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34 WARREN ST - BUILDING INSPECTION (2)
.., �. The.Commonwealth of Massachusetts 4 1 Department of Public Safety ' I .,�,✓ \la..achuvll.Stair Building Code(780 C.MR)Se%enth Edition City of Salem Building Permit Application for any Building other than a 1- or 2-Family Dwellin (rhis Section For Official Use Onlv) Budding Permit Numlwr. Date Applied: I Building Inspector: SECTION 1:LOCATION (Please indicate Block a and Lot• for locations for which a street address is not available) .3 r/ GIAi�/Pew $%, S544 "7`1 /17// Ole F/RS7 SP/R/7-UQL/ST C11 RG/'Of 04tie- .( Xo.and Street C itv /Ta,vn - Zip C,,de Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building O Repair Cl Alteratiun` C Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) . .-GhangeufUse ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Nu ❑ _ Is 5n-Independent Structural Engineering Peer Review required? Yes ❑ No A- Brief Description of Proposed Work: L 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 UseGroup(s): Proposed Use Group(s): f Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA I Existing Proposed No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.) - Total Area(.sq. ft.)and Total Height(ft.) SECTIO 9:USE GROUP(Cheek as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc O A-3 A4❑ A-5❑ B: Business O E: Educational ❑ F: Facto F-I ❑ F2❑ 1 H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ r H-5❑ 1: Institutional I-1 ❑ 1-2❑ 1-3 O 1-t❑ M: Mercantile Cl R: Residential R-1❑ R-2 ❑ R-3❑ R-1 ❑ S: Storage S•1 ❑ . S-2 ❑ U: Utility❑ Special Use❑and please describe below: -' $pedal Usr: _ - SECTION 6.CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ Ilea IIIAO IIIB ❑ 1 IV ❑ 1 VAO VBO •'SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Su m pply: Flood Zone Information: Sewage Disposal: Trench Perit: Debris Removal: Public❑ C'heck it uubrdr Flood Luna•❑ Indicate munrapal ❑ A trench will not be Llcenwd Dispu.d Site❑ required❑ or trench or,pecdv: I'ncate❑ unndcntr(� Zone: ur un.rtr.v.trm ❑ permit r.vnch,. d O Railroad right-of-way: Hazards to Air Navigation: - \l t I[.,I.-n, t . ionm�i� n R...,r.. [or, \nt Applicable•❑ 1,4tructun tcrthm arrpnrt a ppn,a ch.,era.' I: Ihear rreri.r Con,plvted.' or l ar.cnt n, Build vlidovd❑ Ye.❑ ar Nu❑ Ye>Cl \n ❑ SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY 1 ,I1tr„n ..I C.,de•: Lv r.prot Comtnrctum: OCCupont I.nod per l lour I Nw,the building iont.un an Spnnklrr Special Stipulation.- /2 SECTION 9: PROPERTY OWNER AUTHORIZATION N.Ci^�rr��CUnd.\.(dress of Prupnncr/h•lhvnrr Vance(Print) Nu.and Street _ City/Town Lip I'roperiv the ner Contact Information:,,.., - s1 Sire -�Lf'/,-dr/ "/�\ a?o 9.Q — — � t.SP a>,er.S✓f/ - 'Title TrlrF+hone Nit. (buvtnrr+) Telephone Nu. (cell) . r-mad addn•>s I.1pplicable.the property owner herebv authorizes r Street Address. City/Town State Zip Name to act on the +ru eov owner's behalf, in dll matters relative to work authottird by this building permit application. SECTION im CONSTRUCTION CONTROL(Please fill out Appendix 2) (If buddin is k".than 15.000 cu.tt.of enekwd A aiv and/or not nndef CUn+tm♦ti"n CUNNI than check here O and Jup Section I0.1) 10.1 Re 'stered Professional Responsible for Construction Control Name(Re histrant) Telephone No. - e-mail address Registration Number <. SttetR Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Cum an Namr: S,ban iSZ Name of Person Res msible for Construction License No. and Type if Ap licable j- C©Nst tlr lY�O.1 D l�7Ai2l3tc�fc�D Zj O/951s- Street Address - - ,City/Town State Zip Bh'tla DSUn/S�'Ex C/rEa C o/ i Telephone No.(business) Telephone No. cell - e-mail address SECTION 11:WO NC w AV (M.G.L.e.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? Yee O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=f 1. Building f Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical f appropriate municipal factor)=S 3. Plumbing S 4.Mechanical (HVAC) S Note:Minimum fee=( (contact municipality) 5. Mechanical (Other) f Endow check payable to (2� �— 6.Total Cost f (contact municipality)and write check number here SECTION 13-SIGNATURE OF BUILDING PERMIT APPLICANT fly 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. rr(t ; 9?r-'Jrf$a- a.QQB f'ATx a!A '�4 . ! �7t�S C e/! 2 x aS �f 19ea,e print and, ign name title Tcicphu r. 'u. Dat �trrel Addrr,, Cat/Town state L ll? Municipal Inspector to fill out this section upon application approval: ,Name )a to CITY QF, SALEM A��' PUBLIC PROPRERTY . ,N01 DEPARTMENT %1%vt to 12-�W A]NING LO N SfaEh7• SAL E.M.MASSACI II itrl IN Glri70 'rta_978.745-9595 • Pax:978-74^-7846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers n tlicsnt Inforination Please Print Leeibly Name(t3usiiwworganizatioNlndividuul): A 6/Z<lW© Address: CiiyiStatei ip: /Jl/3/ Lr/�r7F� !n/l e19W Phone 1"- 77 • -trc you an employer'.'Check the appropriate box: 'Type of project(required): 1.❑ I am a employer with 4. ❑ am G. ❑1 a general contractor and I New construction --employees(full antllor part-time).` have hired the Cached sheet. 7. ❑ Remodeling 2.0 1 ant a sole proprietor or partner- Thee on the attached sheet. ship and have no employees These sub-contractors have 8. El Demolition working for me in any capacity. workers' comp. insurance. 9, Q Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.) officers have exercised their right of exemption per MGL I l.❑ plumbing repairs or additions - 3.❑ I ant a homeowner doing all work c.152, t 1(4), nd w• have no myself.(No workers' comp. � 12.E] Roof repairs insurance required.) t employees. [No workers' 13.0 Other comp. insurance required.) -Any:rytplicant that chucks box 01 must also fill out the section hclow showing•their wurkua cumpeneution policy iolinmatiun. 'l lomcuwnets woh submit this affidavil indicting Ihey are doing ull work and then hire outside cmuneton must subm e i,a new airdavfr indiumng etch. �c,incurs that check this box must atiached an additional sh of showing the name of the sub-contraCWa and their workers'comp.policy information. i ant un employer that is providing workers'compensation insurance for my employees. Below is the policy and job ate information. Insurance Company Vane: --- -- Policy is or Selr--ins.Lic.V: - Expiration Date: Job Site .address: City'slateizip: Attach a copy of Cite workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of.\,IGL c. 152 can lead to the imposition of criminal penalties of a tint LIP 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 S250.00 if day against llte violator. tic advised that a copy of this statement may be rurwardcd to the O17ice of InvtstigJU,UIs ul the DIA for insurance coverage verification. i do hereby certify un file ufperjury thut the information provided above is true and c'orrecr. - tu r �rnfdties I)atc N� Phorc;v _ (yrcial use only. Do not Irrite in this area,to be cottpleted by city or town aj)iciul. City or'l-myn: - issuing Authurily (circle one): 1. Board of licallh 2. Building Department 3.City/Town Clerk a. Electrical Inspector i, plumbing Inspector 6.OI her _._.. ._ Contact PMOU: _ _-- Phonc H: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employs. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the - receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152. §25C(6)also states.that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additiynally, lvIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall _rnter into any contract for the perforrttance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractors)name(s),address(es)and phone nuntber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the _ members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you arc required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the boiiorn of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. !lease be sure to fill in the permitflicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the _ applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. Hie 011ice of Investigations would like to thank you in advance fur your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 Revised 5-26-05 www,mass.gov/dia 1 s CITY OF SALEM PUBLIC PROPRERTY An, DEPARTMENT ',I 1 t:,i.rr Construction Debris Disposal Affidavit (reiLluired litr all dentoIit it)❑ and renovation work) Tln accordance t�itl It I ic sixth edition of the State Building Code, 780 CNIR section 111.5 -Debris, and the provisions of MGL c 40, S 54; Building Permit is issued with the condition that the debris resulting front this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c 111. S 150A. The debris will be transported by: 1 name of hauler) Thee debris will be disposed of in (names of'fac Ray) laddress ul facility) a ezx _ � ttae ut pcnuu .tpphrant I:nr bu TOWIP- VJIM EXN siNe `A" EASE CASJl ,V:TS Wiitt C.OfmTclZ 24N Fx15i IH� PLAN 1110 ✓ I 34 wAgpzN, 57, s A LRI ; rr1 �RST t'cF �1UFi�d S� c14-!jecEA 0 F ��e_