23 SUMMER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Department of Public Safety
�`�w,,.,✓' %Iassach U.ettS State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(� (This Section For Official Use Onlv)
Building Permit Number: Date Applied: 1'7�ll,o9 I Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for I cations for which a street address is not available)
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No.and Street City /Town. Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
xIf New Construction check here❑or check all that apply in the two rows below
Existing Building IV Repair❑ 1 Alteration Cl Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 91"
J� Is an Independent Structural Engineering Peer Review required? Yes ❑ No IL
Brief Description of Proposed Work:
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SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): S
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5 ❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 14 ❑ M: Mercantile❑ R: Residential R-i❑ R- 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 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VBA
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:
FF Y•
Public❑ Check if outside Flood Zone ❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site ❑
required ❑or trench or specify:
Private El or indentifv Zone: or on site system ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: %1 A I Ii,t,m, Gvnmin,iim Pr nc..:
\ut Applicable ❑ Is titrudure within airport approach area? Is their rem ie,c cumpl led?
ur C iinsenfto Build encored ❑' Yes❑ or No❑ Yes❑ No
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: L'se Gwup(s): Type of Construction: Occupant Load per Fluor:
Doc, the building amtain an Sprinkler Svsh•m?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION -✓
:'dame and Address of Propertv Owner
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
Name Street Address City/Town State Zip
to act on the pry perty opener's behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed s pace and/or not under Construction Control then check here O and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
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Nome (Registrant) Telephone No. e-mail address •-AO Registration Number
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Street Address City/T iz s
own State Zip Discipline Expiration Date
10.2 General Contractor
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Cgmpany Name: (S( - IDoZ 3a 9
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l� Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c.152.§ 25C(6))
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 tS No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ %S 4D Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAQ $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ S gM, � (contact municipality)and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest tinder 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.
F5 E. a 7 9
Please print and sign name Title Telephone No. Date
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Street Address City/Tovtin to Zip
Municipal Inspector to fill out this section upon application approval: s/7f0
/ Name Da e
CITY OF S.II.&M NL-1SSACHUSETTS
• BcaDLNG DEPARMEINT
120 WASHINGTON STREET, lro FLOOR
TE1_ (978) 745-9595
FAX(978) 7449846
KI,BFR2 FY DRiSCOLL
MAYOR THO&W ST.PEERAS
DIRECTOR OF PL OLIC PROPERTY/11MDLNG CO%L%BSSIONER
Workers' Compensation Insurance Affidavit: Duilders/Contractors/Electr(cians[Plumbers
Anplicant Information Please Print Leaiblr
Naine IBusimw Or;.trttzariotulnbv1dua1): 16A43-n L)t'J7t)tV Address: .29 (,02L AJ LPr (S7. SOUL /G
City/State/Zip: ' 454600 T ei 9w Phone S3Z-
.%re you as employer'Cheek the appropriate box: Type of project(required):
1.L9 i am a employer with 4. ❑ 1 am a general contractor and I
employees(full and/or part-time).• have hired the subcontractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7. ❑ Remodeling
:hip and have no employees Them sub-contractors have V. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
1 No workers' comp. insurance S. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑Electrical repairs or additions
J.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152.91(4),and we have no 12.❑ Roof repairs
insurance required.It employees. [No workers, 13,[i]'Other [hLo�4.Q.tJ1
comp. insurance required.)
-Any Applicant run drab boa 11 mum alwr rill out the section hcltwe showing their worked'compensation policy mr nonaac.
'I l mw,wnam who suborn i this affidavit indicating they are doing all work and then him outside contractors mast cuhmit a nnw ilndavit indicating noel.
T.mnrs9nn than•heck this box mud anachd an additic d dtaal showing the name or rbe mA coerwooss and their woken'cane.policy inrormati a.
I am an employer that&providing rvorkers'comptnsadon Insareace for my relplayms, Bdow/i rho poNq+and Job alp
information.
Insurance Company Name: yV*AQ IMeS�iJlDl RnIC
Policy Nor Self-ins. Lic. N: Expiration Date: zo/0
Job SiteAddrem23 1rumao� sr, City/State/Zip: 1,91664 met 0-9;;0
,kttacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration dabs
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
nine 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 rind
of up to 5230.00 a day against the violator. Ile advimd that a copy of this statement maybe forwarded to the Office of
Invcsugatiuna of llte DIA far insurance coverage verification.
I do hereby c erri/y under tha pains and penalties of per/aay that rho informadvor provided above is rrae and carnet
�n�n;uure: I)utc:
Phone 4
iOfrial sae only. Do nor write in this area, fa be canrpieted by city or fawn u/Jkiai
i city or ruwn:
_- __ Pcrmit/LlcenseN__
1%suing.\uthurily (circle unc): j
I. ltwrd of lleallh 2. Ruilding Department J. City/town Clerk 4. Electrical Inspector 5. Plumbing Imptetor
6. Other
l."ntlact Person: _ -_, _-. Phone 0:
" CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
III ' •e-V� 'I�'� � I \� 'i•3 'J: "i L,
Construction Debris Disposal .affidavit
(ICIInIted Ior all demolition and \Volk)
In accordance %%ith the sixth edition of the State Building Code, 780 CAIR sccuon 1 11.5
Dcbris, and the provisions uf'IvIGL c 40, S 54;
Building Permit it is iSSUcd with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will he transported by:
(name of hauler)
I he debris will be disposed of in
t name of I'aa rty)
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