86 WHARF - BUILDING INSPECTION t ;
;► ' The Commonwealth of Massachusetts
\' I Department of Public Safety
�`„ \las�tchu.dts State Building Code(780 C\IR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a I- or 2-Family Dwelling
(rhis Section For Official Use Only)
Budding Prrmlt Number. Date Applied: I I Building Inspector:
SECTION 1: LOCATION (Please indicate Block 0 and Lot• for locations for which a street address is not available)
ACZF S/�`EM h.E. V\G�yz-,A S<'ACaon/
..\u.and Start City /Tuaen Zip Code Name of Building lit applicable)
_ SECTION 2:PROPOSED WORK
If New Construction check here O or check all that apply in the two rows below
Existing Building Repair O Alteration Addition O Demolition O (Please fill out and submit Appendix 1)
ChangeofU O Change of Occupancy O Other ❑ Specify:
Arr building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes O No O
Brief De 1 tiun of Prop,sed Work: '�L4J�rb�l'C Anr� ��FZAG'� 25 W�nd�x>VS
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): f
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 8:USE GROUP(Cheek as app licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-S❑ B: Business ❑ E: Educational ❑
F: Facto F-I O F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H 4❑ H-S❑
1: Institutional 1-1 ❑ 1.2 ❑ I-3 O 1-)O M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R4❑
S: Storage SI ❑ S-2 ❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA O IIB ❑ IIIA ❑ li1B ❑ IV ❑ VA ❑ VII ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR I I1.0 for details on each item►
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: , Debris Removal:
Put, cc ClC heck if uul>,de FLx�d Lunn O Indicate municipal ❑ A trench will nut be Licen. d DiNptc.sal tine O
required 0 or trench ur.peC11%
Pr,caty❑ or mdentdc Zone:. I.r on.,te ac�tem Cl permit i,enclo. d ❑ `
Railroad right-of-way: Hazards to Air.Navigation: x1:1 I I,•1,,,,, (-,nnmi••o•n It...,... I'n•
\ut Applic.iblc❑ I.tilrunun•.anhu,airport al+Ivnach area' 1, their rev,e.r annpleted.'
rt l',vt�enl h,11udd endued Cl Ye.❑ ur Xu❑ 1'e>❑ \n ❑
SECTION 8:CONTENT OF CERTIFICA Ti OF OCCUPANCY
I dawn �d ( �nlr: L,v ra peal Cun,trucl,un: Occupant Load per Flour:
IL.r. the buil.hfig...n u la,n. ,Sprinkler ti mStipulation,:: Special Stipulation,:
SECTION 9: PROPERTY OWNER AUTHORIZATION I
Namv and Adc(ress of Pnq+crty Owner
Name(Print) No—Ind Street City/ rown Gp
Imparts. 0%%ner Contact Inlurm.11lnn: q
Title Telephone No. (business) Telephone No. (cell) a-mall.lddr..r
1 ap dicablr, the property owner hereby authorizes
Street Address City/Town State Zip
Name I
to stet on the pnl pert\ owner'%behalf, in all matters relative to work.udhonzed by this building permit a + pbcatiun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is loss than 35,000 cu.(t.of endosW. ace and/or not under Com truction Cuntrul than check here O and !�!e Suchun IU.!)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name:
Name of Person Resptmsible for Cunstruction License No. and Type if Applicable
Street Address - City/Town State -Zip
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 O No 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item - Estimated Costs: (Labor .
- and Materials) Total Construction Cost(from Item 6)=S
1. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=S
3. Plumbing $
4. Mechanical (HVAC) S Note: Minimum fee=S (contact municipality)
5. Mechanical (Other) S Enclose check payable to
6. Total Cost S (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Ilv entering my name below, I herebv attest under the pains and penalties of perjury that all of the information ommined in this
appliedtwn is true and accurate to the best of my``knuwlledgeand understanding.
-Oct 3
I'Iva,a print and aign name 1 rille relephune.\o. Pate
\Q WCi -\A^ O\qQ
;tivet Addres C]t.%,Town Slate Zip
Municipal Inspector to fill out this section upon application approval: � /d
Name Pole
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
A N,J]I M. IN',I IL IT # SAI I M. NIAIiAt :I! �i I ,
3-1745.9;95 * 1:\x: 1),8.74--1 9841,
Construction Debi-is Disposal Affidavit
(required li)r all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Dcbris, and the provisions ot'MGL c 40, S 54;
Building Permit # - is issued with the condition that the debris resulting from
this work shall be disposedOf in a prupe.rly licensed waste disposal l7acility as defined by MGL c
I 11. 5 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
.1 facility)
(address offacility)
—Llm�
Si6flatuleof permit applictilt
zP 0 kcl)
qr hi I a!
CITY OF SALEM
rt � PUBLIC PROPRERTY
' DEPARTMENT
tiy�P
'n I kW:RL EY DIth C0l.l.
WMI-fiNGIONSTRELT • SALEM,M.\Sti:\CI1I:SII'I iS01970
T1:1.:978-745-9595 • 1':\x:978.7449846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
y 3lit ant Information Please Print Leeibiv
-Natne lausidessiOr,-,anizatinNlndividuap;
'Address:
CityrStste %ip: Phone (..
A e)low,%it employer' Check the appropriate box: 'Type of project(required):
. ❑ I ;till a general contractor and 1
I. i am a employer with� 4
_ G. ❑ New construction
enl ylu full and/or une).• have hired the sub-contractors
1 yces( P art-t listed on the attached sheet. �• ❑ Remodeling
2.❑ 1 ;tin a sole proprietor or partner-
ship and have no mnployccs 'these sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
To workers'coin insurance 5. ❑ We arc a corporation and its
I p•
cquireJ.] of 10.❑ Electrical repairs or additions
officers have exercise) their
right of exemption per MGL 1 I.❑
Plumbing
repairs or additions
3.❑ 1 ant a homeowner doing all work g P P'
myself. [No workers' comp. c. 152, j 1(4),and we have no 12.❑ Roof repairs
insurance required.j t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any:ylplicanl that checks box#1 nurst also till out d1c NMooll w.ow showulu their wU llurs cumpensatiun policy information,
r Homeowners who subnitl this, indic:uing Ihey are doing all work and then him outside cuounetors must auh-al a new of ldavit indicating such.
C.ultmcuas that check this box most atla;hcd an additional sheet showing the name of the sub�conlractors and their workers'comp.policy information.
/ant air employer that is providing workers'compensation insurance for my employees. Belo v is the policy and lob site
infuriation. ,
Insurance CompanyVame: ,,./ _ s�".S._ _-....._ ____..._---.___._
Pnliev 4 or Sell'-ins. Lie.t:: \fib\V✓G�'7G- -4- -- ---- Expiration Date: \Q
Job Site Address: R( VAAA-4*5-5 Ste, Citylslatelz'P:
Attach a copy of the workers' cwnpensation policy declaration page(showing;the policy number and expiration date).
Failure Lo secure coverage as required under Section 25A of.\,IGL c. 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. He advised that a copy of this statement may be forwarded to the Office of
lnvcsllgaittnls ul the DIA f'or insurance coverage \verification.
l do hereby certify under the pains and`penaltors fperjory that the inforinalion provided above is trite and correct.
Datc• L� �7 a
(Jfffcial use unly. Do not irrire in this area, to be cumpleted by city or lown official.
City ur fown: _ ... . _ Permit/License X__---
Issuing Authority (circle one):
1. Board of llcalth 2. Building Department 3.Cityffocvn Clerk 4. Electrical Inspector 5. Plumbing Inspector
G. Other
Contact Penuu: __-- .. - -. __--. i hone
i
Information and Instructions
;Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an empluree is defined as"...every person in the service of another tinder 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, bIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtnnce 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-contractor(s)name(s),address(es)and phone nunber(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 insuraice. If in LLC or UP 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 su re 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,re4uested, 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 till out in the event the Office of Investigations has to c"ontact 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 penniUlicense applications in any given`yeai;need'only submit one affidavit indicating current
policy-informatiom(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. it dog license or permit to bun leaves etc.)said person is NOT required to completcithis affidavit.
I he OI t ice of lnvestigations would like tt5 thank you in advaiue 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 Invesdgations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05
www.mass.gov/dia