56 TREMONT ST - BUILDING INSPECTION �4
c
"PermitNumber
The Commonwealth of Massachusetts
Department of Public Safety
BuildingCode(780C\IR)Seventh Edition
City of Salem
Permit A lication for an Buildin other than a 1- or 2-Famil Dwellin
(This Section Fur Official Use v).
Date Applied: Build4 inspector:'
SECTION 1: LOCATION (Please indicate Block F and Lot N for local or a WGIt6dOWs is l"ilable)
5Yv "7'LENt e>yT— s"
No. and Street City /To%%n 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 Repair❑ Alteration K Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑. 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ No�
Brief Description of Proposed Work:
� r
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
WFloors/Storiesrs/Stories(include basement levels)&Area Per Floor(sq. ft.)
(sq. ft.)and Total Height(ft.)SECTION 5:USE GROUP(Check as applicable)
ly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
nal I-1 ❑ 1-2 ❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R- R-3❑ R-4S-1 ❑ S-2 ❑ - U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ JIB IIIA ❑ IIIB ❑ IV VA V
SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Infomaation: S=��stem
Trench Permit: Debris Removal:
Public❑ Check if Outside Flood Zone ❑ InA trench will not be Licensed Dispo al Site❑
PI1c,Ite❑ or indentilc Zone' nrequired ❑or trench ur.,peclk:
Permit is enclosed ❑ _
Railroad right-of-way: Hazards to Air.Navigation: \l:\ IIi,I��rfal Rrnr•, I'n",,.:
\u[ :\pl+hi.tb C❑ I.of picture acuhua airport approach,rrc•a' I, [heir reN C%, completed'
„r l „ri.Cnl [o BUlld encln,ed ❑ Ye, ❑ or No 0—
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I ll'i n oI C�Ri C: Lie Gnn�pt,): fcpeof Con�[rUcuon: llccupanl LOad per Floor:
PIK" the huildin};umtaua an Sprinkler s%,tcm.': Special Stipulations:
f)
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name.and Addre.. of Property 01 ' e
Name(Print)
. and Street City/Town Lip
Propertv Ov.ner Contact InkWmation:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, thr property o%%ner hereby authorizes'
Name Street Address City/Town State Zip
to act on the pro perty owner's behalf, in all matters relative hi work authorized by this building permit a >plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It buildin•is less than 35,000 eu ft.of enclosed space and/or not under Construction Control then check here❑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 Expimlion Date
10.2 General Contractor
XNa��of Peyyjn^RKsuslnsi 1tCu�) nstructiun �� o. and Type i A plicable/9Y/
Street Address �C /! City/Town State Zip O
97?-7,/) Irmo ----
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE 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 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
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 $
4. Mechanical (HVA
X C) .` Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost S (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 knowledge and understanding.
and .ign na r ^ , , Title elephh
pri it . '0 yt ,
?treet Address - Cita'i Town . to to Lip
Municipal Inspector to fill out this section upon application approval:
Name I)al
CITY OF S.U.EM, , LxSSACHL-SETTS
13L'DDLNG DEPARTIJUNT
I'_OWASHINGTONSTR,EET )eO•FLOOR,
TEL (978) 745.959S
F.Vt(978) 740-984
KL.,,®EjtLEY DRISCOLL
MAYOR DIRECTOR,
ST.PfFJuts
DIRECTOR,OF PL BLIC PROPEATY/BCDDLNG CO%LVQSSIONF1
Workers' Compensation Insurance Affidavit: Builders/Contractor/Electriclans/Ptumbe►s
_%Ianlicant Information ' Please Print Letliblr
Nattle (Busin� Ortanituiomindavtdual): � 401/ 1k.E ( 1C QAZ A65
Address: .'S6 �ernE40 tr s,r nQ
City/Statezip., r X-A Phone
%,r�e,you a■employer!Cheek;the appropriate bolt: Type of project(required):I.L✓J l am a employer with co2 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or pan-tines)." have hired the sdscorursctors
2.0 lain a sole proprietor et or partner- listed on the attached she 7. Remodeling
,hip and have no employees - These sub-contractors have 5. 0 Demolition
workingfor me in any capacity. workers'comp.insurance
P tY• 9. 0 Building addition
[No workers'comp. insurance S. 0 We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.0 l am a homeowner doing all work right of exanption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees.LNG workers'
comp. insurance requited.] I3.❑Other
-Any applicant that dtoctts boa el mug aim fin ted the sectien below showing their workaa'c panaudxl policy infurmallaa
'I I.rtwuwrare who subinit this an chroit indicating they ant doing all work and then hire ataefde caetnctote trout s thmil a new aMdovil indicating awk,
:C,mtrsYon that cheek the boa mutt alrachtad an=kbiiaaal sown showing tti n of dW Albewatrnd"and their wurkees'camp.policy infafanaYen.
l am as employer that b providing workers'comprrssadon/nsareace for my employees, Qelew/s the polley and/oh slM
information. ,,� ./
Insurance Company Name: ON� b lC co/Y /�,,�, �n�fp
Policy 4 or Self-ins. Lic.a: Expiration Date: tf's�� 2947L/O2,I/(l 7
Job Site Address: � J/ AAQNr Sr City/Staucizip. y71L.6k1. L4
,%ttack■copy of(be workers'compensation po0cy declsnlbe pap(showing the policy number and expiration date)6
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 S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tad
Of up to 5250,00 a day against the violator. Ile advi*ed that a copy of this statement maybe forwarded to the OtBce of
Jnvesugauona of the DIA ror Insurance coverage verification.
/da hereby certify u I r rhr viats un4 penulder of pa/atry that the inforararlort provided ve is true and corrtd
P'•ur
01rhiul use only. Da not writer this arer, to be,utnpleted by city or town o/f c-i nl
i
City or ruwn: _ _ . eermit/Llcense
hsuinr.\uthurily (circle one): i
I. Huard of Ilvallh 2. 9uilding Department I Glytrown Clerk 4. Electrical hsspector 5. Plumbing tn.peetor
6. Other
Vernon:__ ._ .. Phones: —
a
' CITY OF SALEM
PUBLIC: PROPRERTY
J.,.,.. DEPARTMENT
1:. \1 %Lill r 11\II V. \I\••\I
Construction Debris Disposal Allidm it
(I%Aluircd I6r all demolition and Irnucatlun work)
In accordance \%ith the sixth edition ul'thc Slate Building Code, 780 C•MR section 111.5
Debris, and the provisions of MG c 40. S 54;
Building Permit 0 is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I1I. S 150A.
The debris will be transported by:
N zgX/Z CMsT�c_
Inane of ha0er)
I he debris will be disposed ofin
lname u!Iaclhly)
A
I.uldlcw ur l�whrV)
a • alm[ of p:nnn al pll\unl
�T lar: