96 SWAMPSCOTT RD - BUILDING INSPECTION (18) The Commonwealth of Massachusetts
s i,jy Department of Public Safety
^�-+• Z .�ta.sachu>ett.State Building Cede(%80 CNIR)Seventh Edition
City of Salem
BuildingPermit Application for an Buildingother than a 1-or 2-Famil Dwellin
(This Section For Official Use Onlv)
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)
�G SWAeK 5 sAIe. 01`170
:No.and Street CiIY /Town Zip Code Name of Building(it applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repnir❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: ton. Sl t 6
Are building plans and/or construction documents being supplied as part of this permit application? Yes 8— No ❑
Is an Independent Structural EngineerinPeer Review required? r r Yes .� No ❑
t: � ZE
Brief Description of Proposed Work: Y drx-m T .t=_i x f irV c iE-f � 4,39L
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): 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.) 1
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 93-- F2❑ H: High Hazard H-1 ❑ H-2 ❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ I-4❑ 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 ❑ UA ❑ IIB ❑ IIIA ❑ f11B ❑ 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 V,� Check if outside Flood Zone ❑ Indicate municipal A trench will not be Licensed Disposal Site❑
Peimatt• ❑ or indentifv Zone:_ nr on'1 to system ❑ required Our trench or.pccity:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \L\ I li>h,nr('ummi��iun Ro:m� Pr,, :
\ol \PpliCable ❑ I.}trilctmnr�,ithin all p,nrt apprnadm area.' L, their rem iew Cnmplclud'
r C"m.cnt to Build enclosed ❑ Yus❑ nr.\'n❑ Yen ❑ \u ❑
SECTION 8: CONTENT OF CFRTIFICATE OF OCCUPANCY
F:dni�m .d Gai c: C.e Oroup(.): Fcpe.d Con.truCuon: l)ccupant Lund per flour
the budding;Conlaum an Sprinkler ti(.tem': tipecial Stipulations: .
• •
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name.Ind Address of Property Owner 6070
Name (Print) No.and Street
City/Town 8 Z4' I
Pro,erty Owner Contact Information:
' 78 -NY 1606 '?Of- T3 79
Title Telephone No. (business) Telephone No. (cell) e-mail address
((appliable, the property,%%tier herebv authorizes, A
7Prm c e; Dal e �/�{ U�03�
ae4i ?3 uxl(sy f{✓t1e
Name
r Street Address City/Town Slate Zip
to act on the property owner's behalf, in all matters relative to work authorized by this buildin 6 permit application
SECTION to:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,1A)0 cu. ft.of enilos,d space and/or not wider Qmntniction Contrul then check here O and ski,Section I0.1)
10.1 Registered Professional Res onsible for Construction Control p q
I,1e,7�w,J Aln q12.- -,5-5$Z U L'
Name(Re�istranp Telephone No. e-mail address Registration Number
1 d,yw [vow tk<,f7 ,ver 6 ont Ma 01 s-o
Street Address City/To n State Zip Discipline Expiration Date
10.2 General Contractor
Company Name: ! BU�eY
Name of Person Responsible for Cun_ ruction License No. and Type if Applicable
�4,cIA 0303�
Street Address City/Town State Zip
-�7_ S�Y(q Jkkp GnN� Aal_ Go.+,
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION it:WORKERS CONWhNSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6) _$
1. Building Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $$ Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13: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 accn rate to the best If my knowledge and understanding.
- Mks 17 I S-t`/� z
1/CV h
I'Irase print and sign name Title Telephony No. Dale
titncl Address City/Town Sta ip
%to ici pal Inspector to fill out this section upon application approval:
Na' e I ,tte
5
CITY OF SaU.E.`[, 2%L-kSSACHUSETTS
Bt IIDLNG DEPARTNIEI iT
' 120 WASHINGTON STREET, 320 FLOOR
TM (9718) 745-9595
FAX(978) 7.104S ib --
KIN
(gEgIEY DRISCOLL I?iob1AS ST.PI>FItRs
MAYOR
DIRECTOR OF PUBLIC PROPERTY/11VI DING CO%L%aSSIO.%'ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ala nllcant Information ^�— Please Print Legibly
Nalne (dusin 0rVni:ation,lndsvtdual):_'J /m CbyU s+�e.Cud Co.
Address: c5tS KJe_1(s u( JIM,( ,ems.
City/Stateizip. G'k, sJe�,, lift Phona M: qt>& 6 ,77 5/Y(y
Are you as employer'Cluck the appropriate box- Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor,and 1 6. ❑New construction
timc ,e have hired the ad)--contractorsem loyca(full and/or pan )
7.
2. I airs a soleproprietorar partner- listed on the attached sheet : ❑ Remodeling
ship and have no cmployccat These subcontractors have s. ❑Demolition
workingforme in an capacity. workers'comp.insurance.
Y P tY- 9. ❑building addition
[No workers comp. insurance S. ❑ We are a corporation and its I0.0 Electrical repairs or additions
r11 uired. officers have exercised their
1
right of exemption 11. Plumbing or i
3.❑ I am a homeowner doing all wont ISh Pt per MGL ❑ g repairs additions
myself.(No workers' comp. c. 132.§1(4),and we have no 12.❑ Ro9Frepairs
insurance required.) r :mployccs.(No workers' I1.�Other
comp.insurance required.)
'Any applitaN clue dWdM Iten al mitt alw fill UU1 Iha 141101011 below dtswisg their warkrs'ewttpenadon policy irrfomrllon
'I lo,neownen who subinis this affidavit indicating itio are doing all work and then him ounids o penscrr must suhmil s raw a111dwit indio its attek
:r.x~ara ilia than this has mwt anached an addiliwd Aser showing the—D(du auk-tonrrscwrs sad their worker,tamp.policy information.
I am an employer that b providlnb workers'conrparmadon Insurance jar my enrplayees Below Is the pa ley and fob site
injormruioa _/-
InsuranceCompany Name: �rtc �s �7SU✓� 4N�2
Policy N or Self-ins. Lic. N: Expiration Date:
lob Sire Address: �C_ QA 7n S co-fZ`- 2n� City/StaWZip: 511e, MA-
,%ttacb a copy of tbe workers'compeosatio a pollry declantba page(showing the policy number and expiration dab}
Failure to sceure coverage as required under Seclion 25A of MGL c. 132 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. lie advmod that a copy of this statement may be forwarded to the Office of
I avcsugat ions&of ilia DIA for insurance coverage vuilication
I do hereby c ijy a the 'A mad penalties ojperfurythat Ike injarmalloa provided 7urve is+rue wood coerDol : 6
Phone ri: -/7 ej i�, 1 g 7
i0fricial use Drily, 0o not write in this area,to be cuinpleted by city or town o1flrlai
I
City or ruwn: _ Permit/I.IcenseM___ _
hsuing Authority (circle one):
I. ISoard of IlrallA 2. Auildlng Department J.City/town Clerk 4. Electrical hnpector S. Plumbing 1n+peetor
6. Other
C,mijct Person: __. Phone N:
r.= .�`� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I U Ic 110 WAiI HNG IONS-1'N LET ♦SAI r\I,SlASSMA It it I'i:�14
978-743-7595 • FAX:978 74D-9846
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 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit i1 - - is issued 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
111. 5 150A.
The debris will be transported by:
(name of hauler)
The debris will disposed of in
tllb a
(address of facility)
I
signature of permit applicant
date
Jcbii:all'due
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