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8A TRADERS WAY - BUILDING INSPECTION C=+< 2-8 I `I The Commonwealth of Massachusetts . Department of Public Safety '+ 1 Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or'l'wo-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: Z q SECTION 1:LOCAT ION (Please indicate Block#and Lot#for locations for which a street ad is not available) S ot�a� SQineil Ml_4. (�r4�o-- --- �°HcrA'r No. and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑ or check all that apply in the two rows below NExisting Building ❑ Repair❑ Alteration Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupautcy ❑ Other ❑ Specify:_,-_ _ Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑ / Is an Independent Structural Fngineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: l Re^"a A4, Wa L '"', urb,% limi Vi F✓l ,x(N / 11P4J 3 x'I• '(�pN r FcI� "/ G.'c.�l _ 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 CMR 34) ❑ Exisli ng Use Grou p(s): 1` S9 Proposed Use Grou p(s): -9AK 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-2❑ Nightclub ❑ A-3 ❑ A-4 ❑ A-5❑ 1 B: Business E: Educational. ❑ F: Factory F-1 ❑ F2 ElH: High Hazard H-1. ❑ 1-I-2❑ 1-1-3 ❑ 1-1-40 1-1-5 ❑ I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4 ❑ M: Mercantile ❑ R: Residential Rd❑ R-2❑ R-3 ❑ R-4 ❑ S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use ❑ and please describe below: ' Special Use: SECTION 6:CONSTRUCTION TYPE (Check as applicable) IA ❑ 16 ❑ IIA ❑ IIB ❑ IIIA ❑ IHB ❑ IV ❑ VA ❑ VB ❑ SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Suppl 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 inden lily Z e: or on site system ❑ required Ell or trench or specify:permit is enclosed❑ Railroad right-of-wa Hazards to Air Navigation: 4L11-historic Cunuiu_siun Re,rcw Pnni•s�: Not Applicable Is Structure within airport ap ach area? Is their review comple e 7 or Consent to Build enclosed ❑ Yes❑ or No Yes ❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): 9-/ Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: 'yPs Special Stipulations: Rick Donnelly P.O. Box 591 Tel 781-246-9015 Wakefield, MA Fax 781-246-9045 01880 Cell 781-389-3721 DezljLJLV,.; dezineskcialties®earthl ink.net CITY OF & L.EM, NLkSSACHLSETTS BUMMING DEPARTM&NT • t p )30 WASHINGTON STREET, 3m FLOOR oaf TEL (978) 745-9595 F.AX(978) 740-9W KI\fBERLEY DRISCOLL MAYOR THo\us ST.NERRE DIRECTOR OF PCBLIC PROPERTY/BUILDNG CO\MaSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ihly Na[ne (Bu<im. Orsanization/Individual): bc:&2v' LLC. Address: ,S ueto Sptet.\. sT. City/State/Zip: 6jAVal ,td RA. 61556 Phone 4: 791 -dY6 " 90/S� Are you an employer? Check the appropriate bo �". "type of project(required): I N 1 am a employer with� 4. '`, 1 am a general contractor and 1 6. ©New construction employees(full and/or par-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7" emodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, workers' comp. insurance. g. pudding addition [No workers' comp. insurance 5. We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.[3 Roof repairs insurance required.] f employccs. [No workers' comp. insurance required.] 13.❑ Other •Any applicant dart checks box of mutt alw fill nut the section below showing their wokken'compensation policy information. 'I lnmeown,as who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new alridavit indicting such. :Coramcton that check this box most attached an additional sheet showing the name of the sub-contractors and their woken'cc mp.policy information. 1 am art employer that is providing workers'cotxpeasaflon insurance for my employees. Below is the policy and Jab site information. Insurance Company Name: de—c& / 4 Policy a orSelf ins, Lie, N: G/GQ 00Lsa/977 Expiration Date:_ 3'l�— 16 Job Site Address: S k rnr oltw- (1)/k / City/State/Zip: SiALent mA 01410 r Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. /do hereby eertify�-- L%under �tthhee�pains and penalties ofperjury that the iaformadan provided above is true and correct. Sieniltitre: (2 A Datc Phone.Y: 01TIcial use only. Do nor write in this area to be completed by city or town oj)irlal City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.01her SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) 6 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 /7A 7waaH,' i r i rfi�0aa t AurL Cfle/as� N4• oo Lame Street Address City/Town State Zip to act o❑ the pro ert.owner's behalf, in all.matters relative to work authorized by this bnildin ermit a lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) --(If buildinL is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section'10.1) 10.1 Registered Professional Responsible for Construction Control &;V S le& W`C- 130- 3310 Tee� ,foul Name(Re Is rant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor eiiiii Merin\('e5 L(L CM n-t NU b3.2 Company Name t Z-( S-I 'FIrA4 Dawell j CS . o563N� Name of Person Responsible for Construction License No. and Type if Applicable —�D� IUP,U SQIYd1 3T &)4K' dg101 _Im 01&90 Street Address City/Town State Zip 721 -0?y,6- lw W1 - "f - 37a1 Q 0jN1f464 aYi Telephone No-(business) Telephone No. cell a-mail address SECTION 11:FVORP9i1 Y COMPENSATION um;LIRANCE 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 milli 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? YesA-'Nc, ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ td. 1. BLlilding $ Building Permit pee='Total Construction Cost x (Insert here 2. Flectrical $ appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (I-TVAC) $ Note: Nlunnmm fee=$ (contact municipality) 5. Mechanical (Other) $ C7 Enclose check payable to 6. Total Cos $ 8C00 (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 accurate to the best of my larowledge and understanding. 1icALAwA e l./ �,i.I/1/ Please print and sign name Title Telephone No. Date s�. tfJal FW MA A 14 oho Street Address City/Town State Zip Municipal Inspector to fill out this section upon.application approval: Name Date w\u- -P\C v� . CITY OF SAL.F.M. Nb SSACHUSE-M N' BL: .DI\G DEPAR'I1IENT 120 _0 WASHNGTON STREET, 3° FLOOR TE1- (978) 745-9595 FAX(978) 740-9846 KI.NtBERL.EY DRISCOLL MAYOR THows ST.PwAiLE DIRECTOR OF PLBLIC PROPERTY/BCII.DING CONWISSIO iER 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 ofMGL c 40, S 54; Building Permit # 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 111, S 150A. The debris will be transported by: HMUJ &z. iXX32 sez.,' o (name of hauler) The debris will be disposed of in : (name of facility) 030% (address of facility) I `a Oh signature of per it a licant o/ /8 / date dcbri.tH.do Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submit d Incomplete Not Required 1 Architectural 2 Poundati.on X 3 Structural 4 Fire Supnnession 5 Fire Alarm may require repeaters) X 6 HVAC 7 Electrical r/ 8 plumbing include local connections 9 Gas Natural,prepare,Medical or other 10 Surveyed Site Plan Utilities, Wetland,etc. 11 Specifications x 12 Structural Peer Review 13 Structural Tests&Inspections Program _1.4 Fire Protection Narrative Report X 15 Existinn Building Survey/In vesti.ati on 16 F ner v Conservation Report 1.7 rchitectwal Access Review(521 CMR 18 orkers Com sensation Insurance 19 Hazardous Material Miti ation Documentation )e 20 Other(Specify) 21 Other(Specify) F _22 Other(Specify) 'Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein. Work so identified must not he commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the orriginal permit fee. Registered Professional Contact Information / -�J �/ O a3YO V a �AIZGNir 7 .Coe'I Regi�Otion mber Name egistrant) Telephone No. e-mail address ___, ?'"SO-6__._LMJAJ -, AbzTaaJ NA 01f1YM��. ro 31-/4— Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Name(Rem shunt) Telephone No, e-mail address Registration Number Discipline Expiration Date Street Address Citv/Town State Zi Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8ah edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Comcast renovation Date:02-10-2016 Property Address: 8A Traders Way- Salem,MA 01970 Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: Minor interior renovation to construct storage:area. I Gary J. Sadler MA Registration Number: 20054 Expiration date: 06-31-2016,am a registered design professional, and I have pr irectly supervised the preparation of all design plans,computations and.specifications concerning': X Architect ral Structural Mechanical Fi otection Electrical Other: for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. B RED RP 4 Enter in the space to the right a"wet"or rv� Qy .3. SAG�T�� electronic signature and seal: 0 nl f o. 2oo�a 1;317 =� ATTLI:SORO, O Mwss. Phone number: 1-774-430-3390 Email: garys@55iupland.com o -j� Building Official Use Only Building Official Name: Permit No.: Date: _ Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If'other'is chosen, provide a description. Version 06 11 2013