3 WATSON ST - BUILDING INSPECTION (3) i +1
7171
The Commonwealth of Massachusetts
y y Department of Public Safety j
4' I j \Ius,ochu•eUs 1�tme Budding Lode(%80 CMR)Seernth ELI i l it in
City of Salem
Building Permit Application for any Building other than a I-or 2-Family Dwelling
t rhis%iec tit in For Official U+e Only)
Budding Prrmn .Number: Dote Applied: Building Inspector
SECTION I: LOCATION IPeease indicate Block s and Lot a for locations for which a street address is not available)
41r'm IAA. oilicyio I
No. and Street Ctic /roan Lip Cade .Name of Budding(it.tpphcable)
SECTION 2: PROPOSED WORK
If New Construction check here O or check all that apply in the two rows below
Existing Building❑ Repair W1 Alteration ❑ Addition❑ Demulitiun ❑ (Please fill out and submit Appendix I)
Change of Use ❑ I Change of occupancy O Other ❑ Specify:
Are building plans andlur cur tructwn documents being supplied as part of this permit applicatiun? Yes ❑ :Nu ❑
Is an Independent Structural Engineering Peer Review rcyuirrd? n Yes ❑ No x
Brief Description of PNpused W'A p�li 1 1^I oOrL �I El-\(�rD\A R lAT� 'OOh+��
�,JJ (l W
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 Croup(s): Proposed Use Croup(s):
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CNIR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
R�A: Assembl;yA-10
(include basement levels)&Area Per Floor(sq.ft.)
Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A-2r ❑ A-2nc❑ A-3 ❑ A40 A-5❑ B: Business ❑ E: Educational ❑
F: Facto F.1 ❑ F2❑ H: HI Hazard H-I ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional I-I ❑ I-2 ❑ I-3❑ I-�❑ M: Mercantile❑ R: Residential R-111 R-2 ❑ R-J❑ R-4❑
S: Storage 5-1 ❑ 5-2 ❑ 1 U: Utility❑ Special Use❑and please describe below:
special Use.
SECTION 6:CONSTRUCTION TYPE (Check a a Ilcable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 1115 ❑ IV O 1 VA ❑ VB ❑
I SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) _
Water Supply: Flood Zone Information: Sewage Disposal:
rrench Permit• Debris Removal:
Public ❑ C'hvck tl,ndrldc FLn�.I Lena•❑ Indw.nr municipal❑ �\ trench will n+n hr Liicn�rd Ui.f"�„ri�rtr Cl
ircyuucJ ❑or trench r.pcaic _
� I'ri c.tly❑ err inden lda Zone;_ ur,m rtr•, trm❑
)•rrmrt I.cncln�rJ ❑ _ __
Railroad rlght.of-Way: HJLard3 to Air.Vavlgillorl: N1 \ I Ir.L.ru t .•nin„••i.•n 14...„ 1'r.
Cl I, slrualurc,s ahut airport ep)•u each an•.t' I. thou ivl is+a r •m l,I,tc.1,
.nl •cnl o' Ito,I.I"I' ""'f ❑ 1 Nc,❑ r r\„❑ Nr. ❑ ❑
—�
tiEC'rIUN N:CON TE.VT OF CFRTIFIC.1 rE OF UCCL'P,1NCY
I ,Mom d, _ .__ C•r ln nipr-i _ (s pv.a ln�tru.ti„n llri u)•antln.l )rrll,„ r
ILn'� ihr l`wl,lun;, ml.Iin ut�pn nkivr ?t�Icm' `prri.Il �ti)'u lauan.
SECTION 9: PROPERTY OWNER AUTHORIZATION
\'.one.utd Addrean of l'n perlP l),v nee
\anty(1'ruil) No. and Street llh , ru,,n
I'n,l,a•rtr th,nvr Controo Information: -
ride ra•lephone No. (busmen,) relephone No. (cell) ern Jtl ed,f rv.. I
I f a pp heat b Ir, the proper" ,r„ner hereby a u t hon res
\.Ime Streel Addrv.`* c,",ru,vn State Gp
to act,m the vo erne u„nrr n behalf, in.Ill matters n•latnr lu,vurk authurtta•d by the.bud,bn • 'rrnnt a + 'I cation.
SECTION to:CONSTRUCTION CONTROL IPlease fill out Appendix 2)
11t 1•uddm g is is than 15,(XV<u. it..,f envlonasl.+ace and/or m.1 under C,-mlruetwn Contrul then check hurt❑.nnl 4. +5.•.eon to 11
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-m,nl address Registration Number
Street Address City/Tuwn 91ate Zip Discipline Expiration Date
10.2 General Contractor
5-
Comp, y Na e
�E tL Ma-Rsom �J1J�o� tnc(2cSlo,ir%� CEO
Name of Person Respn�blr for Cunstntctiun tense No. and Type if Applicable
BAR OD09,
Street dress / City/Town Stat Zi
- �(9D5 - •-Q�7� G,SO�Tc(LGr7r141(o� �mfA% .� nm
Telr hone No.(business) Tele hone 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 si ned Affidavit submitted with this a lication7 Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials 6
Total Construction Cost(from Item 6) _$
I. Building $ r"
Building Permit fee=Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor) _$
3. Plumbing S
d. Mechanical (HVAC) S Note: Minimum fee=f (contact municipality)
5. Mechanical (Other) S Enclose check a tble to
6. Total Cost $ payable(contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Ry enlermg my name below, I hereby. ICI tinder the pains and penallies of perjury that all of the mhrrmatlan o Int.uned in this
.lpplicahon is true and accurate to the bent of my knowledge and under,tandtng.
I'Ir.ne pnnl .ut,l agn n.nne title __-- rrleph, i, \ __— I/die —
�ttrel \,I,I n•" (lh: r,n,n gene Gp .
I �tn111CIpJI IIISperhll to fllf nYl tf114 SCINOn upon JppIICa11Un JppIOYJI:
CITY OF SALEM
t PUBLIC PROPRERTY
*L,• DEPARTMENT
11C WAVM..aa o.'S Is ELT • Snu•.m, M.\».lr.tn yr i IN ,)7-
l•ta.:V1.715•9595 a I:nx. 179-74vIx46
Workers' Compensation Insurunce Affidavits Builders/Cuntracturs/Electricians/Plumbers
Ulnlicant Information /� 1 ^ Please Print Leeihly
Vig ITIC IHuuttCssi l)rganvaiinNlnJivaluull:_ S 1d•1.,O1 A 6\hV 1O,Y� Cl �.NC
nn
City,Slaw,Zip: L—�iVf�l1 �lk. �� I'hunri/: _ � D� — ' 90
IAn u an vtnployer7 Check the appropriate box: Type of project(required):
1. I mn a umpluyur with q _ 4. ❑ I am a gcncr3l contractor and 1
unlployces(full amUur part-tinge).• hove hired the suh-contractors fa' Q new construction
2.Q 1 ant a sole proprietor or partner- listed on the anachc(l sheet. 7. ❑ Remodeling
ship and have no umpluyecs These subcontractors have S. Q Demolition
working for me in any capacity. workers'camp, insurance.
(N�workers'comp. insurance —5:-.0 We arc u coi ration mid its -- - —�—
rcquirud.) otYcen have exercised ihoIf 10•0 Electrical repairs or additions
J.El am a homeowner doing all work fight of exemption par hlOL WE].Q Plumbing repairs or additions
myself. [No\vorkurs'sump. c. 152,q 1(4),and we hove nu 12.❑Rriol'repdirs
insurance required.) t amployccs. (No workers'
comp. insurances. irvd.J IJ.QUOger
•any.q,phe:uN that checks bea nl mute:Jan gill user iha aaCban below dwwiny(hair uwkni eun,penuaiwr pulley infitrmusiurr.
'I luman,wMrs who t,drmit this affidavit indiu,ins I"ur Joine all wurt and then him outside Contractors must suhma a now afnJavit inJiaaina wash.
-(,vnm I ry IhW Chcck this bos'n""Cashing an odditiunNl..hwl.huwinx lha nano of the sub.contractda and Ihen wurkan'comp.poky infoonariw.
/sear an catployrr thuf h pruvfJ/ng workers'cutnpenrnNon inwrunce for my employeer. Behnv is the polity send job sife
iof✓neuti✓n.
Imurancu Company V:nne: _. ..
Policy d or Sclf-ins.Lic.is: -_ . .._ Expiration Date:
lob Situ -ldtimss: Cny,Stule/Zip:
.Utach is copy of llte workers'compensation policy declaration page(showing the policy number and expiradua date).
Failure to secure cwvemge as required under Section 25A ul'\IOL c. 152 can lead to the imposition of criminal penalties of a
line up to-it 500.00 and/or ur,e-year imprimmincnt,is wull is civillKnuWcs in the term of a STOP WORK ORDER and a fine
Of up to 5250.00 it Jay.lguinhl the violater. Be advised that a copy of the xfulcmm)t may be forwarded to the ol'licc of
111% ul'lhe DIA for iu,urutce coveragu Iel ili,lion.
/du hvn•hy ter ' y n d pet r/Ne perjury that t/te infurtnat/dn prop,Veedja s e is true yid id correct.
0077
U/jlc/uf nw✓,tly. no not 1rrile in thin area, to be ruotpleled by airy or fown✓/Jici✓it
i
i
City or I'nwn; PenniUl.ieeme p
hvuinu.\ulhorily (CIO one);
I. Huard of Ilvalth 2. Ihtildiuq Ih:p;irtulcol 1.(:ilyi Torso Clerk 4. Electrical luspcctor 5. Plumbing lnvpccior
6. 011lur
l'�uuacl 1'cnow. _ I'hune q•
I
Information and Instructions
�lassaelmsetts licneral Laws choP[er 152 rcyuircs all elliployers
on in the service of another wuleron for litt""c'"Ployces'
ny confect of hire,
!'ursuant to this statute,an emplur'ee is defined as"..every p'
e%press or implied, oral or written."
.%n employer is delincd as"an individual, partnership,association,corporation or tither legal entity,or any two or more
of the foregoing engaged in a joint enterprise.and including the legal representatives of a Se`n'slo employees.employer.ed However the
rci:erver or uuuee ul'.ui it'd three
piumership,assoelantia or other legal entity,employing p )'
owner r r dwelling house having not more than three apartments and who resides therein,or the occupant of the
.Iwclling house of another who a ploys persons shallrnotnbecatrse of such employment be deemed to do aitenance,construction Or repuar work on c househ dwelling
be an employer"
or art the grounds or building appurtenant
.mGL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a Ilecnse or permit to operate a business or to construct buildings in the commonweulth for any
:rppllcunt who has not prod
need acceptable evidence of compliance with the Insurance coverage required."
Additionally, MGL chapter 152. §25C(7)states"Neither the commonwealth not any of its political subdivisions shall
enter into any contract for the performance ufpublic work until acceptable evidence of conrPliar'ce with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
- orker_compensation affidavit completely,by checking the boxes that apply to your situation and,if
phase fill.wt the-w
—— — .supply s workers'
sub-contractor(s)n rne(s),•aJdress(es)turd phony number(s)-along-with their-certiftcate(J of ____
necessary,
ecessary Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry worker' compensation insurance. If as LLC or LLP Does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
\ccidents for confirmation of insurance coverage. Also be sure to sigh and date the affidavit. The affidavit should
he rcnrmed to time city or town that the application or the regarding ermit of the lawns if you arerreyuircd to obmequested, not ut(u workcrs't of
Industrial Accidents. Should you have any q
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the a ro riate line.
City or Town Officials
please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the buttom
Of die affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant.
Phase affidavit
sari to till in the permit/license nunnWr which will be used as a reference number. In addition,an applicant
that must submit multiply crolit,,license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and tinder"Job Site Address"the applicant should write"till 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 nut each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
f i.e. it dog license iir permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he ()tli�v of Investigations would like to thank you in advance fur your cooperation and should you hate any queftions,
please du not hesitate to give us a call.
fhc Ucpanmcnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfRee of Invesdgadons
600 Washington Street
Boston, MA 02111
'rel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax H 617-727.7749
www.mass.gov/dia
"a
b CITY OF S.ULE.`1, 1L1SSACHUSETI'S
• Elurimmr,DEPARME.NT
' 120 WASH NGTON STREHT,Jw FLOOR
TLL (978) 743-9595
FAx(978) 740.9846
KIJBERIBY DRISCO[l
MAYOR THouts ST.PtExRB
DIRECTOR OF PLDLIC PROPERTY/13MO (G CO\OIISSIONER
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 l t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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 : h
�oQ_ 1k
(name of fat:di —
(address of facility)
signature of permit applicant
date
Icbnvlf d•i.: