a'7 Ate—+y 'MA Oi97b
Addrok City&State
The above statute nequuu that debris fivm the demolition, renovation,rehab or other
alteration of balding or savcam be disposed in a popaly-licensed soli&waste disposal
facility as defined by M(X all,S150A,and the building permits or licenser are to
indicate the location of the facility.
Sc I Pm
I
kPPROVrn S�,Lt auo11
Subject to approval by ari
authorityha:ice^,jay=s�'diaic .
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APPROM S�a�/d oo�+
Subject to approval by SvY c'-
authorfti hm-im gj• _•' c _c3.
CITY of SAT
ly
TYFE AND LO !MOA Or' ` er
ALL FIRE 6 ROTFCTION -g
Pa,JALTEST AND INSPECTION,FOR ComrF FTE C'`"
AWE WITH THE FIRE CODE.
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