0046 WASHINGTON SQUARE SOUTH - BPA 160-12 The Commonwealth of Massachusetts
-a
Department of Public Safety
I � Massachusetts Stntc Building Code(7811CMR)
Building Permit Application for any Building other than aOne-or Two-Family Dwelling
(Chic Section For Official Use Only)
Date Applied: Building Official:
Building Permit Number
SECTION 1:LOCATION.(Please indicate Block#and Lot#for locations for which a street address is not available)
No,and Street
City /Town Zip Code Name of Building(if applicable) -
SECTION 2:PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Fxisling Building Mr Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out;md submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ i Other ❑ SpeufY: —
Are building plans and/or construction documents being supplied as part of this Permit application? Yes ❑ No
Yes ❑ No [�
Is an Independent Structural Engineering PecnRcvf ui d? P �7.. /�rA,l A
Brief Description of Pro used Work:_
I d Al �l�J
a rw a ;•�
SECTION 3:COMPLETE THIS SECTIO N,CHANGE IN USE OR OCCUPANCY
DING RENOVATIO ADDI'CION,OR
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CA1R 31) ❑
Existing Use Group(s): Proposed Use Grou P(s):
SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed
g
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
#i
SECTIONS:USE GROUP(Check as a Plicable)
A: Assembly A-1 ❑ r\-2❑ Nightclub ❑ A-3 ❑ A-f❑ A-5❑
B: Business ❑ E: Educational ❑
F: Pacto F-1 ❑ F2❑ Hi Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-1❑ H-5❑
R: Residential R-1❑ R-2❑ R-;i❑ R-3❑
1: Institutional 1-1 ❑ 1-2❑ I-3❑ I-f❑ M: Mercantile❑ Special Use❑and Please describe below:
S: Storage 5-1 ❑ S-2❑ U: Utility❑ P
Special Use �
SECTION 6:CONSTRUCCION"TYPE(Check as a licable)
- IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780CMR 111.0 for details on each item)Debris Removal:
'French Permit:
Water Supply: Flood Zone Information: Sewage Disposal: A trench will net be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify.
Private❑ or indentify ZUnI'1 or on site system❑ permit is enclosed ❑
Railroad right-of-way: hazards to Air Navigation:
Is Structure within airport approach areal? Is their review completed' "
Not:\ppl"cable❑ Yes❑ No ❑
or Consent to Build enclosed ❑ Yes❑ or
No❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
` l_)ccu pant Load per floor'. ...
Edition ut Code:_ Use GruuP(s): Tvpc of Gmslniclion'. 1 f ---
Dues the buildiol;Contain an Sprinkler SYstenh?: Special Stipulations: — .—.—
ky -
SECTION 9: PROPERTY OWNER AU'FHORIZATION '
Name anal Address of Property Owner
.9
Name(Print) No and Street �� City/Town Zip
Property Owner Contact Information:
Fitle - Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes f
Name Street Address City/Town State Zip
to act on the 2roperty,owner's behalf,in all matters relative to work authorized by this building permit aE21ication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildin is less thin 35,OIX1 cu.f,.of enclose)s ace and or not under Construction Control then check here O and skie Section 10.1
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) - Telephone No. e-mail address Registratio9ber
Number
Address City/Town State Zip Discipline
10.2 General Contractor -
Comf�any Name
/� ah c2lol �.`/�S CS � y
Name of Person Responsible for Construction - License No. and Type if Applicable
Xr' ✓�� rS7 �vG -CGGI��
IT—
Street Address ��City own State
Telephone No. business Telephone No. cell e-mail address
SECTION 11:\VOi_I:�;it5 Citku'ttN5n nc.)N h�:aur:iuCT,AtP1u;\_tt M.G.L.c.352. ZSC 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 a lication? Yes❑ No 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 4 0
1. Building $
2.Plumbing Building Permit Fee=Total Construction Cost x_(Insert here
3. um inK S appropriate municipal factor)_$
$
T. Mechanical (HVAC) $ Note: Nlininmm fee=$ (contact municipality)
�. Mechanical Other g
Enclose check payable to
6.Total Cost $ •(7+0 (contact municipality)and write check number here
p. .
SECTION 13:S GNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the infornmtion contained in this
application is true anal accurate to the best of my knowledge and understanding.
Please print and sign name Title Telef one i U e
Street Address City/Town Stilt Z
Municipal Inspector to fill out this section upon application approval:
Name Date
� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
iris::9:1 r;/a1H,111
41
t1:\VnHtl.\l;l U.\ I V CL•1' $.1 t F.N,M.r11.+1.I11 V 1 1 1')7:
I'IA- '17{.713-9i'13a1:tx )71.74C.•Ix16
Workers' Compensation Insurunce :%fildavit•, Builders/Con tractors/Electrlcians/Plumbers
16 1 )Ilcant Inrorinutio
f� ) Pt ax Print Le 'ill
Name IUuantcryr)rgmfrniafvinJlruluall:_ /1 0 � c� �� � /`�/is•
Address: /`/ 3 /-S
Cify,Slarc./ip l c � i?P! O/9ltf� Moneit! ci;i :P� — 9.1 )1 r
Are y tits an vmployerl Check the appropriate box:
1 1'>p1 of project(nqulrrJ):1 ❑ 1alrta em lu ar with 4. ❑ I : n a gcnenl contractor and 1
�/enlPluyvcx(full indiur part-time).• buve hio:J the sub-contraclors fi• ❑New construction
-'•W I.Im J tole pmpricnx or partner- listed-in the.inched.vht:ct. I 7• ❑Reinodelin`
.'Ship and have no clnpluyct.'s These subcontractors have tl. 0 Demolition
working fire me in any capacity, workers' comp, insurance.
I No workers'comp. insurance S. ❑ We are a corporation and its 9. ❑ building addition
3.❑ required.) Officers have cxercirled their 10.0 Electrical repairs or additions
1 a1n J homeowner doing all work right of exemption par bI(IL 1 I.O Plumbing repairs or additions mystklf.(Ko workers'comp, C. 152.41(4).a we Iolvo no
insurance required.) r employees. tK workers' 12'0 Ruul'repain
enlnp insurrncxrrcyuinsLJ 13.QUther
•nnh.yiphcaW film checks Aar of mum:dw rill mu 11w rcrlluo law fAuw;n I _
'11un,w,w,wn whe rWlnul this anldcvil iadit Jalna thus Jrs Jain ml.rurk mW Ih Asir•w rids e a Ion mini.0 rhn4 a nor alrlJrarit inJlufline vNh.
•f.,ntrarnwr Ihm'Sheet this less 1w ntaArd•,n addiliunal'Sham+Auwina 1hY nasty truly Iu0remnnars and Thew otrrhws romp.pultey nlbneaatte.
/inn all eulplayer that Ir prodding,)up rAtirs'rurnprormdan hlmrnnes�ur my etnp/agree. Br/ov/s the pu/ky and/ub.rife
its/arnnud'as.
Insurantxt C'ontpany Vmne� _
Policy 4 or Salf--ins. Lic.d: -_--
-- . .. . Expiration Data:
)ub Site Address:
cilyrSate/Zip:
.Urack It cuPy of Ibe workars'eulnpenlatloe Pulley declaration page(showing the policy number and esplrarlun date).
Failure to.aura cuveruge as required uodur Sccliun 25A ul'JIGL c. 132 eau lead to rile imposition orcriminal altit of a
tine up to S 1.3110.0f)JniYur cue-year imprisonment, Js well Js civil pctwlllcs in the form ore 5TUP 1VURK URpe pen
and a fine
�+f up to i?Sn.tM 11 Jay Against the vL>latnr. Ile advised that a copy orihis malcment may be forwarded to the UI)icc u1'
61re.nyJunna al';hc DIA li)f rIN11/:Il:ee ef+OetJye eel ltieJl(tJn.
/Ju ha•reby r:rtily nndce dref�pui�m onJ pe��n/fire u/•prrjnry'Shur the in/bnnullon provided above is true rind c0r1.ee4
�I ,:�: far• -""—=�� �� UJh ����
I)/)(riu/ore au/y, l)d nor write in this area. tube cuurp/ried by cityL
L
I
('IIV Ile I'mrn:Irruing Aulhurity (circle tine):
IGtarJ u(Ilrahh 1. IhuIJillq Ikparhuc1. Cit):'(afrnC'Ierk pecrOr i, phunbing Inryeefar
G. ,)tierC-11.1ct I'arwo:
Information and Instructions
t.a in the service of another under,Iny contract of hire.
�Lusachusctts General laws chapter 132 reywrcs all cngsloyen t to provide workers compenrsunn fix their employees.
llwsuinl to tit,%astute, an ernplut're is defined as , every pc
cpress or Implied, oral or written.
An empluper Is defined as"an individual, partnership.associauoa,corporation or ,that legal eatery,or any two r t more
vm to «s. However the
,�t the tixegomg engage) m aSomt enttrpnse, and including the fugal rcprtseutatives of a JeceaseJ employer,oft e
ant of the
ece,ver or uuste-of,al individual, paamershtp,assthan illran.1 ar of other legal entity,employing p
owner of a dwelling{house having not more sons to Jo fir n enan ants and
construction neof repair work uncut h)walling house
,twelling ,oust of another who employ. fx
or ,it the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.'
�IGL chapter 152. f2SC(6) also states that"@very state or local licensing agency shall withhold the Issuance or
srenelval Of*ppllcant"Ile has not produced +ceeptahl@---dent@ Ofmilt to operate a business or cumgillsoce with the construct einsurance coverage trequired.
Additionally, has notptr 15 , i?ccept abates"Neither the commonwealth not any of its Political subdivisions shall
the -rfomutnca atesu Nc work until acceptable evil-nee ofcon+pliartce with the insurance
sn contruct for p tin authority."
nto contracting•rater t Y con g
requirements of this chspt-r have been pies-rate)to She
Applicants checking that p to our situation and.if
Please rill of the workers' compensation a1Y1davit completely.pho nuber(s)along with theirlcenificaht(s)of
necessary supply sins-contractors) name(s), uddres tl- )' P with no employees other than the
nswancc: Limited Liability Companies(LLQ o rLimited Liability
ce itnurance,(If an)LLC or LLP do"have
imembero or Partners, are not requirea to carry be submitted to the Depurtm-rat li Industrial
employees,a policy is required Be advised that this utio avitbe s may
.\ccidents for confirmation of insurance coverage. Also be sure to sign and Jut@ the uClldavlt The affidavit should
he recanted to the city or town that the upplication for the permit or license is being requested,not the Mink"m-rat of
Industrial Accidents• Shots W you have uny questions regarding the law i; it'you aretirecrequired to obtain a workers'
Innstrial.risa ion policy,please call the Deparoment at Ilse number listed below. Self-incur-d companies shoal-enter then
self•insurance license number on the a to dare line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided u space h the boron
Of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
1'l.:usa be sure to till in the permit/license nummber which will be used as a reference number. In addition,vit is applicant
. ions in any t it tit
Policyiliatmust submit
m multiPIG
nary)IsnJ under applicat ice Address' he appl Ca rat hould writeit"I'llno'locations Ifri in indicating Lunen
y be
ovided to the
town)•"A copy of the affidavit that has been officially stem e�m is ord or ahcenaes ked by tIA now it city atiidavit town uua berfille!Out each
applicant as proof that a valid affiduvit is on rule for future p
ye+r. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
1 i.e. a dug license or permit to burn haves tie.)said penwn is NOT required to complete this atftdavit. uesuons.
I he Mice Ill Investigations would like to drank you in advanca for your
:aoperation and shoal)you hoc-:utY y
please do nut hesitate to give us a call.
fhe Ueparnnent's address. telephone snd rax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Iavesdgadona
600 Washington Street
Boston, MA 02111
fel. p 617.727.4900 ext 406 or 1.877-MASSAFE
Fax M 617.727-7749
s.'n.ns www.man.gov/dia
CITY OF S.U.&Nt, >�LuS.kCHL'SETTS
BCILDLYG DEP.IRTIENT
120 W.UHLNGTON STAEST, 3'0 FLOOR
T9L (978) 745-9595
FAX(978) 740-9846
KI51HERLEY DRISCOLL
MAYOR THO-%W ST.Pmx a w
DIRECTOR OF PULIC PROPERTY/lIUMO C;CO\MtssIONER
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 a 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
i
c/l�t 4w. /P 0 A ff e �
(name of facility)
.f<.,znd, Ccot
(address of facility)
signature ofpermit applicant
Ate