34 WALTER ST - BUILDING INSPECTION (2) f
� . The Commonwealth of Massachusetts
Department of Public Safety
\Ltstch kiwi In Mate Burldrng('udir l%BOC�IR)Sea-vnth Edition
\ I City of Salem
Building Permit Application for any Building other than a 1- or 2-Famil
(This Section For Official Use Only)
Dudding Permit Number: Date Applied: G a7 Building Inspector:
SECTION 1: LOCATION (Please indicate Block 10and Lot a for locations for which a street address is n available)
31 WAPEC- �ST ZM-9M lvtA- 147t:�)
.\u. and Street Cite /Town Zip Caste Name of Budding(il.applicable)
\/ SECTION 2:PROPOSED WORK
A`\ If New Construction check here❑or check all that apply in the two rows below
' \ \ Existing Building❑ Repair Alteration O 1 Addition ❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ I Other ❑ Specify:
Are building plans and/ur cunstroctiun documents being supplied as part of this permit application? Yes ❑ No/0-1
Nan Indr�endrnt Structural Engineering Peer Review reyuired7 Yes ❑ No
Brief Descriptiu f Proposed Work: '`{ t^2 �
P92Ct ( Q�14tt7Ltr T 2LPtA2C PALS eFMIO/L Lbw 0"—Ilf—`Y
'Ta GDD� T
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) O
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(.sq. ft.)and Total Height(ft.)
SECTION!s USE GROUP(Check as a IleablN
A: Assembl A-1 ❑ A-2r ❑ A-2nc O A-3 ClA4❑ A•5❑ B: Budnew ❑ E. Educational O
F: Facto F-I ❑ F2❑
H-I ❑ H-2❑ H-3 ❑ H4❑ H-5❑
M aa
1: Institutional 1-10 1.2❑ 1-3❑ h ❑ Mntll ❑
R: Residential R-1❑ R-2❑ R-30 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 ❑ IIAO 1180 IIIAO 11180 IV ❑ 1 VA ❑ VBO
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❑ C heck d uu1>adv FLnral Luna•❑ Indicate municipal ❑ A trench will not be Licensed Di.pra.d Site
I'm-.ate❑ ur mdentih Zone: ur on,rte,%,tens ❑ required ❑or trench ur.pa:dc:
permit as vnclis v l ❑ _
Railroad right-of-way: Hazards to Air.Navigation: xl\ ILdrrn \ nnun-on I<ra rr.a I'n• c.•;
\nt \p'phc.rbly O 1,1�tructun•arnhua aupnrt apprnach arra' I.Ihvar re%ivw completed.'
a l nt�cnl br Ihnld vnduval ❑ „ h•.❑ ur.No❑ 1'v.❑ \u ❑
SECTION 8:CONTENT OF CERTIFICA IE OF OCCUPANCY
Lv cumtrucuun: Occupant Load pvr l lr,rr
Ih,r. 0w1""khog cunlem.ut tiptnnAlcr ja.Icm` >pvcaal?lipul.auun.:
e cV?
p"
�lI(0/w,l
` 1
SECTION 9: PROPERTY OWNER AUTHORIZATION
.N.Ime.u,d Addre?.,of Propertv Owner _
2E1,)WAt- e)E)V- rem'- 14/fdWEit IDr - d h
.Name(Print) No.and Street lily/rows Lip -
l1rul vrly 0%%ner Contact Intormauo
Title Telephone No. (busmen%) Telephone No. (cell) a-mail addrv.r
II apnccable, the properly owner hereby authuncr+
• 4
Name Street Address Cilv/Town State Lip
to act on the +ro +rrly onvner's behalf, m all matter%relative its work aulhortced by this building +ermtt,t + licati in.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It bwldin is Ics thin 35.0tiU cu. It.uI enchlvJ s cr and/ur not uniler Com%truction Colurol then check hen O and sJup Seclwn lu.l)
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 p
t1-
e
Naga Pr�r+u %i to r Cunstctiun License No. and Type if Applicabi,.A.
(7 r ¢z7 X Gr
�Street Address City/Town State Zip
9�2-Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WO V (M.G.L c. 1S2.j 2SC(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:CONSTRUC 7ON COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
I. Building S Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)-S
J. Plumbing S �—
4. Mechanical (HVAC) f Note: Minimum fee s•S 2? b (contact municipality)
5. Mechanical (Other) S Enclose check payable to
6. Total Cost S (contact municipality)and write check number here
ON 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering r n"me
he
rrb allrsr under the pains and penaltle%of perjury that all of the information amtalnejh,%
applicauu is true and ac rate tot best of my knowledge and under%tanding.
I'Iv nr riot and .i •r�i ime rifle relcphone No sh-a•e1 .Wdre.. Clhi7uw'n State Zip
Municipal inspector to fill out this section upon application approvel:
`Y R
1. t
CITY OF S.U.E.NI, 11LXSS.XCHU5ETTS
XMDLVG DUAR IE'OT
1'0 W.taimTON srume )NO FxocR
Jew (978) 7+5-9599
F.%x(973) 74496"
KJMBEALEY DRMOLL -
711ON1At ST.PIvtaRs
MAYOR OiRICTOR OF n SLJC PROP[RTV/K RD4VG C0%04SslCL%ER
Workers' Campensatlow Insurance AMdevile Guilders/ContraetortOtleetr(clansiflumlflers
annllcant InfnrmatlQw _ Fleasa Frint Lestiblr
Notre Iota,tsnrOryatranewttvkrtdtsal): �� ,w, �-i��l f_��
Address:
14 LJTOue< �1
Cilyistatr/ZiR ,SQ Plwrle N: 9 ��i%1i
F
rarpleyw!Ckeek tM a0propr/aNN Mtge TYP P/o/�(n9�aaployar wits b. ar a gnarl taoalrscaae ad1 ❑Now coasructiaw
ea(fbd tod/or parl-darl• have hind Aft ar►eatraearBaudasrAesttadtedshay = (]Ramotleling
tole prpriatn tx partner• Theo rlt►eontreaars have t><molitiaw
Mwo ro awtpbya'a taro nis is gay eapeity. wort..'romp.intaams 9. p uuirllty addition
rker'comPt insurance J. 0 We am a earporaden gad in
mvd"l odk in have ttterelasd dale 10.0 Etecrical repoirs or O"do w
).0 1 am a horneownor doing au work ^Ito downpioo par MOL 11.0 Rums"repair or addMov s
myatlf.(NO taerYara'carry` C. la#1(4X ad we hsw into 12. Roorrepairo
insurance ragaind.(I `Mp�1�'ao�s' 1314 Othv�FEtf Q �PAtQ
Camp,inatranoe mgsko/.l
•nq aMYws itr tttras asa n atsar aiw rue ate tav roue trtoeaaaw6sg tart way mopon4o pwim irammdm
'16wr.wsu who shad Nr rlatvil i.rldq tM am Joint tee aaA age tin 6M aaRrawramaa resat merle a NOW+nhlwY idlosiae..►
l.r,ttw daft clew►this tuft naer artt than m aJalinrr.ltr tMaltq eaaaar wefts a&woo taram sae net wow•lwv,plky larlttw.rta
l Not an"view tAar bar awemkig wtrnbrs'cow/awrdra Auwsatoe flit,trq eairbyws SsAnr b rAe'.0j aw/EMI alb
informatica
Insurance Company Name: e � �Sr ��
enlicy for SON-ins. Lis.N: l Eapiralioa DW:
Job Sire Athlreaa CityiSlatsrZip:
.\naek ace"of Itrs werker'componeuee Palley deelerstlaa pop(akstt h g tlae pttlley nrbar cad esplraalae daft)6
F'idure to mum Icc 'red under Action 3JA trf NOL a. 152 can Ind to the impca;0a=o/criminal panalMes ofs
(na up to$1.100. atal/or etu•ya imprisimmo k as wed as civil pearlMas is the rarer of a STOP WORK ORDEK arrd a Ana
01'up to S2Jo.00 Jay iplinsl rho ioluor. I advisoll thin a wpy of this statement maybe forwarded to the Olttee of
lnvc.rtgariurr oft a n1A far ins once coverage tnvitlaatioa.
/1/0hereby cern/&a to Prins and penaiNes w(per/aq rAaa Ain infWalorlon proviM ubva is true a":wreeL
nffl'idale Wa/y /70 nor wrinr is this Were.to Sr a ufwpkw byt'ilyor teaw ui/lr•iud
city at rutvn: errmial.leeesal__
lausng .\ttthrnly(tircle nne):
I iluarJ ul Ileallb 1. Rutbllag Mpartnsvnl ). Cil1/rower Clerk A. ffrclrical Inspector 1. Plumbsng Inspector
6.01 her
i L•,nrnl Pcrtan: _ Prone M.
CITY OF SALEM
PUBLIC PROPRERTY
4�1
DEPARTMENT
r.u; rU) .���. I� �1.�JMV...pv)latl'f •j,H1 N,\IdK�� ��� � � .:I'r•:
constructionuired r.11 demolition DNJ Disposal
n worrk)v1t
in rcconla me with the siath edition of the state Duildins Code, 730 CMR section 1 11.3
Debris. and the pro of tNGL a .s issued ng e c
Duildiny Permit M _ • _ is isrued with the condition that the debris resulting ftom
this walk shall tx disposed of in a properly licensed waste disposal facility as defined by
111. S 150A.
The debris will be transported by:
punw of hauler)
'fhe debris will be disposed of in
.^ (nurr ul o ayy
;uWraf ul'I'acJiiy►
coN
.lase