99 WASHINGTON ST - BUILDING INSPECTION (5) The Commonwealth of Massachusetts
y Department of Public Safety
I A. � „% \LI.•aahu•vus State Building Cade o 80 C.\IIII Srrcn I Ed It tun
City of Salem
Building Permit A lication for any Building other than a I- or 2-Family Dwelling
I Phis 1e Iwn For Ofhc 1.11 U,e On Iv)
Building Permit .Number: Date Apphed: Building In>pectoe I.
SECTION 1: LOCATION IPle.ase indicate Block s and Lot s for locations for which a street address is not available)
\u. and Street C tn i Town Zip Code Name of Budding(it apphcdble)
SECTION 2:PROPOSED WORK
MDt
t New Construction check here❑or check all that apply In the two ruw5 below
7Ex tin ButWing Repair❑.- Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
uf Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Arebuilding plans and/or construction documents being supplied as part of this permit applica uun? Yes ❑ No ❑
dependent Structural Engineering Parr Review rryuired? Yes ❑ No ❑
Briefscription of Proposed Wurk: - °��9
ION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
ere if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Use Group(s): Proposed UseCroup(s):Hazvd Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: HI Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-I ❑ 1-2 ❑ 1.3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-J❑ R-4 Cl
S: Storage _ ❑ S-2 ❑ U: Utility❑ Special Use❑and lease describe below: '
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ Is 0 IIA ❑ Iis a IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
I SFCTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) _
Water Supply: Flood Lone Information: Sewage Disposal: Trench Permit:
Debris Rnnuva l:
Public ❑ C'heiA tl•ni bide IIo..J Lnna•❑ LtJ li.i tr mumnp,tl❑ A trench well nut be Liicn.cd Uri/„�.,il�itr❑
rcyuuvJ Our trench m.1•n dc._ _
I'nc.uc❑ ��r ut.enblt Gme:_ ��r.-n ate•c•trm ❑ ed ❑
prrmrt r cncl n•
t Railroad right-of-way: Harards to Air Navigation: \1-\ I L.t,.n, t .,,, „n••i .,� R, ;•,.,,
\ot I• ' I• Invu rrtirt. .,nnlclr.l'
• � 1 •• vnl b• Il of l.I'ml'-,J0 1 la•❑ .-r\u❑ to- ❑ \.• ❑
SECTION 8:CON TENT OF CFRTIFICA fE OF OCCUPANCY
I ,litb n d 1 .„Ic __— L-r lnul•i-I _ (t i•c.•I l-.n�-Inicll,nl ___ l +iiu(•dnlln.i,l lcr lL.,., .-_ ___-_____. '
0
II. r. Ihr l•irLLnq, netin.m �(vutAlrr�t •tcm• `F`rrial snpulalu n. _____._____—_— �
SECTION 9: PROPERTY OWNER AUTHORIZA"rION
\',t n+e.sal A,I Ire..ul I'ruF+crte l)tenrr
\on+e l l'nm) No..utd Nrvel lltt ;'ro,n LiF+
I'n+l,erty (hc ner Cont.rct Intorm.own:
rule relephone.No. (busoness) relephone No. (cell) r-marl ,"Idr,"
10 pl•hc.t b 1e, t hr property o.c ncr hereby.net hones
N.ime Street AJdre>s City/Town State Zip
to act un the ,r,,pvrtc ot.ner .behalf, tn.Jl matters rclaMe to teork aulhorrtad by this buddm •=2)
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appen(fil•u d.hn•'s los Than 1i.0oucu. It.of endoej,race anJ/or not tnal.•r Conntructut Cunlrol then che \vlum IU 11
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mall address Registration Number s
Street Address City/Town State Lip Discipline Expiration Date
10.2 General Contractor
Ct my Name:
T l_ �
'S /n / -q5
Name of Pe son Responsible fur Construction —S�� License No. and Type if Applicable
q-2r�rno 31 r.7 `�,�--. t"1 fT _i`�t3.�
Street Address City/Town State Zip
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'CO ENSA ION SURANCE AFFIDAVIT(M.G.L.c.152.S 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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building S BuildingPermit Fee=Total Construction Cost x
ES
_(insert here
2. Electrical appropriate municipal factor)=$
3. Plumbing
a. Mechanical (HVAC) Note:Minimum fee=Il (contact municipality)
i. ,bfechanical (Other) check a able to6. Total Cost payable EdEnclow
(contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Hv entering my name below, I hrrebv attest under the puns and penalties of perjury that all of the nfnrmmwn c,�ntmned m thts
.t FF\..rlicd hun n tt7A(ruj�y���J,d1J,U:(uuatr to the best of my knowledge and underUarding.
fcicpht nr \ I)ntc
�n.rl \,Idrv" (lot; Gnvt
Sod tr
1
Municipal htsptctur In fill out this section upon application approval:
rn c v
CITY OF S:U-E.NI, , LNSSACHUSETTS
l3UM1: L`G DEPAR-t-.\tE—NT
• 120 WASHLNGTON STREET, 3"FLOOR
I Fs (979) 745-9 Fax 46
KI\fBERL•EY DRISCOLL THodlASST.PIFRRE
yNIAYOR DIRECTOR OF PUBLIC PROPERTY/BU1LD1\G CO\LUISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electric fans/Plumbers
4 v licant lnfarmation Please Print Legibly
Name lUushwyyOrganimtio yIndividual): SQ uyy"- V�fq
Address: 'L" G.
City/State/Zip: �yiL M� Phone N: I r 2 �
Are you an employer?Check the appropriate bo Type of project(required):
1.❑ 1 am a employer with 4• 1 am a general contractor and 1 6. ❑New construction
ees(full and
employees part-tim
e)." - have hired the sub-contractors
P y listed on the attached sheet. t 7• ❑ Remodeling
2.❑ 1 a sole proprietor or partner-
shipip and have no employees These sub-contractors have B. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its l0.❑ Electrical repairs or additions
required.) officers have exercised their _
right of exemption r MGL 11.0 Plumbing repairs or additions
},❑ I ys a homeowner doing all wont c 6152, '1(4), nd we have no
myself. [\o workers'comp. 412.❑ Roof repairs
l t employees. [No workers' e�ltt��
insurance reyuired.J U.�✓]Other
comp.inwrance required.]
-Any applic:an dal ducks box rt must alto fig uut the section below showing their wwkm compsnwion policy intbnnation.
*I Lxneowners who wlenit this affidavit indicating they am doing all work and then him outside contractors must submit a xw an davit indicting such.
:Comneton that check this box must attached area isitiunal shsel showing the name of the wbt ntractom and their worker'comp.policy infornutien.
I am an employer that is providing workers'comprneradion insurance for my employees. Below Is tire policy and fob site
information.
insurance Company Name:-
Policy 4 or Self-its. Lie,4: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation Polley declaration page(showing the policy number and expiration date).
Failure to sccuru cov a as req ' ed under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to Sl,5oo. and/or one-ye r imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 day against th violator. Ile advised that a copy of this statement may be forwarded ro the Oilicu of -
investigatiunt ut't a D1A for i urance coverage verification.
I do hereby cardjy de thr pulps mud penaU/es of perjury that the frefurmallon provided above is true coed correct.
Darn: �) o
phone A /
OJficfd use only. pu not write in this arrive to be completed by city or town affleetal
i
City or Town: __-- . . Permil/I.Icense q---_--. •._--- . ..--
Issuinit Authority(circle one):
1. hoard of Ileallh 2. fluildinU Department }.Cily(ruivn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ _ ._.. -.. Phone th
Information and Instructions
\ ass.tchusens Gcrleral Laws chapter I J2 requires all employers to provide workers' compensalion t;)r their employees.
Pursuing ro this statute, an employed is defined as"...every pet:son in the service of another under any contract of hire,
:apress or implied, Ural or written."
An employer Is defined as"an individual,partnership,association,corporation or tither legal entity, or any two or more
.,t the 6xewing engaged ;n a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of at Individual,patmership,assoctatioa 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, cumtruction 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."
NtGL chapter 152. §25C(6) also stares thug "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 cumpUance with the Insurance coverage required."
Additionally. MGL chapter 152, 4, 25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence ui compliance with the insurance
requirements of this chapter.have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely, by checking ilia boxes that apply to your situation and, if
necessary,supply sub-contractors) name(s),address(es)and phone number(s)along with their certificatc(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
\ecidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he 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 are 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 he sure that the affidavit is complete tad printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Phase be sure to till in the permittlicense number which will be used as a reference number. In addition,an applicant
that mu t submit multiple pennitilicense 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 ilia 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 hume 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 bur leaves etc.)said person'is NOT required to complete this affidavit.
I lac t)llice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call.
The Dcp:aruncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMCO of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or I-877-MASSAFE
Fax N 617-727-7749
www.mas3.gov/dia
CITY OF sikL.EId, UxsSACHUSETTS
BI:ILDLNG DEPARTNIENNT
130 WASHLNGTON STREET, 3' FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIMB Ri GY DRISCOI.I.
THO
MAYOR NtAS ST.PIERRB
DtRECTOR OF PUBLIC PROPERTY/13UM \G COMMISSIONFIt
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 1 l 1.5
Debris, and the provisions of MGL c 40, 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 disposal 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)
(address of facility)
permit applicant
1l 10/
/ 'date