2 TRADERS WAY - BUILDING INSPECTION (5) -►�� ,-The Commonwealth of-Massachusetts,
17 I �• I, Department of Public Safety
\Iass,tchusells tittle Budding Code 0780 CJIR)Seventh Edition
+ j City of Salem
Buildirill Permit Application for any Building other than a I-or 2-Famil
(This Section For Official Use Only)
Building hermit Number: Wte Applied: Building Inspector:.
SECTION 1: LOCATION (Please indicate Block 0 and Lot 0 for locations for which a street address is not available)
a 'C� S^'*-A, "41 MOO Fbr1,s`ut`- Cog
Xo. and Slreal Cin• /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❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition 0 (Please fill out and submit Appendix 1)
r _ Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Peer Review requ ed? �I yes ❑ No
Brief Description of Pr used Work: �r�rNC't�r .¢�Q EIJ-r lJ+e+tit• ev-1
,KO OIV4r
17W I
tJ' u r?YA- vvtn.
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
`° T' 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): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
4—
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-I ❑ F2❑r� H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional (-1 ❑ 1.2 ❑ I-3❑ f4 ❑ M: Mercantilei9 R: Residential. R-1❑ R-2❑ R-3❑ R-4❑-
S: Storage SI ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a llcabie)
IA ❑ IB ❑ IIA ❑ IIB 111 1 II IA ❑ f11B ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION Irefer to 780 CMR 111.0 for details an each item)
..,,Water Supply:; r Trench Permit:•, Deb ris Removal:t
Flood Information: Sewage:Disposal:
Public❑ Check if outside Flood Zone Indicate municipal ❑ A trench will not be Licensed Di:pusal Site❑
reuired❑or trench or,pecifv:
I ovate® ormdcnliA Zone: ur un q
' ate sv,lem❑" permit is enclosed ❑ '
Railroadright-of-way: Hazards to Air Navigation: %1AIli,hgn,(oim ,i t.mIt,,t,+, Pn,v,
"Nol Apldic.:ble❑ I.Structure wnhut,nrpurt uppm.tch orra.+ Is their reeiew completed,
a'Crm,vnt to Budd rnclo,ed ❑ N'e,❑ or.No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Fdawo .,I C,(de: _ _ L,e 61mipi,i: rr prof Con,trucllon: Occupant Load per I lour
I La•,the buildutl;contain an Sprinkler tic,lem': ?poaal titlpulallons:
,
SECTION 9: PROPERTY OWNER AUTHORIZATION
y,1�pe and Address of Property Owner A
(��. 1 �
5n•,k��••1..
:Name(Print) No.and Street C itv/Town Zip
Vruvrl%UwnerCont ctlnfurmaliun:
W�
lam-• •�• 'a2� - - glane �a�Qrr.q�• C
Title Telephone No. (business) Telephone No. (cell) a-mats address
If pprcab1r. thep+nrperh owner he ebv authorizes
�ge\act: 1 \'s Cn, cot 2 54. }�la.-:•mil n... A on
Name Street Address City/Tupvn State Zip
to act on the pop pert%owner's behalf, in all matters relative to work authorized by this buildin• permit a +plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) ` • ' -
(If buildin•is less than 35,000 cu.ft.of enclosed s ace and/ur nut under C.nutruction Contrul then check here O and skip Svown 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Tel No. e-mail address Registration Number
Strut Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
V. 6-; /5
o an-(Namr: ( t`�
N turf`Plppnrwn Resy�m.ib for c}a�structiun License No. and Type if Applicable
VJ nGe[i 'r• `O.,COcdd4ilWo
reet Address City/Town State rp
6!6 - - (A-)'1 rn
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2SC(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 O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate mu icipal Factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ e Note:Minimum fee: (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ �1 O 1-w--z (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
B%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 knowledge and understanding.
fill oqr
Me p nl anp ;pgn nam� >� ritir Telephone No. Date
sheet :lddress Cit.%Town State Zip
Municipalppspector to fill out this section upon application approval: ' _
Name U.rie
i`
CITY OF S.U.E.`[y ANWs.-iCHusEl7s
EILMDLNG DEPART ENT
120 W.uNDIGTON STXM. r FLOOR
TEL (978)145.9595
F.tx(978) 7.149&W
Kj.%CqEAiEY DR)SCOLL INOAW ST.PIRt
MAYOII
DIRBCI'Oa or t1 aLIC PROKRTY/n'aDLrc coaanssto.%i ER
Workers' Compeasatloa (nsuraaee Aflldavits OuilderilContractort/EI@OrlclanslPlumpen
%nnllcsnt Informatlos Pleon Print Lealeht
�Ialntt Ieunae.rOrtarntanon,lndrrdual): V�r1'�'^ ��lck�S Vim'
Address:
City/Stateizip PMrW* (tjV,0 %,;o- 036�
,ire yoo ao ampleyer'Check the appropriate bees 'type of protest(requlred):
I.0 1 am a cmployde with 4• ❑ 1 are a general couneror and 1 6 Q Now construction
employtea(IWI and/or part-time)."' hove hired the stib.eorsractors
1.❑ 1 am a so&@ proprietor tw pa nrwA6 lined on the attached aheea t P. Q Remodeling
.hip and have no employee Thess ar►comracters haw e. Q Demolition
%working ror me in any capacity. worker'comp iruusaea. 9. Q Building addition
I No workers'comp insurance S. Q We art a corporation and id I O.Q Electrical repairs or additionsrcquiseL i onkes have ameciaed tMr
).❑ I am a homeowner doing all wort right of exemption par MGL t I.Q Plumbing repairs or additbro
myself.(No worker'camp c. IA 11(4)6 and we haw no 12.Q Roof mpoin
insurance required(t •mph LNG werbors' 1).❑Other
comp innttantat"ins&]
•nor+ryaor iti ceee4 has II nwra seer ne w iM rnria octet akreiy thafr woMA'mgateiM valfq indrrniarlea►
I6wamwnae who sub"AY ale6vis indiedq hay an dime as U"aw"hkomwamweem wKM mhnb a MIX,d devil 4wimdos M"
'ra<'.+ara+wa tint cMb Ain Im aiaa anrhre as aJAriwel.haa Aawky da raw leas aArenteOna aadl tlrk wwhaeng porky fehnadoa
I one an emrfoyor that bprov//Aeg ieerAers'eompnuedre/wemrwm fw aq ImV feyeea ddbw is t*WPanep ew4f]4 flan
infwmedo a
Inwrantce Company Name. [- Sol t b4
Policy e or Self ins. Lie.A* w LSo ?D 7 Expiration Date: 512 ala)—
JubSifeAddecss: .a �(e�S �J1t^ CityiStaWZip: <4X", MA OI�fk7
Attack a can of the warbon'compendides polity declaration pop(showing tkn Pelky modeling,sad espiranon date).
f ailura to secure coverage a required under Section 2JA of MOL e. 132 can led to the imposition arcriminat penalties are
fine up to S 1.500.00 and/or one-year imprisonmarK as well or civil penalties is did farm of a STOP WORK ORDER and a floe
,if up to 5230.00 a day ugainn the violator. Ile advitid that a cupy of this siatcmlom maybe forwarded to the Oates of
incc bit piuns of the MA for insurance coverage v-yillL ition.
/do hereby cat �Mjfr, A ins and peso/Nos elPerjury tAw/Ae infwmot/mr provided above is true and Cw►eea
Con I Uatet
P`n a• -mac) , a3b'3
OJJ&•id we anQi. Do noI wren is this tree,to 61.urny/ird 6y city w/eMm a//Icir{ �
City orruwn: PcrmiN.lcrnsee__.
/,suing.%uthuriiy(circle une)t
I. Ilu.rd of Ilrallk 1. Rwlding Department y. City/rows Clerk J. Electrical Impactor S. Plumbing tntpeelor
6.Other
l•.nlacl Pcrion: _ . _ .. Phone 0:
CITY OF SALEM
PUBLIC PROPRERTY
�• DEPARTMENT
I'.li: Mlfl "Mlv.'ll
Ilt:R.t.I II\L.�CI YrNlrr 0 S•\I I\I,11.\KN I II .I I,•.I'1 _
I'rt�'i't•7�}•r}v! �I'\!c:'Ns•1rS'1NM
Construction Debris Disposal Aflldavit
(rt.'yuired lur all demolition iurd renovatiun work)
In accordance with the sixth ctlrtton of the State building Cole, 780 CMR section 111.5
Debris,and the provisions of MGL c 40. S 54;
Dui Wing Permit p 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.
MP W�4�CQ
t name at'hauler)
The debris will be disposed of in
MA �
(n:unt ur aci uy
taallreN1111r I,.duyl
.Isnature ol'Iwrmit applicant
• �191a�,�
' liars
s
Massachusctts— Department of Public Safct'
Board of Building Rcr ulations and Stjjndards
Construction Supervisor License
License: cs s8237 _
Restricted.to: 00
ANTHONY M GAGLIARDI
492 COMMONWEALTH RD
WAYLAND, MA 01778 '
o--
�—.G_ Expiration: 6/1/2010 j
t'nnmisximer Trx: 27462