157 WASHINGTON ST - BUILDING INSPECTION '1 The Commonwealth of Massachusetts
�"I 1
Department of Public Safety
(-•!9. Alassaclum•Its Slate Building Code(7811 CAIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block p and Lot M for locations for which a street address is not available)
No.and Street WJ City/Town Yip Code Name of Building(if applicable)
SECHON 2:PROPOSED WORK
Edition of CIA State Code used- If Ne+' onstruclion check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration Addition❑ 1 Demolition ❑ (Please till out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: _
Are building plaits and/or Construction documents being supplied as part of this permit application? Yes ❑ Nu
Is an Independent Structural Engineering Peer R wt required? Yes ❑ No f3�
Brief Description of Proposer Work:—
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CvIR.'~M) ❑
Existing Use Group(s): Proposed Use Group(s): _
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.) =:F==
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ F.: Educational ❑
F: Facto F-I ❑ F2❑ H: Fli h Hazard H-1 ❑ H-2❑ 1-1-3 ❑ H-4❑ 11-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R•2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION'IYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ 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:
1 ublic❑ Check if outside 19uOd Zone❑ Indicate municipal❑
A trenCh will not be 1ACOSMI Disposal Site❑
required ❑Or trench or
Private❑ or indentily lone: or on site syslem❑ permit is cnclnsed❑ _
Railroad right-of-way: 1'fazards to Air Navigation:
Nut Applicoble❑ Is Slnrrtu rr within airport appraich area? Is their review cnmplvlyd?
Or Consent to Ihold enclosed ❑ 1 es ❑ or No❑ Pes❑ No ❑
SECTION 8:CON"IEN'r OF CER-I'111CA'I'E OF OCCUPANCY
Edition of Code: ---___-- Use Group(s). _______ I\pe Ot CansI ruc I it _ -- I. culatit I wI per Ioor:
1)ues the building canlai❑an Sprinkler S�stem.': -_-- _Sl'eri,11 Stipulations:
SECTION 9: 1'ROI'1:1i'IY OIVNIiR AU'1'iIORIZA"PION /
Name and Address rf Property Owner —
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
"Title Telephone No. (business) Telephone No. (cull) a-mail address
If applicable, the property owner hereby authorizes
-- Nome Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building,permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and ski;Section 10.1
10.1 Registered Professional Responsible for Construction Control
r
-Lu4-
�.af
Name(Registrant) Telephone No. e•nu a address fit'" 'f•t Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
eq Mp rl� gSg g�
Nan�f Person esponsible for C rostruction License fYo. and Type if Applicable
Street ddress i /Town State Zip
Tele shone No. business Telc;honc up cell e-mail address
SECTION11:w0l\'K1rs'ct.,nirb�s:aru�Ni;�'ln:.aVCP.AlFWAVIr M.G.L.c.152. 25C6
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 a lication? Yes O No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=5
1. Plumbing $
1. \Icrhanind (HVAC)
Note:. %linimum fee-$ (contact nuuucipali )
S l-�
3. Mechanical Other S Enclose check payable to5�
6.Total Cost 5 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By unterin g art'ra line b rnv" hurcbv attest under the pains and penalties of perjury that all Of the infonuation On incd in this
applic atiut is true and accurate the best Of nay.knowledge and understanding.
I'Icasc +tint and si n rat Title Trlcp arc NO D lc
tilrect Address City/rown Stale -.ip y
Municipal Inspector to fill out this section upon application approval:
Name I. ate
�lascichusctts - Dcp:ulnleot lit'public Safch
Board of Buildin-, Rc_ulations and Stand 'is
Construction Supervisor License
One-and Two-Family Dwellings
License: CS 45482
DENNIS M GRAPPI
2 KENNETH RD
GEORGETOWN. MA 01833 ., y
Expiration: 5/2/2013
Tr#: 14334
(lrnuais9iuner . . ...._
0��i��21Jr6�/[.IR16
_Office of consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR Type.
i gistration: 129410 Individual
xpiration: 8130/2013
Dennis M.Grappi
Dennis Grappi
2 Kenneth Road
Georgetown. MA 01833 Undersecretary
CITY OF S.U&M, AASSACHUSETI'S
8UMDLNG DEP.um NT
120 W-ks)iL%` STREET,
tGTON }1O FLOOR
TEL (978) 745-9595
KI.NMERLEY DRISCOLL FAX(978) 740.9846
,MAYOR THouns ST.PMUx
DIRECTOt OF PLouc PROPERTY/8vMMCIG CO\LNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cade, 780 CMR section I t 1.5
Debris, and the provisions of MGL a 40, S 54;
Building permit M 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
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
fac
( ameot '-� �f � C�(Q�.
(addresa of facily)
sidneureofpermZachant
aite
;,hn v Ir.1q
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Ull,w
I!C\Vn,ru.vl:ate i t arnt'a iel I•u, M.ueu.i n a t i�Jlvl:
Il•.i: )7L,'ISv3'IS • f l.r '//y-'+C•'ISM
Yorkers' Compensation Insurance atOdav'it: Builders/Con tractors/Electric(ans/Plumbers
'60 111cant In orination
PI •as Print Le •bl
V;IITfa Ilhlanc,vl)r;tyllrltinrvinJiv�Juul1:
Address:
city,sr: 'Zip- e
I hunt;ii:
IAre uu an viold yor'!Cheek the appropriate box:
I. I am a Cmpluyer with 4. Q I :till at gencnl contractor and I l ype urproject(rrquirrd):
anlpluyCew(full and/ur Part-lime).' hava hirer!the Muh-comraclura rl• Q New construction
2.Q I am a sole proprietor ar partner- Iisled on the anachcd sheet t 7• ematkling
Mhip and have no empluycee These sub-contractors have
working for me in any capacity workers'comp. Insurance. g' Q Demolition
I No workers'cutup, insunact 3. ❑ We art a mlpontinn and its9. Cl Building addition
3.0 rCyuircd.J atttccn have gumitied their 10.Q Electrical repairs or additions
1 can a homeowner doing all work right of e.eemption per&ML I I.Q Plumbing repairs or additions
myself.INo workers'comp. C. 132,41(4),and we have no
insurance required.) r cmPloyCew. [No workers' 12.0 Ruol'rclluiat
crnnp, insurance nyuind.J I2.Q Other
luww
•l ue v phc,n iher aheAe tw 11)muY alw rill tint the v:rlron heluw Ilwwiny�Avir.wwMlsi ewm nlWiwl
'I lwrwth whwwk this box all
thatinaiulin i W ptliey t"it wwiwr,
•C,Mlrl.nw.ihN lM•ek this Dos rwuN atixhd ran aaJiiturwr),char,huw'ny the ,awwal s/the lu0comrrawa and their uuhall" 'nWsvn;nJilaw rn rn '
little till
rtuployer tier lr pror•id/ng nvltrten'rutnpenrnNen Jerarnnee er to en a, 'I"iliy'nliwrnan„w
in/unnwwta � y p/J IrR Bdwv Is IAepu/sty und�ub.tire
Insuraucc C'umpany Vmne: -
Vielicy 4 or Sclf-ins. Lie.H: 444 l Y l
- Expiration Date:
lob SiW ,\ddnss; n �� r
Cny,5tatetLtp;
Utaeh it Cully of Ike workers'Cmnpensallon ollcy'doclarullon page(showing the policy nwnbur and explratlua data).
I+alluro to alxuro cov erage as required under Sccliun 251%ul'MU e. 152 call lead to Ilre imposition orcriminal penalties of a
ring up is$LSOOJM JnJ/ur uoe•year impriv,mincnt, as well Js Civil Pcnulucs in the loon ol'a STOP WORK ORDER sal!o fine
of up rn i!JO.iM a Jay.Iguinwt the violator. He advised that a copy orihu.uulCmull,may be lorwarded to the Ol)Il'e uC
III1'�.111�JIIn111 v1 111C UI,\ for rat+ur:u:cC cnvcrJge lcrilicauun,
/du/h•rrby r rrri/r nmler be p tnJ/.tern a v�pr/nry/hut Ilir in/unnrrlon pwviJr ubuve is f r lord rorrert
)
Ofliviul rue wily. l)w nor Ivrire in little ur,,u, lu be rualpleted by airy ur tolvtt al/it lot
lily fir I'olvilt _—
PCnnit/l.ln•mr
Issuing Akilhnrily (circle )ne):
I, lI1,JrJ Of Illvldr !.G. thbvr Ihohlinq Dcpartuleot I, (:il)i fulrn Clerk J. L•'lectric.d inspector :. plumbing lolpeelor
Information and Instructions'ntorthvircmployces.
lion in the service of another under any conlnct of hire,
�Ltssavhu.etts licneral Laws chapter 132 neyunrcs all employers to provide workers compensa i
I'ursuanl to(iris.latuit.an neplurre is JelineJ as"...every fri
%Preis or implied. oral or written."
�n employer rs defined as"an Individual,partnership.as50Cialtoa,corporal of other legal entity,or pity two r the
more
„I the I:xegomg engaged in alomt enterprise, and including he cgal"ProlIggyhemployin ecm ale eer.stj IH""er the
I eceiver or trailed of .In individual, prtmenhtp•asset or other legal entity,employing therein.g ' D Y
owner of a Jwellin){house having not more than three apartments and who resides lion of rpair work on or the occupant el the
(welling house of another who employs hercto shall uotnbecause of such employment be deemed tocbe tidwelling
empl yea."
or on he grounds or building appurtenant
�lGl chapter 152, tf'_SC(6) also states that"Ivory slate or local Ilcensfng al"cy shall withhold the Issue
acr or
sIGLrene% ul of r(keno ar permit to operate■business or to construct buildings la ,he commdawcullh for any
dxc@ with
:Ippllcra, "lto has not produced uSC P�,blilei(Neither he once of nnonw rich not any of its polit calC the insurance gsubhi the
nurancl
Additionally, %IGL chupter 1 S_', ,2
enter into any contract for he Perfomwnresof public
ubo thwork e contracting g authority."
ufcunipliaiice with the insurance
requirements of his chupter have been p
Applicants to our situation and if
pleas" rill out the workers' compensation affidavit completely,by checking the boxes that apply Y
necessary,supply rub-contraclor(s)name(s),addrens(es)and Phone numbers)along{wnwith no employees other than the
fl
insurance. Limited Liability Companies(LLC)of Limited Liability workeits. compensation insurance.hips( f an)LLC or LLP door have
inernben or punters,are not required to carry
en+ployees,u policy ndustrial
is requited. Be advised that this Alfw be sun to Ingo and Jute he uflidand2vit may be submitted to the vlt.nt Tile of lotlidav t should
Accidenu for confirmation of insurance coverage.
utsted,nos the Department of
ho renmmd w the city or town that the application iofor the slregarding it Or the law of if you is anng required to obtain u workers'
Industrial accidents. Should you have Any y
compensation policy please call the Deputanen►st the number listed below. Self-insured companies should enter their
self-insurance license number on the allialroPratc lino.
City or Tows Officials and printed
ibly. The
rf%rho affidavit for you to I'll outsin�he oven,n the OIl eelompletef of has toncontact you regarding the appl cant
1'I.aie be sure to fill in the permit/liccnse uurnbgir wh in anch y
been ge a need only csubmitonelatTidavit hid eating current
Illat must iubmit mulliple pennio'lice lsc tinder
applications
yg y r
Policy lu
inif'or mahi1'f he u1ilJuvitylhrt has been offlc ally stamped or marked nbt;1 a eu+vor towrite n inaatbe provided to theions in y or
Y Y y
town).'A copy permits or licenses. A now afiiduvil must be filled out each
applicant as proof that a valid affiduvit is on fild for futiaro p to any business or
e`ir.'i`�Where
horn�owner
tor citizen is bum leaves etc.)obtaining d P rs�or NOT pennlrequiret not d to complete this ut'ffdavitmnrercial venture
I he allied ul Investigatiuns wuuld Ilk*to hank you in advance for your ooperation and should you hoed;iny yuesuons.
please do not hesitate to give us A call.
the U'v[tincnl's address, telephone and rapt number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfRee of Isvesdgadons
600 Washington Street
Boston. MA 02111
'fen. p 617.727-4900 ext 406 or 1.877•MASSAFE
Fax M 617.727.7749
4.]mus www.mam.gov/dia