56 WARD ST - BUILDING INSPECTION a
i
The Commonwealth of Massachusetts
�I Department of Public Safety
.\tassachusetts State Building Code(780 CNIR)Seventh Edition
_ City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwellin
(This Section For Official Use Only)
�1 Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
r
r 7No.and Street City /Town 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 ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 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: 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) ❑
Existing Use Group(s): Proposed Use Group(s): S
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ T H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
"I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 ❑
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 ❑ IIA ❑ FIB ❑ IIIA ❑ IIIB ❑ 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❑ Indicate municipal ❑
A trench will not be Licensed Disposal Site ❑
I'ri va to ❑ or indentifv-Zone: or on site scU required ❑or trench ur specifv:em ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: ..\I:\ I listom.-Cunnni>�io, Roc irIe Prnrr..:
.Not Applicable❑ Is Structure IN ithio airport approach area:' Is their rer iew completed.'
or C"msent to Build enclosed ❑ Yes ❑ or No❑ Yes❑ .Ab ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Uae Gn¢ip(s): Tc pe of Construction- Occupant Load per Flour:
Dne9 thebuilding containan Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY NER AUTHORIZATION
ame atxSi A lures.,of Pro�rrh,Owner A ,y�/,�ay
(L I (7 l��YrC�
Name(Print) Nu.and Street City/Towan 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 *ro perty uw ner's behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) ` .
(If building is less than 35,000 cu.ft.of enclosed s pace and/or not raider Construction Control then check here❑and skip Section 10.0
10.1 Registered Professional Responsible for Construction Control
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Name (Registrant) Telephone No. e-mail address gistratio Number n
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Con! ctor
many N eS oqz' 111110
I
N me of Pers Resp� sable fur CmUction ice s No. and Type if licable
JP1 . .. Dv vyt 1 • l yp
Street res M City/Town i Slate Zip
Telephone No. (business) JTeeleehorn No. (cell) e-mail address
SECTION 11: WORKERS COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c.152.§ 2506))
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. Building $ IQ 00 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) $ Enclose check payable to
6. Total Cost $ ` (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 a curate to the best of my knowledge and understanding.
111-i pri�e ��• /J � itle /s �Teleph n� Ni'.� Date
Street Addie Cite/Town State Zip
Municipal Vpector to fill t this section upon application approval:
Name Date
CITY OF S.UX_ NI, ,AA SSACHL;SETTS
BUILDING DEPARTMFUNT.
120 WAS14INGTON STREET, 3aa FLOOR
TEL (978) 745-9595
F.Vt(978) 740-9846
IV,I$FRiEY DRISCOLL
THoatws ST.Pmm
MAYORDR
DIRECTOR OF PL BLIC PROPERTY/at:QDLNG CO%L%USSIO .ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers
A a licant Information /j / PI Printe
Name (ausiM� Othani:uiOmindivt/dwl): /41/1TU 124 o � ,1r✓//�
Address: f06 D�OVV(o� S �/ Mrs (�
City/State/Zip: Nl 50 &4- �/ FY Phone N- "/ — PIS
Are you as employer?Cheek the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
mployees(full and/or pan-time).• have hired the subcontractors
2. ale a sole proprietor ar partner- listed on the attached shceL : y.�Remakling
am
and have no employees These sub-contractors have a. ❑Demolition
working for me in any capacity. workers'comp•insalraataa 9. ❑ Building addition
INo workers' comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs of additions
required_) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself. [No workers'comp. C. 152,$1(4),and we have no 12.0 Roof repairs
insurance requircd.l t employees. Wo workers' 13.❑Other
comp. insurance required.)
-Any applicant 00 a"'M has el MUM aleY rill 01a the faelim below showing their workm'uttttptenutiun pubry infumtMlo c
'I hwneuwlem who submit this affidavit indicating they are doing ail wurx and them him otmide watrular a ttwut submit a new affidavit indicting ,k
-C.wltnnon AM cheek this ban mug aamhed an additnnwl wheel showing the notate otnte suh. fflnwwm and that wusbsa'uwnp.policy intstematim.
i am ant employer that b providinir workers'comptnsadoa Insgronee jar my employees. Below/s the pel/ry and job sI&
information.
Insurance Company Name:
Policy M or Self-ins. Lie. M: Expiration Date:
Job Site Address: City/State/Zip:
%ttacb a copy of tba workers'compensation policy declaration page(showing the polley number and expiration dab).
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 51.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 i day against the violator. lie adviw:d that a copy of this statemcnl maybe forwarded to the Office of
Invcaugations ol'the DIA for insurance coverage verification.
/do hereby certify un ♦ enaldes of perjury that rho hiforma don provided above is true and aarrecL
/�n r t r Dutc: ��d
Pharc A
iOfficial use a s/y. Da not write in this dreg, ro be'ompleted by city or town offlviax
I
City or ruwn: __ __ Ycrmit/Llccnse N__
hsuing Aulhorily (circle erne): --� — - --
I. Ituard of Ileallh 2. Building Department J. Cilylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. thher
Lwalacl Person: _ __. __ Phones'
CITY OF SALEM
r� s `
PUBLIC PROPRERTY
DEPARTN/IENT
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III 'I'y '4+-'I"I; I \\ 'i_9 V: ' i L
Construction Debris Disposal Affidavit
(required 1'ur all denlulition and renovation \Volk)
In accordance \\ith (Ile sixth edition of the Slate Building Code, 780 CNIR sccuon 1 11.5
Debris, and the provisions u 'NIGL c 40, S 54;
Building Permit # 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
111, S 150A.
The debris will be transported by:
1 name ul huller)
I he debris will be ddissposed of in
(nume ul laelhl.v)
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