6-12 UNION ST - BUILDING INSPECTION ' 1
rllsl�
The Commonwealth of Massachusetts
Department of Public Safety
\ Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
G/"2 l//1;4-1 Uj, 1-041PM q&;PD t/n)&t u-774td ca
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 Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
l� Are building Plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engincerinf�,Peer Review required? n Yes ❑ No 1�
Brief Description of Proposed Work: ;iCP fC CLAP{>1 �'to t/';OinJ, IZAA;-r
C74 nCW. ?n-t'—)A4 .el m:-,,. 5.17tn A*-Un..06'oF Ra,u( ✓-:oCweFlt !{fF+;rT �WHTC
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE INUSE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use.
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA ❑ IIB ❑. ItIA ❑ IIIB ❑ 1 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 2( Indicate municipal9l A trench w}'�I not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required ®or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \:IA I t n, Co m...m � Re,i r, I r cec.,:
Not Applicable 0� Is Structure within airport approach area? is their review completed?
or Consent to Build enclosed❑ Yes❑ or No V Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Coale: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler Svstem?: Special Stipulations:
rce
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
1?EAf40 /(C74t/ctL �2 tJni�t ✓i. i c1AL€r, 019�
Name(Print) 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
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 O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) TelVhone No. e-mail address ✓ Registration Number
Street Address City/Town State Zip Discipline Expira ion Date
10.2 General Contractor
,04R2owcLv14
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION Ili kVORKFRS COMPEN5A'rION INSURANCE.AFFI DAWY 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding $ d
Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other S Enclose check payable to
6.Total Cost $ Q J l (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLI NT
By entering my name below,I hereby attest under the pains and penalties of perjury that, of the in W
ined in this
application is true and accurate to the best of my knowledge and understanding. /
on) /7,on. _01.1CLu✓fy � d�✓�1t�L y y/p/�/
Please print and sign name Title Date
may/ �T'Street Address City/Town Sta
Municipal Inspector to fill out this section upon application approval: pl4ew
Name Dat
, 1
CITY OF S,V[ &Nf, AASS.-kCHL'SETI'S
9CtLDLVG DEPAJUNLENT
120 W.UHLNGTON STREET, Y°FLOOR
rEL (978) 745-9595
KIJC9FRLBY DUXOLL FiLX(978) 74069846
MAYOR T i0!64U ST.?MxAS
DIRECTOR OP PLOLIC PR0PERTY/8LMj3LYG C0.%0jlSSI0NER
Construction Debris Disposal AtEdavit
(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 Al 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
I 11. S 150A.
The debris will be transported by:
•/�JJ91", JA/4/`7f Cy,
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address or faciLty)
liyna a ofpermit appliant -
dare
:1 CITY OF SALEM
/r [PUBLIC PROPRERTY
DEPARTMENT
.,uc, a;I Y:)AI-4,n 1
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I�� \Vn„u.4a u.�i1atAT • i,111•v1,AQ,\U:aJ 11 Ni I I,.i 177�
I'c1. 'ilt•)1Svi'r3 •Psx Y)x.,��,,1eM
\�'urkers' Cumpentatlon Insurunce :1111duviC Uuilders/Contracture/Electriclans/Plumbers
\ , dlcdnt In urrnrflon
— r� Print Legibly
NJIneI111mlW% Orarn,/11iom Ind,v„1uu11: ��( L✓((O / ��3iyLe
tn$ LLL
Ci1y,.Srltc.%ip• '��b1L�/� o/%�j I'hunai/��yrF—/�'ZZ
1 \re nu an engtloyort Check the apprnprlure box;
1.LCI 1 .fen i cmpluyur wills a— 4. ❑ I .nn a gununl cowraetor and 1 1 ype�rf proJeee(rryulrrd);
?.❑ enlpluycca(cull und/ur port-time).• how hint the suh•cuntrulon rr' new construction
1.ui,a sole prnpricnw or partner- listed on the anached.sheet t y emodeling
.hip anal have no umpluyeu'a These subcontractors have
working rior me in any capacity, %orken'comp, insurance. a' Mmolirion
I No warkers'cunp. insurance J. ❑ We are n ern 9, ❑ Building addltiun
nyuired.J parstinn and its
otytcers have cswciscd their 10.0 Elecrrieal repairs or additions
J.❑ I sort ,homeowner doing all work iyhr ofuxemprion per M1ICL 11.[] Plumbing repairs or aJditiorfe
myself.(No workun'comp, C.
112,¢I h),anJ we hnvu nn
insurance nyuired.J r cmpluycur. (No warkers' 12.0 Rout'repuirs
ernnp insurancunyuind,J I3•9Uther
'rfry.,;q,Arur iAw chcb Asa sD marl:dw till few Ilse v:cbw,yaluw a.. ilgy wwYrJy'nwlgtn„ryar Iaricy udiulrssiun.
'I lumw.wnaw rho"Almil fills amdsvi,indic ulna Ihty ale Juina ell.writ a1W ihav Ayr uWriM eurlatron mw,wtw,y a new a111drr;1 india•I,lin v
•('.mIrwl,wv Thal k4vk Ihis Gal miss sashed an iedil,efig, wt,6uw11,x IfWi1Lm Ifim IYbteltprldrx]xe IhfN 4rletla'
a cA.
It nrn fen emplayer thus lr proeiJlnr 1vil k Cufnperrnt/on htrarnnee ar rn ern o. camp,pd,cy In/br,,,a,lw
iujurfnururf6 j y p/J set. Brla,v lx the Pa/fey und/a1 sib
Irourauw C'dmpauy Vmne: � R .�rj,/� Cd. -
Iholicy 4 or Self•ins. Lic.
/ - Expiration Date: f /Z
lob Situ Address:ji_�Z,
C1tyrStateiZlp: �Lf%�/vfq O/��
.lttach is elyy of the workers'ctnnpematlun pulley duelarallun page(showing the policy numbur and eapiratlua date).
I'alluru to secure cu,eruge as required under Secliun 2M ul'SIGL C. 112 eau lead to rife im
line uit ties of3
no SO M.6N1 and/ui uie•e vi. i.1mr.Ile unt.advi us IIIe11 us civil Ixnarurs in the turm ofj STOP WORK OROERIsnd a rive
of up ro i'1A.g0;,Jay.illuitul the violan,r. Ile advi.u:d Ihfit a copy athis.dasemen,may be rurwurded to the Utlica of
Inc.anyun'nls ul':hu I11,\ for nl,ar:m'ce a,vcruyu ,crificauun.
/du lter"bl a err' r ufnlcr flit paint and pnrfdNrr per/nry them the injurmrNon prvvlJar/an .y i fruit ored correct.
u�1• 9L�
II)/Jlciu/fur fen/y, po nnI write in Ihir urcu. ru Ae rurnylered Dy city ur roivn a//!t'iu(
( ifv ur 1'nwn: _
PenniuLkrnrr 1
I„uing .\Whnrily (circlo noel;
I. 1411 rd of Ihvllh I. Iluddin, Ikp.Irnncnt 1. Cit�. unu C'Icrk J. L••kcfric.il hIr Ice fur ;,
6. thhvr
I Plumbing In,ycctor i
I
I'a free:
I
I
information and Instructions
ve on In the servic un,ler any. of hire.
�I,m,;achusetts General Laws chaplet 152 tcywrc e of mother :Onlrl
s all euyiloycrs to proviJe workers' cwnpensruon tiff their cmplhyc
es.
1`unu.utl to tills .latuta, an to"plurre is dcIIlted as -e ry P a+
.prcxs Jr unplicd, oral or written." two or more
artnenhip,.tssoetation,Corpora llJn ur other legal cnnry,or any Mr or the
�n ,•mpluprr is defined as"an individual, p i" o in vm loyees. However the
.�t the Gxegoulg engaged in a joint enterprise,and including the legal gal enoty,employing
to a deceased ces. Ho
hCerver or mrualea of .In Illdivrdaal, ptumenhnp,asfoe'ariuo or other legal enuslj D Y g F
to r+ons to do maintenance.cunstruclion or repair work on wch dwelling house
owner of a dwelling{hatnse having not mores thaw Three apartments and who resides thercm•Jr the occupant of
,Iwelli ,a house of another who employs Pt
"Ore
on the grounds Jr building appurtenant thereto shall not because of such employment be deemed to be an employer."
all
is is ac 0
\IGL chapter 132. §33C(6) also stamthat hu�n state or local ass or to coosttruet buildings INcensing 2S1*114y the wmmoawteulrb far any r
renesvul or a license or parrult to operatefable evidence of eumpUuaee with the Insurance coverage required."
Applicant who has not prnducad acc(7 of ill political subdivisions shall
\dditionally, �IGL chapter I S— i?SCt7)states"Neither the commonwealth not any
hitter into any contract for the perfomano of pit work until acceptable evidence of conmpli:umce with the insurances
requiramcnts of this elmuplar have been presented ro the contracting authority."
Applicants ing the boxes that apply to quill situation and if
e11"i'ion atttdavit conmpletely.by
mben(s)Along with their earri'Catolf)of
Plc:m+a lilt out the workers' comp namo(s),adthess(ea)and phone
necessary,supply suit-eontractor(s)
workers' compensation Insurance. if an LLC i LLP duos have
inswance, Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other t an •
members Jr partners,are not required to carry be submitn:d to the Department of industrial
.nrpinyee$,a policy is required Be advised that this alltdavit rosy davits of
heaagedOA for the permit or licen» is being requested,not the I),p
\eeidens for confirmation of infutanco coverage. Also be sure to slgts tied data the affidavit. me an arum thou
he rctumed to the city or town that the app ueftions regarding the low or if you are requited to obtain u workeold an a'
Industrial A"idents. Should you have any 4
connpensatiun policy,please call the Department at the number listed below. Self-insured companies fhauld enter their
sclf•insuranee license number on 1ha appro riatel line.
City or'rows Officials
The Department has provided a space at the bottom
the app
Please he sure that the affidavit is cwnplete ;Ind printed legibly. hcant
of the IlrWuvit Pur you tJ !ill Jot in the event the Otltea of investigations has to contact you regarding
lieutions in an given year, need only suborn one till indicating current
of the be sure ro till in the pl;rmit/licarsa nwnber which will I be used as a reference�c nwugwr. In addition,an aPD
lhat must submit multiple pannit,'liceuse appthouppli
lication" provided to the
Policy inFormatinf the ut7lduvi�hrt has bean officially stamd under"Job Site cpad or marrkedlbyi the city or townm ll be pin c3 h
town)." \copy permit*or licenses. A now 3111duvit muss be tilled out each
applicant as proof that a valid affidavit is on file t'or Nntmue D annit not related to any business or commercial venture
y dar. \Where a home owner or citizen is obtaining a license or p
t i h. A dug license or permit w bum leaves cte.) said person is NOT required to complete this affidavit. umuons,
,li
) ce ui lJvevtiyatiuns would like to thank you in advance for your cooperation and should you hu.a.mY 4
please do nut hesitant to give us a Mail.
fhc Ucpurt'ncnt's aJJfe+.c, telephone aTh C rnmonweallll of MassaehuscrU
Deparaaent of Industrial Accidents
office of Investigations
600 Washinsto^ Street
Boston, MA 02111
-f el, Al 617.727-4900 ext 406 of 1.877-MASSAFE
Fax M 617-727.7749
;,:•.,..d <.2f) www.mass.glov/dia
•. ,�.. >lasctchwct[s - DCpanmcnt of Puhlic Sal'c"'
1 Board of 6uildims RC-ul:dior Liccense
e Jtandards
Construction Supervior s
One- and To-Family
Dwellings
License: CS 48291
THOMAS A BARROWOLOUGH
341 RAp1TOUL ST
MA 01915
BEVERLY,
`
y_ tion: 711712013
Expira
TM: 1T704 .
i„n c ram..,
Office of Consumer Affairs& Business Regulation
R HOME IMPROVEMENT CONTRACTOR
Registration 108188 Type:
Expiration 8l13/2012 Ltd Liability Corpo�
BAR OWCLOUGHCONTRACTING
Thomas Barrowclobghi ,
341 R RANTOUL ST. g ,moo
a—
Beverly, MA 01915 _ - Undersecretary
R ,