2-10 TRADERS WAY - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
� 4
Department of Public Safety
•'f� %: Massachusetts State Building Gwle(780 CNIR)
J
Building Permit Application for any Building other thamaOne-or Two-Family Dwelling
(This Seclion For Official Use Only)
Building Permit Number: ___ Date Applied: Building Official: .
SECr1ON 1:LOCATION(Please indicate Block p and Lot H for locations for which a street address is not available)
No •u l I;trc• ` y /It zip Code Name of Building;(if apPlic,lblc)i
t• SECTION 2: PROPOSED WORK
Wilion of NIA Slate Code used If Nett Construction check here❑or chock all that apple in the two ruo's b0ow
N�
Fxisling Building 5( Repair❑ Alteration Ur I Addition❑ 1 Demolition ❑ (Phase fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy Other ❑ Specify:_
Are building plans and/or construction dtwmnenls being supplied.ts part of this permit application? Yes No ❑
Is an Independent Structural Engineering Pee Review re Yes ❑ No 2(
Brief Description of Propose Work:
lop—
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION, ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CNIR 34) ❑
Existing Use Group(s): *A Proposed Use Group(s):
( SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.(If Flours/Stories(include btuentent levels)&Area Per Floor(sq.ft.) Oo0
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-I ❑ A-2❑ Nightclub ❑ A.3 A-4❑ A-5 Cl B: Business Rr E: Educational ❑
F: Facto F-I ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-4 ❑ H-4 ❑ 1-1-5 El
Institutional I-1 ❑ I-2❑ 1-3❑ 14 ❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe bell)%:
Special Use --
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ff IIIA ❑ IIIB ❑ IV ❑ 1 VA VIM ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Checkif outside Flood Zone d Indicate municipal
r1 trench will not be Licensed Disposal Site 5/
required Ed or trench or specify:______ -
Priyatc❑ or indenlify Zone: or un site s)Salem ❑
permit is enclosed ❑
Railroad right-of-wa Ilazards to Air Navigation: tit7' ),-s
u : phIs Sl nirlure tcilhin airport ap mrach ama? review i ontplewdor Con.enl to Build enclosed❑ Yes❑ or No(� ❑ No ❑ -
SE, fTON B:CONTENT OF CERTIFICATE OF OCCUPANCY
I[dition of Code: _ Lse Group(s). -- I%pe of Construction, _ --__.- On upanl Load per Floor _
Does the building contain •nt Sprinkler System?:A194...__Special stipulations: .----__—._-- --- -._ --- ---. ...
SECTION 9: PROPER1Y OWNER AUf11ORIZA'11ON
:Name and :\ddrrss of I'ropt-11% Ow nor
No L (I frill) —_ No.and Street City/Town "Lip
Proprrty 0%%ner Contact Information:
f�- 83- a15- 690- 3;9a CkI4,A
Title .I clephone No. (busif tss) Telephone No. (cell) c-mail-mail _
It.IppliCabIV, the propertc owner hercbN,authorizes
Name Street Address City/Town Slate Zip
to act on the properly owner's behalf, in all matters relative to work authorized by the; building permit application.'
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) `
If hi ildin p is less than bS,0W cu.ft.of enclosed s pace anJ ur not under Construction Control then check here 12(md skip Section 10.1)
1t1.1 Re istered Professional Responsible for Construction Control
603-?o - $137 pia • r, ,•. CS 7193i
Nam (�q,�y,p front) l'cl I me. o. •-mail a s Re pistnhon Number
Wgw'o,yee►ar, Ln je 03q b Zo
Street Address C /Town State Zip Discipline Exp' ation ale
10.2 General Contractor
-4 il fZv! _
r Compajw
I Name
I _
Name of Person Responsible fur ,struction License No. and Type if Applicable
ou �h Q:zvl
Street Address City/To n State Zip
Tole,hone No. business Telephone No. cell e-mail address
SECTION II,• ( i.)n114 V,A 11;IN I,u:_tJu.\.NCI Al L 11 ,VII M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this a p lication? Yes❑ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item EsItinwted Costs: (Labor o-m O
and Nlatcre Total Construction Cost(from Item 6)=$ 775'
1. Building $ -
Building Permit Fee=Total Construction Cost it (Insert here
'_. Elcctrird $ ace appropriate municipal factor)-5
t. Plumbing ; S d
I. Nlechanic it (HVAC). "5 S"Q ' Note: Nlinimwu fee=5 (cuulact municipality)
S. \lecholal Cosa
Other S�j Fndose check payable to
h.Tolnl Coll 5 Qlnnlact numicipality)and write check number here
SECr1ON'I'SIVIXTUREOF BUILDING PERMIT APPLICANT
By coloring my name below, 1 hereby altest;under the pains and penalties of perjury that all of the information contained in this
tpplication is true and accurate to the b 4, ( u I, uc ledge and understanding,
I'Irasr print and silo oat c Title Telephone o. Dale
- 1' _ VA-
tiI n•rt :\dd n'ss Cih' Town Slalc Zi,
Municipal Inspector to fill out this section upon application approval:
-- Nan Daly ----
CITY OF SALEM
(PUBLIC PROPRERTY
DEPARTMENT
i w:.e:l Y:ntlN, ll
rt
12:WA Na.\G I%^S1.4ftj'f Sdt t•.N, M.t11.14.111 vt t n51'17^.
Il•.I: r747ti'si'H s P,x v7s•NC•nMM
Wurkers' Cumpenaallon Insurunce %in4wsit: Builders/Contractors/Electrlclans/Plumbers
1,I)Iffleallf In urinallo PI a.� r) t Le 'hl
N:III1CIIluullevtit7rpanv.,linry lnJlvuluull: � � �.
�tltlresr: �� �GX �I..3 �p
Cily,.Starcr%ip llu1;^ O Phone0: (0(?3-75D - GYX7
Are you an essiWayer?Cheek the Approprlal s;
I1.❑ 1 and a cmpluyer with 4. IY.C+rnr a general contractor and I l SPe°/prujset(required):
e'Itpluyrt:»(full and/urpuratime).r /T have hired the+ub-contracture (r' []New cunxttucUun
2.❑ I ,on a sole prnprictor or partner• listed on the anaehcd.heat 7• Retntxlaling
.ship and have no empluyetm Tlicso subcontractors have S. arkmoliriun
,larking rim me in any capacity. ,vorken' comp, insurance.
I Na workers'sump. insurance 5, ❑ We are a corporation and its 9, ❑ BuiWing addition
requirud.) officersiavc usunisv'd their 10.❑Electrical repairs or additions
3.❑ I unl a holncuumer doing all work right Ofexempfion per hl(IL 11.0 Plumbing repairs or additions
inysclL(N'o wnrhers' comp. c. 152,11(4).and we haw ran 12.0 Reef repaira inxurancorequired.)I anpluycec Ii' worked'
comrk inxumncv rcquircd,j I)•Q Other
,rat,yq)IICYY MalCr:a:eYf IkY III mug slaw sill out11,Y oms Wass,IrNlwgiir,ro;;r•'wY,f;4IM,tM111Yl,lp pl,ticr udinnwlia�
'I IVrrMlwrwn'ho 1,Jlael this fdavll' dla"i"S Its"JIf Joins all work and mm hire"skis avanta sam mtu, Ir
serial
a eN a111atfY;1 Mll�l,;lla utak,
f rwa,n thfl ahrrk this bell mull ntaeltfe ran WJillu yl,r.I.,.huwins the„Opp ff the nik•t0/I1rie1JN alto IhfM serial 'etxnp,plltey mlurntanow
.ml
%wt
lam oil employer thus Ir preeidi'm learken'rernpenrrldeir lntanince for illy rsnp/oylrrf. Br/mv/s the puflay and/rr1 wile
initrrrnulAn4
Insurance C'untpaay Vame:, I,- •-�'1.�� �lll!
"EA3
Policy is
--c� (e n Enpirutlun Date: t — pZ0 i 7?
Job Site addresx: Als X- ?/ f(-Z g�� v�JlataGp: _ Mk ®` ( 7t:�
httueh n coyy Of the workers'tumpensutlnn policy Juclsretiun puke(showing the policy number and expiration date).
I allure to vccure coverage as required under Section 15A ul'.%tGL c. 132 tan lead to the imposition of criminal penelries Ora
tine up 6111 5110,00 anWur one-year imprixanmunt as well ax civil Innullius in,he lunn Ufa STOP WON K ORDER and a fine
,,(up ra S250.00 I Jay-:Iguinxt the vialalnr. Ile adviwd thul a copy of th
I e..lutclnnm may be ruMarJeJ to the Ullita of
n%c111 IPM,ul';hu DIA Ior imuaa'a .'overage ,a ilicahun.
/,/u herrAy t errifr ender I ,tin I pens/ ' U rlury shut the in/brrnu/ riled ubovv is bw and rorrert
I'I,n: •u
I17//1,its/it If only. pa nor n rife in dIb u • , Is,be cenly/eled by city ur rolYrr n//slut
I (!Ir ur fawn:
' — Ycnnial.Icvma 4
Itvuiny .tulhnrily (circle noel:
i I. Ih,arJ of IIva110 1. Ihuldrnq Ikpartulcnl I.(:ity,'1•o,tu Clerk J. Llacrrira) h,gsecrur i, pluu,biny lu,yecrar
ib. Illl,ce
( lit nun: t
- I'huae Y:
i .
Information and Instructions
r+o in the service of another un,lef any cuntmcl of hire.
\IJai•IChUSerls locnerJl laws chapter I J2 rcywres JII employers o provide wurken' wmpensau„^ for their employer
1'unu.rat to Jill$ +latuld, in rtnP1I Is delined Js"._every {>`
;,prtas or unplicJ, )JI or written." of Illytwo or more
urwership, 13sociatwo,corporation or other legal cnhry, er it the
\n cmplupef J, detincd as'•an individual, p to in vm loges$. However the
.,t ,he toragomg engaged m a joint enterprise, and including the legal representatives of a deceased cmP o of the
,ecetver or trustee of,n iodivi Mai, P More shoo three a lod of nu grid wr lggjhatresides therein,or 1h Occupant
owner of a dwelling{house having a Hans to ee maintenance,d*he coon or repair work on such dwelling hull"
Jvvclltng house of another who employ. lx
ar on the grounds or building appurtenant thereto shall not because of wch employment be JeemcJ to be+^employer."
�IGL chapter 152. 425C(6) also state$that",very sloe or local trustlicen buildings
agngs I shall withhold the Issuancefan or
renewal of a license or perrult to operate a busineu or to construct bal is the le the Insurance
coverage
ove wgelre fore .
applicant,wlro has not produced acceptable
71 sbJtesY'Neuher the onnnonw alth not any of its poll cat gsubdivisrons,hsll
\dJitionully, NIGL chupter IS?, 42 l
enter inn any contract I-or the perforrI of public work until acceptable evidence of contPliwue With the insurance
roquiremcnu of this chapter have been Presented to the contracting authority."
applicants checking the boxes applyto our situation and.if
PlcaIte gill out the workers' compensation affidavit campletelyhone out along with their caniAcutaU)of
necessary.supply sub-contractor(s)name(.$),addres$(es)jail p with no cmployuros other than the
insurance. Limited Liability Companies(LLC)or Limited Liability Pannenhigas(LLP)
insurance or partners•an not required w carry workers' ComPerwuian insurance. Iran LLC or LLP does have
employees,a policy is required Be advised that thi,�IS*be sure to jigs gad dale he aflidavill. Tile ltidavu'ttshould
\ecidenu for confirmation of imuranco coversge
s nt of
he reuumeJ to due city or town that the application for the pnnnit ar license f being requested, not the la w
Industrial to t1l sit Should you have any yuestioas regarding the law or if you ors required to obtain u workers'
compensation policy,Please call tha a any at
flu ruanber listed below. Self-insured companies should enter their
self•inSuri nee license number on the appro 11I line.
City or'rows Orriclals
The Department hw provided a spun at the bottom
the applicarlL
Ptca.c be .ore that the affidavit is complete :and printed legibly. applicants
Of the affidavit for you to till out in the event the OlTica of investigations his to contact you regaaddition, an rding
I'I:use be sure to till in the perrniuliceuse m o'b into in anwhich rgg gl be iven Year,das need onl reference
submit t one atfidavit indicating current
y y Y
hat must submit multiple necessary)
and tinder
' provided to the
policy'.
lie affidavit thathas been ofAc ally stomped or marrkedrbyit s III*City Or town11 st a fi each or
town). •\copy
of
as proof that a valid affidavit is on file for ti+rure Permit$tot of related
Anew atusinest must commercial tilled nut ntu
�nro slug IeI ho e p ne fro autrn leaves�e.)t ill P rs�us NOTtrequired of mplete this 41fldsvt venture
im or
1 he fi" ,ii luve,tigations would like to drank you in JJv:uscc for your cooperation and should you have.ray yuesuons,
plcuse do not hesitate to gtvc us a cJll.
fhu U;parnncnt ,aJdre+s, telephone aThe Cortunonweelth of Massaehusett
Depafanent of industrial Accident
OQlee of lavesdiladons
600 Washington Street
Boston, MA 02111
fel. p 617-727-4900 ext 406 or I.877-MASSAFE
Fax M 617-727.7749
4.'n.o s www.mass.gov/dist
sA— CITY OF Sm.E,Nt, NLUSACHUSETTS
BI:ILDLNG DMiRTtENT
120 W N.iICNNGTON STREET, Y"ROCK
TM (978) 745-959S
12AX(978) 140-9846
KIa®FRr RY D&WOLL THOMUST.PLBRrtB
MAYOR
DIRECTOR OF mauc PROPHRTY/BCIIDLNG CONWISSIONER
Construction Debris Disposal ACfldavit
(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 N is issued with the condition that the debris resulting from
this work shad be disposed of in a properly licensed waste disposal facility as defined by b1GL c
l 11, S 150A.
The debris will be transported by:
(nano ot'huutar)
The debris will be disposed of in
(name of facility)
/?aHXS7A•e— 00
(address of facility)
signature of pe i pplicant
date
i.Mn vlf Jew