0155 WASHINGTON STREET - BPA-10-530 FORMER EDGEWATER The Commonwealth of Massachusetts
`' Ix Department of Public Safety
v-,�•� ..\fassdcluiseBs State Building Code(780 CMR)Seventh Edition
City of Salem
Buildin Permit A lication for an Buildin a than 1 or 2 omit Dwellin
(This Section For Official Use O v)
Building Permit Number: Date Applied: B it ng r:
SECTION 1: LOCATION (Please indicate Block B and Lot N for location hi street address is not available)
0T
No.and Street City /Town Zip Code 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 g Repair) Alteration ❑ Addition 0 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ' ❑ Other WSpecify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes OK No ❑
Is an Independent Structural Engineering Peer Review required? Yes No ❑
Brief Description of Proposed Work: �.4ee` '/ i� 6—R PAS//L-3 'r�-/e P�i✓r re.0/L..�
/ inrisvl >/ r wvsere 1cTc
)CPLod 77rL•�
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): p
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 ❑ A4❑ A-5❑ F B: Business ❑ - E: Educational ❑
F. Facto F-I ❑ F2 0 Hi Hazard H-1 ❑ H-2❑ ..., H-3 ❑ H4❑ H-5❑
-'e'i!; L 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:
ECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 118 ❑ IIIA ❑ IIIBN�- IV ❑ 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❑
Private❑ or indentify Zone: or on site sastem ❑ required ❑or trench ur specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air:Navigation: M\ Ill,h.ri,l,nnmi*.iimItrcirmI'n,rr��:
\ot :Applicable❑ Is Strnidiue tcit tin airport appn atch area' Is their rev iem completed.'
,n l�mscnt to Bull cnclox'd ❑ 1'cs❑ or No❑ Yes❑ \n ❑ j
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Lse Gnrup(s): Type of Construction: Occupant Load per Holm
ILn's the budding contain an Sprinkler Scse.m.': Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner O� O
/4pa-/A> -/ e- G P Lyc.
Name(Print) Nu.and Street City/Town Zip
Property 0%%ner Contact Information:
EG >Oti� to A? Xy/ji7 2�'e/
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 pnr pert%owner's behalf, mall 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,tR)0 cu It-of enclosed s pace and/or not under Construction Control then check here O and skip Section 10.1)
10.1 Registered Professional Res onsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
A ,f .15 T
Street Address Cat /Town State Zip Discipline Expiration Date
/LLe�vF de c ' 36 f/•g•�r s� /'`is� 0 2i i
10.2 General Contractor
� N CO.v s-�Y2 vc�.77 r7� IA-
Company Oz-� 6
Company Name: e-X 42 3 I
Name of Person Responsible fur Construction License No. and Type if Applicable
Strut Addre City/Town State Zip
2P2 8603 =_
Telephone No.(business) Telephone 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 O Noix
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building ,Q6 O V•t!k Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (co tact municipality)
5. Mechanical (Other) $ — �
Enclose check payable to �r�.l'
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 and accurate to the best of my knowledge and understanding.
,a L.,G/c;-ry9 I$N440
Please print and sign name Title Telephone No. Dale
tiueet Addles. City/Town State Zip/�
.Municipal Inspector to fill out this section upon application approval: . //1%l D
Name Uate
`` �► "� CITY OF SaI Y. Nfs NLASSACHUSETTS
BUILDING DEPARTNJUNT
120 WASH(NGTON STREET, Yea FLOOR
., * =Y TEL (978) 745-9595
FAX(971I) 74&9&W
KI%BFaf EY DIt15CO11.
MAYORTHOtNAs ST.PIEiRt
DIRECTOR OF PL BLIC PROPERTY/eCB.DLNG COMNOSSION EX
Workers' Compensation Insurance AMdavit: BaildertJContractonlElectriclanalPlumbers
annllcant Information Pteese Print LeeM
ainelausin OrW,zslioirlroLviduall: �� �t�S'Td�'et/ CptiS>'�1-!/C-✓�/O /t- /�'�
Address: 76
City/state/zip: 1'1—c e� M�!'L1 f/Pbone N: z5,3're Fir Z ,�Fd-e 3
Are yoe an empNyw?Clwck the appropriate boas
Type of project(required):
1.❑ I am a unployer with 4. Q 1 use a Berson►cooaaetm and 1
employes(fdl and/or pan-time).a have hired the subcerenemre 6. ❑New construction
201 am a sole proprietor or partner• listed on the attached sheet. ; 1. Q Remodeling
ship and have no employees Those sub-contraetora have S. Q Demolition
working for me in any capacity. workers'comp.insurse ea 9. Q Building addition
[No workers'comp insurance S. Q We area corporation and its
required.) olfteas have exaeised they 10.0 Electrical repairs or additions
J.Q 1 am a homeowner doing all work right of exemption per MGL 1 I.Q Plumbing regain or additions
myself.[No woken'comp c. 152.1110),and wE:j
12.❑Roof repairs
insurance required.)t employes.LNG wo I).❑Odra
comp insurance re
•Any applicants Islas dMU boa sd mar atw as son she ware below da wtq their ollowa•tompnmasr policy iddswntmtlels
'I Lwrawlseo who suboW ibis afllbvle indicating they am dome oil were and dea him euwNe consurmra~ ,bMg a now M&wil indbmd.a esk
T.,nim-e a Ihon cheek shim ben nsue aeaiwd ere=kii wnat Wwo showing tla sears of 1M eA.cemmnon cad Ihrk wNow e'foals.polity isubrivades.
f HAe ear sarp/eyer'bet bPreviNnR workers• ou"Javesstba/na e"c"co jer ary earpfrryers Stfow 4 rAe p/(ep ewd/oI side
inforsaida"
In.urance Company Name:
Policy M or Self-ins. Lie.p: Expiration Dan:
Job Site Address: City/State/Zip.
Ansck a copy of the workers'compensation poft deelas atlee pap(sbowln Ike
g polity somber and eaplrstlrn date)6
Failure to secure coverep as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/crone-year imprisonment,a well as civil penalties in the form of a STOP WORK ORDER and a fins
of up to S250.00 a day against the violator. Ile advi.*W that a copy of this statement may be fursaurclLd to the Office of
invcshgatium oirilte n1A for insurance coverap verititallelL
file hereby certify under the pins end pease/Nis o/par/o tAar tM infonmrotioe Provided above is tree and correct
:, , t e�r--/h-0 /�/10�/ gorse• 2 — `�—/O
Phoned•
O/f(r•ief use only. Do not wrier in rAir area,re 6r.arsep/std ey dry or retvsr o/JUMA
City or town: Pcrmif/Lkcnst wf �
i
hsuinr Authurily(circle une):
1. Ituard u(Ilealih 2. Ruildln1l(department I. C itytrown Clerk J. Electrical Impecto► S. Plumbing Inspector
6. other
l.unlad Person: __ _., Phones•
r
_ I �! CITY OF SALEM'
PUBLIC PROPRERTY
DEPARTMENT
\I`.,,�Il 1:0�'.st u�t;;<,.v 5 rx[Er •SA t'ft.Nt.Ni.,t 111 " 1 ;•a'�
Tcl:v7g•7�S'1 `�5 979"740.9446
Construction Debris Disposal Affldavit
(required I'ur 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 If _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
q Z // /Z� /or/-i2 in/L/
4n27c of hauler)
I he debris will be disposed of in
t :u -- ...
nne ut aci rty
(address of facility)
4 2 -q- iC2
A�nature of permit applicant
date