28 TREMONT ST - BUILDING INSPECTION 2-7
RECEIVE
ldlonwealth of Massachusetts
4 Department of Public Safety
1015 MAR I b A IW-i4Susells State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Famil Dwelling
(This Section For Official Use Only)
Building Permit Number: D;Oe Applied: Buildung Official:
SECTION 1:LOCATION(Please indicate Block k and Lot N for locations for which a street address is not available)
7AF6WC)/V7-Si. IV-4
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
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition 0 (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: L34z—A0i-047r4'
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Q '
Is an Independent Structural Engineering Peer Review required? Yes ❑ No p�
Brief Description of Proposed Work: K2srzD 06_r �1r/$771/�' RASah�dlfl'rf O✓I
3� �1Xje-
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) ❑
Existing Use Group(s): Proposed Use Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(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 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazud H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ RBI❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe belo%v:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
I.\ ❑ 180 11A13 IIB ❑ F IIIA ❑ IIIB ❑ I IV 1 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❑ hxlicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way; llazards to Air Navigation: \I\I lief nnnni,5 n I •r,I o..is<:
Not Applicable❑ Is Structure within airport approach area? Is their review aanpleteJ?
or Consent to Build enclosed❑ I Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition ut Code: Use Group(s): Type of Construction:, Occupant Load per Flour: _
Dues the building contain.nt Sprinkler System?: _ Special Slipulatiolm _____
,f
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner �
JnNnt &t 011 /F orth A27A11l0 `JGy _
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) a-nnad address
If�a�jpJplicable,the property owner hereby authorizes
,y/cA2/o AN (✓ /, /o 461K r-e—
S•� S/YLE�iv Ay79 O/`Y'7a—
Name Street Address City/Town State Zip
to act on the property 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 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
/1 7 64.,z,o /H (�✓n
Company Name
��cAK�O M �✓nLic�
Name of Person Responsible for Construction License No. and Type if Applicable
/0 4"94*vL SA' S.r.E�. A91 O/c/70�
Street Address City/Town State Zip
918-�4 -j-S-/o r _= if
Telephone No. business Telephone No. cell a-mail address
SECTION 11:WORKEI:S'CC1NIPhNSAI ION INSURANCE AFFIDAVII' 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 it signed Affidavit submitted with this application? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) 'focal Construction Cost(from Item b)_$
L Building $ �OOd> Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ �C)a appropriate municipal factor)_
5. Plumbing $ S Jv
.1. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other Enclose check payable to
6.Total Cost $ d D0 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereb r attest user-the pains and penalties of perjury that all of the information contained in this
flici.tionis true and Decorate t��e best--(my ny kn'n edge and understanding.
(0 VAyIf
PleasDe pr'nt and sign panne Title Telephone No. Date
% �vv Gle�ri e �% Se �i� fXA D/Ofl�
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
�F
w. L
QTY OF SALEM, MASSACHUSETTS
f�-
Rl� BUILDINGDEPARTMENT
120 WASHNGTON STREET,YD FLOOR
r;scx`' TEL. (978) 745-9595
FAx(978) 740-9846
KIIvIBEF,LEY DRISCOLL
MAYOR THOMAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMbIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 3 S \
Job Location
Home Owner Address / L / 1�yd��Z1//2�� T6G � ��i✓ )/�l • �?/�} Q/9�U
Present Mailing Address /)- �7/Z r�i/iG(h' / q , /L//} d11(p0
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and.
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE CC��U
APPROVAL OF BUILDING INSP' TOR
Y
;• -0 CITY OF SAIL.EM, itiWS:kCHl;SEITS
13ULMLNIG DEPARTMEINT
120 WASHNGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740.9846
K .%IBERL.EY DRISCOLL
t:bL�YOR THoaus ST.PIERm
DIRECTDR OF PUBLIC PROPERTY/BUILDING CONNISSIONER
1Vorkcis' Compensation Insurance Affidavit: Builders/Contractors/Electr(cians/Plumher$
Applicant Information /j Please Print Legibly
Va111C InmittessOrganimtian'Individual): -_. /7//9�i`r7 �. / v�I LjaL
Address:
Cily/State/Zip: S'� i . //IA di 9�d Phone N: ' 7r-7L/ i/- 2, -iO
Are you can employer?Check the appropriate box:
Type of project(required):
LEI 1 am a employer with 4, 0 1 am a general contractor and 1
emplo sex(full and/or part-lime)., have hired the subcontractors 6' ❑Now construction
2. am a sole proprietor or partner. listed on the attached sheet.1 ?. ❑Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working*for me in any capacity. workers'camp.insurance. 1. Building addition
(No workers'comp. insurance 5. 0 We are a corporation and u
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No worker:'comp. C. 152, §1(4),and we have no 12.0 Roorrcpairs
insurance required.) t employees.(No workers' j3.❑Other
cutup.insurance requin:d.J
•Any opplicmn duet chscka bar el mwt also fill out the ssttian below showing their waders'compin toolm policy bdunnialon.
'I hunuuwn r who mbntil this aOlthvit indicating they arc doing all work and then biro oupide contractors most ntbm;l a new allldavil indicating such
:t'mumctum that ch vk thin box mtat attached on addidurul shot showing the nm nt of the sub-camractors and their workers'comp.policy infomwtie".
f arse on enrplayer iliat it providing workers'canpettradan insnraneeJar my employers. Below is rho policy and job rite
lttjararation.
Insurance Company Name:
Policy a or Sclf-ins. Lis it: Expiration Date:
Job Site Address: cu>? Sr City/State/Zip; D/ 6
A llach a copy of the nvorkers'compensation pulley declaration page(showing the policy number and expiratlan data).
Failure to sacurc coverage as required under Scclion 2JA oo IGL c. 152 an lead to the imposition of criminal penalties of a
tine up to S1,500.00 und/or one-year imprismmment,as well as civil penalties in the form of a STOP WORK ORDER and d fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be furwarded to the Ohice of
htvesligaio is al'ihe DIA for insurance coverage verification.
1 do hereby ee d mrder the puLu and pen c.ue tjary that die injorntadart provided above is true and carrec•L
� ,• Data
Phone A' `j'1 -7tiiy 7-�!�
Dfl&'%al Yae artly. Do not wtite he thin area,to be completed by city or talon o/priat
CirynrTown: - -- -- Permitl.Iconseq_-'.-.---. .._---.
Issuiag Aulhurily(circle one):
1. hoard of lleallh 2. Iuilding Dcpartntvnt .i.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector I
6. Other
Contact Perron: