4 SUMMIT AVE - BUILDING INSPECTION (2) nn
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",► The Commonwealth of Massachusetts
I Department of Public Safety
J .l %lassachosettS State Building Code(780 CMR)Seventh Edition
m��u✓Y
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION(Please indicate Block N and Lot M for locations for which a street address is not available)
:No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair palAlteration ❑ 1 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 4—
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 9—
Brief scriptiu of Proposed Work:
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 78 CCMR 3402.0) ❑ '
Existing Use Group(s): Proposed Use Group(s): p
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❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ 1 M: 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 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 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 indentifv Zone:_ or on site sastem ❑ required ❑or trench or,peciIv:
permit is unclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I:\ I lianri:c"iinunisian Iteci � Prnr,•s:
Not \pPhc,A,1e❑ I.Strucl,nr wuh in airport approach area.' Is their reciemv completed?
1 l ntt.ent to Build enclosed ❑ Yes❑ or.No❑ Yes ❑ Nn ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
DGdrtion of Code: L (�'.e roup(s): Tcpe of Construction: Occupant Lund per Fluor:
l ocs the huilding contain an Sprinkler S\stem?: Special Stipulations:
S+P Ln0 i0 Svrn,n r r S-4
SECTION 9: PROPERTY OWNER AUTHORIZATION .�
Nam e }i Address of Prop ,Owner
Name(Print)
Nu.and Street City/Town Lip
Properly O%%ner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to act on the ro pert%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,(Xw cu.ft of enclosed s ace and/or nut under Construction Contrul then check here❑end skip Section 10.1)
10.1 Registered Professional Res onsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town Slate Zip Discipline Expiration Date
10.2 General Contractor
Comps A,
Name a rsun Respo Construction ` ,// License No. and Type if A plicable
`�{rye ` /J City/Town State Zip
_ /1.1 /�� g/'� 35 Gib
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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minemum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ / GLG (G (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the penalties of perjury that all of the information contained in this
application is true and accurate best of my .nd understanding.
/llLCLf/ �
'Irp t an i i1i � � it�. � — � Telephone \ i �-
�yW/ /f� L
tihrr( Address
Ci"/Toi%n State Zip
,Municipal Inspector to fill out this section upon application approval:
a me Date
` CITY OF S.1I.&M, ,ANSSACHL:SETTS
BL ILDING DEPAR'TJILNT
120 WASHINGTON STREET, Y*FLOOR
TEL (978) 745-959S
FAX(971) 740-984
KIx(BE UEY DRISCOLL THomts ST.PmM
MAYOR
DIRECTOR OF PCBLIC PROPERTY/BL'QDLVG CONLNBSSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/ElectrlclanslPlumben
applicant Information Please Print LeaibiY
Vainc(Rusin 0rtanizsnon lnJsv,dwl):
Address:
City/Statc/Zip: o -- Phone/l:
Are you as employer'Check the appropriate box: Type of project(required):
I.�am a employer with 4. ❑ 1 am a general conowtot and 1 6. ❑New construction
employees(full and/or part-time)."' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached shceL : I. ❑Remodeling
,hip and have no employees Thew sub-contractors have 11. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
I No workers'comp. insurance S. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
3 ❑ I am a homeowner 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. f repairs
insurance required.]t employees. (No workers' 13. Other
comp.insurance required.]
•Any applicam that sitvelra 1101101 MUM alto fill rat the satins below rhawitq their warkm'ewtgensrdun policy mlilm ujio ,
'I I.nstest mess who suhetU this afllMk indicating they ars doing all work and then him ouetide contractions most sufana a now.afflds"indicating wale.
:C.wtnwton.hot cheek this bon mud anuiss d an aaditisod shut showing the tarn•otdw.uD.avmnelors and their wswom'comp.policy infarmmim,
l am oat employer that b providlnB workers'rompensadon lnaurea ce for my employees. Below/s the pollry and Job r/fe
- information.
Insurance Company Name: �b
Policy N or Self-ins. Lic. N: rC����3 Expiration Date: 40 / G
Jub Site Address: y �r"�//-- City/StatwWaip
Attack acopy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal 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 fine
of up to S250.00 a day against the violator. Ik advised[hats copy of this statement maybe forwarded to the OIPce of
Invesiigaiions ofthe MA for insurance coverage verification.
/do hereby crrlify dWIAins a nobles o of that information provided obeys is Iru end cotreeL
�I '1' I f p—� �•t-� 1)Uf i
C
iOfficial use only. Donor rvrile in this area,to be completed by city or town a icial
I
City or ruwn: Permit/l.IcenseN
•%suing.ttuthurily (circle une): —
1. Board of Ileulth 2. Building Department J.Cilylfown Clerk 4. Electrical lnspector 5. Plumbing Inspector
6.Other
t.oalAct Person: _ ._. __ Phone N:
y CITY OF SALEM
PUBLIC PROPRERTY
?' =',,p/ DEPARTMENT
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.I'.Ilt NI h 1 ! N Iw i'I 1
\I 1.10 A'.\il ll.\t1:ONSCHUT 0 SA I`\I, %IAii\t Ill
I e1:478-74 7iy5 ♦ I'.\Y:978-740-I)846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordwice with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit tf 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
I 11. S 150A.
The debris will be transported by: /
(name of hauler)
The debris will be disposed of in
I. (name of act ny)
(address of fact ny)
.ignalurc of permit applicant
date
Iahn•al(Cui
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Fax Server EDT 2/9/2010 8 : 33 : 24 AM PAGE 2/003 Fax Server
Client#: 1079742 02SPCLEANGUY
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