23 TURNER - BUILDING INSPECTION �t li3- I � - 135C�
The Commonwealth of M SERVICES
Department of Public Safety
t " A1assachusetl5StateBuildin Code QQ���j /Q� (�
Building Permit Application for any Building other than�O��r�wo-fa I Ily Dwelling
(This Section For Official Use Only)
Budding Permit Number: Date Applied: Building official: S I
SECTION 1:LOCATION(Please indicate Block k and Lot M for locations for which a street address is not available)
No.and Street CityTown
/ Zip Code Name of Budding(if applicable)
SECTION2 PROPOSED WORK
Edition of MA,State Code used_ If New Construction check here❑or check all that apply I inthe two rows below
Existing BuilJing❑ Repair❑ r\Iteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construdima documents being supplied as part of this permit application? Yes ❑ No ❑
Is an IndependemStructuml Engineering Peer Review required? .
Brief Description of Proposed Work: Yes ❑ No O
D` U
92
SECTION 3.,COhIPLETETt1iS SECTION 1F 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) ❑ i
Existing Use Group(s): Proposal Use Group(s):
SECI'ION4:BUILDINGHEICHTANDAREA
Existing Proposed
No.of Floors/Stories(include biasement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a livable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4 0 A-5❑ B: Business ❑
F: Facto F-I❑ F2❑ E: Educational ❑
If: High Huard H-1❑ H-2❑ H-3 ❑ - H-{❑ H-5❑
1: Institutional Fl❑ I-2❑ 1-3❑ 1-{❑ M; Mercantile❑ R: Residential R-10 R-2❑ R-
S: Storage S-t ❑ S-2❑ 3❑ R-0❑
U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a livable)
[A ❑ IB ❑ IIA ❑ IIB ❑ IIIAO 11111 ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 ChIR 111.0 for details on each item)
Water Supply: 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 indentify Zone: or on site system❑ required❑or trench or Spcv:ify:
permit�s enclosed❑
Railroad right-of-way; Ilazards to Air Navigation: %A,\_I lick rn .nunisum It u l'r ;
Not Applicable ClIs Structure within airport approach area? Is their review completed?q, y;
or Consent to Build enclosed❑ Yes❑ or No❑
Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use GrouP(s) Type of Cunetnicthm. Occupant Load per Floor:
Does file building,contain an Sprinkler System?:__ Special Stipulations:
G�vt �
O� 8E ►b3% Z�; N12r►t �1,11jr
sir elz�') Mn���zl1y,
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner 7, -4 1
/ ortiel- SC//sue
Name(Py nt) No.and Street City/Town Zip
Proper--ItyI Owner Contact Information: ——
title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable, the property owner hereby authorizes
Nane Street Address Cfty/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than35,000 cu.R.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
Name(Registrant) Telephone No. e-mail address - Registration Number
r Street Address _ City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
Comp y,Name
me of Permm esponsible or Construction L' ense No. and Type if Applicable
Street Address City/Town State Zip
� �a7 I LZ 7-1LL?6-&?3 9 (1 S 7TGJl 5 / i e�DPyl ht
Telephone No. business Telephone No. cell e-mail address
SECTION 11:4VORKF:R.S'CONIPENSAIION INSURAN(T AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents most 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[3 No ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE -
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding $ Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3. Plumbing $.
d. btechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ j'QQ,�'(j (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.
Please prom and sign name Title Telephone No. Date
Street Address City/Town I State Zip
Municipal Inspector to fill out this section upon application approval l '� )
��..// Name Date
CITY OF S:\I.ENI, IWSACHUSETTS
Y
1 \ BUILDING DEPARTSIE.VT
120 WASHLNGTON STREET, 3tn FLOOR
TEL (978) 745-9595
RmX(978) 740-9846 i
KIMBERL.EY DRISCOLL
"k—kYOR T HoNw ST.PIFURI
DIRECTOR OF Punic PROPERTY/BD¢.DIVG CO\LUISStONER
1,Vurlcers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluno her$
A i alicant information Please Print Le ibl
V;IITIC(nusiuess,Organirarinn,lndividualh _' O'ti •L Y�
Address:
Cily/State/Zip:_M, a(a 11,0t,61 Phone #:_ `7 e151(
Are you un employer'!Check the appropriate box:
- -- 'type of project(required):
I.(] 1 am a employer with 4. 0 I am a general contractor and 1 6. ❑New construction
iplayms(full and/or part-time).' have hired the sub-commutorx
2 I ran a sole proprietor car partner- listed on the attached slice,. I 7. ❑Remodeling
,hip and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'camp.insurance. ), Building addition
[No workers''comp. insurance 5. 0 We are a corporation mid its
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 workers'camp. C. 152, §1(4),and we have no 12.*Roof repairs
insurunce requircd.) f employees. (No workers' 13.❑Other
cuntp. insurance required,J
•Any oppliemt mar checks boa/I most also rill out the%ccoun below showing their workers'cumpensmtun policy intiarrnation.
'I L.muuwwn who,uhmit this stildnvit indicating they arc doing all work and then hire outside cantmctorx mml$,,limit a new all!davil indicating such.
('aunmuun Out Owk this box mtul mtachal in uWiliurml,hul showing uu name of the sub4aniracton and Their worker,'camp.policy i,oc mmum.
/one can rurpluyer deaf h pruvidlnx workers'cumputsatlun inxurmrce jot my enrpluyrrs. Qeluly is the polfcy and Job site
inforaeaNan.
Insurance Company
Policy it or Self-ins. Lic, 0: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failuru to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition orcriminal penalties of a
line up to S1,500,00 und/or one-year imprisonment, as well as civil penalties in(he form ofa STOP WORK ORDER and aline
orup to S230.00 a day against the violator. Ile advised that a copy of this statement may be furwirdcd to site Ol'licc of
6tvestigmiun.r nl'Ihc sir\ far insursnta avvemgc vcrilicatiun. -
/du bereby eerdfy?ryI r der pulns oar P 'Oldex of perjury that for ivefurvnudon provided above is true and correct
i I it re
l_hnnc i T1 Iqg ��� z y _zq—/.�—
t)f/iciul use only. Ou not rvrile in dri.v area,tube cumpleted by city ur town gjlriul
City n(Town: _ Permit/i.Ieense 4
Issuing Aulhurily (circle unc); - _-- - --
I. Ilunrd of Ilealth 2. Iluildim; I)eparfntcnt 1,Cily/fawn Clerk J. Flectrical luspcctor 5. Phlntbiug Inspector
6. Other
� Cnnrset Person:
_ .-- —----------- .._.—_ Phone 't:
Massachusetts -Department.,of Public Safety
i • Board of Building Regulations and Standards
• .Construction Supenisor -
License: CS-067Q92
LOUIS L VAZQUft
PO BOX 54
GEOBGETOWIYd11A
J..f:..•,lJ �.,r ix�s Expiration
Commissioner 0512412016
Unrestricted-Buildings of any use group which '
contain less than 35,000 cubic feet(991M )of
enclosed space.
r
Failure to possess a current edition of the Massachusetts .
State Building Code is cause for revocation of this license. . - ?
For DP5 Licensing information visit: w Aass.Gov/DPS -t
k
CITY OF SALEM, MASSAQHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET,3R FLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAx(978) 740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
s
(add(ess of facility)
1.
1
Signature of applicant
y
/ 3 - iy
Date