63A WHARF ST - BUILDING INSPECTION ` The Commonwealth of Massachusetts
/'1 o Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-F mil /ing
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street ad re) available)
G3A WkAt-.r Sl-reef , Salem MA ol4'__jo Pckev,.N r
No.and Street City/Town Zip Code Name of tImIding(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration 1 Addition❑, -Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: CoSVOe+pC. al}Crest-inv,s
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? _ Yes ❑ No ❑
Brief Description of Proposed Work: Cos ✓e.- dv dvsj alkvj
7 , AUhay.ce ✓e v 16)i" j eec lrIca(
_ D S uctv»,�l LJo
,A/D Savtn a�/�1JCva , S
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 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) F( ve n
Total Area(sq.ft.)and Total Height(ft.) 90 p
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business k— E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile ❑ R: Residential R-111 R-2❑ R-3❑ R4 ❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 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:
Public W Check if outside Flood Zone❑ Indicate municipal l4f
A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ requiredIff. or trench or specify:
permit is enclosed❑
Railroad right-of-way Hazards to Air Navigation: MA Historic Coumdssion Revicw Prncesr.
Not Applicable V Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes ❑ or No�" Yes❑ No ❑ ,v/A
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Rouk,ar R&Ai Ty Saleh-,� A14
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Rot,kp' -63) _
Title / Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Ka lti ,. Pe.abotiv
ame j 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 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) l 1 e-mail address Registration Number
InT
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
w ../-
a) 9C.c
Comparly Name
wt kay..,, s L&%JR_j c_s 3ffs 4v,41 lr.✓✓eslvj fQ
Name of Person Responsible for Construction SLLicense No. and Type if Applicable
20 /�^4 Sf y)ebt➢ral RAa� et .ctV)470� y3 �33
Street Address City own State Zip
03. 39 -0loo _3d�0 439 0a1 IDI rGtMSUfO�, r✓or''1
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.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? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ O°
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ —o appropriate municipal factor)_$
3.Plumbing $ — 6 --
4.Mechanical (1-IVAC) $ _ _ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost oe
$ 6", (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.
Se.o! I v lSGp C>LJ>n e✓ 6n -49$- Sf a 4 6 Zo
P ease print and sign name i Title or�Teelephone No. / Date
Street Address Cites/Town Zin
63 A Lkevl r W hair s State O )`j 7 1/
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF S. .E.M11, bylaSSACHLSETTS
• BUILDING DEPARTJSENT
• tt 120 WASHINGTON STREET, 3r FLOOR
TEL. (978) 745-9595
F&X(978) 740-9846
jG-,IBFRi FY DRISCOLL
,MAYOR THONIAs ST.PtaRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO\LINBSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ' 1 / Please Print Leeibly
Name (Busim� siOrganizaiionAndividual): W� a Ja& �'vt5 t/ O Cci,+
Address: 2�!3 /�v>7es iav rH R oaJ Sulk 05-
City/State/Zip: 03k33 Phone #: 60 3 ' 354 -Olmo
Are y u an employer?Check the appropriate box: Type or project(required):
I. 1 am a employer with 3 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7• ®Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp. insurance. g, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I EI Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.❑Other
comp.insurance required.)
•Any apph :rat that chucks box#1 must also fill out the section below showing their workers'compensation policy information.
t I,.wnns who submit this affidavit indicating they ate doing all work and then hire outside contractors mast suh it a new affidavit indicating such.
=Comracton that check this box must attached an additional street showing the name of the subcontractors and their workers'comp.policy infomtation.
I um an employer that is providing workers'compensadon insurance for my employees. Below is the policy and Job site
information. _L
Insurance Company Name: Cz11_ 1 Je_l-s-6I rt^t�QvVt ytt- �ftit tf a t
Policy #or Self-ins. Lic. #: �6—�c7S36q� �O rLL'O Expiration Date: Ol 01 2O))�3
Job Site Address: WA W ka✓# S�✓ee r CityiState/Zip: S.)Jew, �r7 76
Artach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 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 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ol'the DIA for insurance covera�e verification.
I do hereby rdfy Under the pains and Pena les perjury that the iufonnadon provided above is true and correct
"i mat tre' Datc• L 9 7-o
Phone#: (n 6 3 '-3 [V6
OJJicial use only. Do not write in this a et4 be ontpleted by city or town official
City or Town: Permit/I.lcense
Issuing Authority(circle one): _
1. Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ __ Phone#•
�la.,:[chusctts- Department of Public sAct%
9 Board of Buildin_ Re,mlationp and St:utdardx
L-� Construction Supervisor License
License: CS 38451
WILLIAM J LOJEK
28 KENSINGTON RD/P.O. BOX
HAMPTON FALLS. NH 03844
Expiration: 10/22/2013
( ..ner Ti--'. 9159
r3
�������-��'� S813N]WVX3 d0 ONYOb
ZU91
ZL/8/9 LN979
93ON3 VSV-EY jj',, VH - 1j0
330V 3H1 iO SNOISIAOHd 2130Nr111yOM
39Y a ^^Il�'qpp SI
)taro'"rrtwdiiiwL
' -53i311Y3�iiti ...•. .-.-
ONIN3W W SvNoF-j
rollrw
Z6Z-618 D\ '311 Sa3NIwvx3 Jo aavoe
Nolso8 do 1.110
CITY OF S.UE.NI, NLksSACHUSETTS
BUILDING DEPART\MNT
,,\ j,�rN• 120 WASHNGTON STREET, 3"FLOOR
T EL (978) 745-9595
FAx(978) 740-9846
Ki. BERLEY DRISCOLL
MAYOR T Ho\us ST.PLER LE
DIRECTOR OF PUBLIC PROPERTY/BunDING CO\I\fISSIONER
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 111.5
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
l 11, S 150A.
The debris will be transported by:
/y0V111.Srde� _
(name of hauler)
The debris will be disposed of in
(name of facility)
_- - (address of facility)
signature of permi pli ant
q "M
date —
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
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."
Additionally,MGL chapter 152,§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 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 number(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 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 be sure that the affidavit is complete and 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
Please be sure to fill in the permit/license 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.
The Office of Investigations would like to thank you in advance for 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
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia
• Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC e
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 S ecificatiom
12 Structural Peer Review (�
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein. rk
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
i