0001A FLETCHER WAY B-11-69 1 j II
�. The Commonwealth of Massachusetts
Department of Public Safety
I a,. \Iassaahusvtts State Building Code(.7S0CJIR)Seventh Edition
City of Salem
BuildingPermit Application for an Buildingother than a 1- or 2-FamilyDwelling
11 phis Section For Official Use Only)
Budding Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block• and Lot 0 for locations for which a street address is not available)
No. and Street City/Town Lip Came Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here Oar check all that apply in the two rows below
Existing Building O Repair O 1 Alteratiun*pl, I Addition O j Demolition 0 (Please fill uut and submit Appendix 1)
Change of Use 0 Change of Occupancy C) I Other 0 Specify:
Are building plans and/ur cortstructiun documents being supplied as part of this permit application? Yes 0 No ❑
Is an Independent Structural Engineerinv.Peer Review requi 7 ," Yes 0 No 0
Brief Description of Proposal Work: t OC -�i14: lo tGW
i in �CL46 zm wt A ks o n eveJ van-+Ij 1 e.
0x&%A. vn_e A t) C ef0 Coln aln.Fi''" lwJreJA KK'f'
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY' ' 1
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) D
Existing Use Group(s): Proposed Use Group(s): t
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.)
SECTIONS:USE GROUP(Cheek as a llcable)
A: Assembl A-10 A-2r 0 A-2ncCl A-3 0 A40 A-50 B: Business 0 E: Educational 0
F: Facto F-1 0 F2 0 H: Hi Hazard H-1 O H-2 0 H-3 0 H-4 0 H-5 0
Jr 1: Institutional I-1 0 1.2 0 1-3 0 14 0 M: Mercantile O R: Residential R-10 R-2 0 R-3 0MR405: Stora a 5-1 0 S•20 U: Utility 0 Special Use 0 and lease describe belowS+ecial Use:
SECTION 6:CONSTRUCTION TYPE(Check as a livable)
IA 0 IB ❑ IIA O Its 0 IIIA 0 IIIB0 IV O VA 0 V
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply:, , .Flood Zone Information: -Sewage Disposil: Trench Permit: th
oval:
a 1'Ubhc� C Ita•ck it uutstdv FI,h,J Z„ne jK Indicate muntctpal� •\ trench will not be cd Srtr�requtradj(a)rtrencftI'mate❑ or tndenuA,Zune: ur„none,%,tem❑ )`rrmit na•nclosiaf O`Railroad right-of-way: Hazards to Air..Navigation: OI\ I Inns, O �„nnn.-nr.\,-141•F•hcA,ly* I..Hrualura•aruhm.urpnrt.t •pn,aahorea' L their re%iv%% .'h•.0 ,-r.\,' Yes❑SECTION 8:CONTENT OF CERTIFICA TE OF(x•CUPANCY
Occupant Load pvr I
)� I h c. iha•bu J,hog o,nlain.,n Spnnklvr S%,ton'' �pax'tal�Upul.th„nsr
SECTION 9: PROPERTY OWNER AUTHORIZATION +
N.1 Ild lalJfr?.�U1 PfUI\rlll' UN'nCf ,y� L,. + ` Lh O! �D
VAj S�R��2a yaEvf/ ,. fie-td\c�L�[�`f Ppa'zi: zLA +
Name(Print) .No. end Street l ih'/ ruwn zip
I'nl +rtlY the rise l-untaet Inlurmalnm:
lilts T Telephone No. (business) Telrphone No. (cell) a-mall addra'>s
If ej.+ +hcablr. 'hr priryor owner h 2r auth IriLes �L�
�,4.yl�s L.oa,Q� �4s �1Arltfxl!Sj 12�8 .✓�
Name — — - Sum Address lily/Town State Zip
to act on the pro+ert% ,%%nrr's behalf, in all matters relative to work at+lhorized by this building \rrmut a , lication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If t-uilding is kss than 35,LW cu.11.ut enckwsl s ace and/ur not ulldar lon:inlc tiun Control then check hrre O and akjjs Secitun ILIA)
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephune Nu. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cum�ny IVamr: D�/0.�'1" -' .+. •^V
J aV47z L. 86-ii9
Name of resin Res�i Insible hx Cunslructiun License No. and Typed A plicable
3 ' S� 1�1`cNTQ to L 5� @V GFZ L V
Street Address City/Town Sta�q Zip
_So'� lt3o °178_'$n7 li3o �Ptfr�l.syo„i'f- (o
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:W V (M.G.L.c. 1S2 § 28C(Q)
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 0
AND PERMIT
SECTION 12.CONSTRUCTION COSTS AT E
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =f
1. Building f bo®. 0 d Building Permit Fee.Total Construction Cost x_(Insert here
2. Electrical f appropriate municipal factor)=f
3. Plumbin f
3. Mechanical (HVAC) f Note: Minimum fee.f (co ct municipality)
5. Mechanical (Other) f Enclose check payable to / wi
6. Total Cust f p O :p (contact munici alif )and write chec t number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
11v entering my name below, I herrbv altest under the pains and penal)ies of perjury that all of the informanon con6uned in this
al., licauon is true aInaccurate to the best of m,Y knowle\lgeand understanding.
svzCPr es LOVA T ow ryLv 174 .W. 130 1 to 0
I'I a r print and .Ign na�m_�er•� rtllr(�- relephu a..Na . ""^\ Dale
iTCr� \ 1 'T ao-ey Qicr -f ► Ck I
strecl .%dJres Cin'i Town at p
1unicipal Llsprdor to fill out this section upon application approval: `
�l1
N r D,or
LN CITY OF SALEM
PUBLIC PROPRERTY
,
DEPARTMENT
12CWail-nwIONSrt(ELT . SALEM.M:(s'.uan
SE nsG1970
978-745.9595 . P:,x: 978-740.9840
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
3nlicarit Information Please Print Leeibiv
Namel0usinessior);anizatinNlndividuup: games Lora +
Address: ��� IZ ST
City SrateiZip: 3t1�E�1 Y MA o"tu ('hone ,'.:Ccl 607 It 30
Are you an employer'.' Check the appropriate box: Type of project(required):
. ❑ I am a general contractor and I
1.❑ 1 am a employer with 4 G. ❑ New construction
employees(full and/or part-bale).` have hired the sub-contractors 7. Z„Remodeling
2. 1 am a sole proprietor or partner- listed on the attached sheet. :
ship and have no mnpluyces These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp, insurance. q- ❑ Building addition
5. ❑ We are a corporation and its
I To workers'comp. insurance 10.❑ Electrical repairs or additions
required.) officers have exorcized their
S
right of exemption er MGL I t.❑ Plumbing repairs or additions
3.❑ 1 ant a homeowner doing all work P P'
myself LNo workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13.❑ Other
comp. insurance required.]
-.Any.ppl,aui that ducks box al must also lilt out the xecliot bcluw showing lhcir workors cumpcnotlion policy inburrwtion.
I lumwwtwrs who submit this affidavit indicating they are doing all work and dtcn biro outside contractors moat submit a new arfdavit indiomng such.
�C,o, racton that check this box mustat1whod an additimal A%Tl showing the '-'Into of the sub�onlractom and their workers'comp.policy information.
I am col employer ilia!is pruriding workers'c•onipe».cntion incurmtee for uty employees. Belo,is the policy and job.cite
infornruriOlL
Insurance Company Name: .._._
Poliev 4 or Self-ins. Lic.*=: ..__-_.___ Expiration Date:
Job Site Address: City/Stateizip:
attach it copy of the workers' compensation policy declaration Inge (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 5250.00 it day against the violator. lie advised that a copy of this statement may be !forwarded to the Office of
InvCstigaliuns ul file DIA for insurance coverage verification.
l do hereby c tijy corder the pains and prnrrlfies o perjury that rite information provided above is true and correcr.
Sienalard: ----- I Datc: 7 ZO
pbt n:e;t:
74ti - o - 11 3a
Official use only. Do tint tvrire its this area, to be cmnpleted by city or fovn official
City or Town: _-- Perin it/License#.----- -- -...._..._.. .---- .. - .
Issuing Authority (circle one): --
I. Board of health 2. Building Department 3. Cilyi fovea Clerk 4. Electrical Inspector 5. Plumbing Inspector
G.Of her
Contact Person: Phone
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,piumership, 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 tliereto 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
applicanrwlio•has`not.prtiduced•aecep-table evidence of compliance with the insurance coverage required."
.additionally, HIGL chapter 152, §25C(7)states"Neither the commonwealth nor any ofits'political subdivisions shall
enter into any contract for the perfommnce 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 nuntber(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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must Submit multiple pennit/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 01'tice of Investigations would like to thank you in advance fur 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 Al
Department of Industrial Accidents .
Office of Investigations t
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
{ CITY OF SALEM
y S
yr a; PUBLIC PROPRERTY
f
y` l ' DEPART'NIENT
•,I ., r. I'. ��.,;i n.;.., �,n<i:r r . ti.o n+, �L�;;�, .a :� i ;. _r/ :
17i: v'y -�i.li,/i • Ins: 'nxJ;_ Isa�;
Construction Debris Disposal Affidavit
(reLluired for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 Cb1R section 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as debited by MGL c
I 11. S 150A.
The debris will be transported by:
_ 1n
,a te LO�a4 I �ND J . L .
(name of hauler)
I'lie debris will be disposed( of in
5q,�4.l�n �1'ciwt'1Zr �� -
(name of facility)
(address of facility)
signature of permit applicant
zo ( •2-V o
— 1 date
.Iabu.a fl d,.
Massachusetts- Department of Public Safety
Board of Building Re,'ulations and Standards
Construction Supervisor License
License: CS 80239
Restricted to: 00
JAMES E LOVATT
348 RANTOUL ST UNIT 208
BEVERLY, MA 61915
Expiration: 4/20/2011
('....... .nrr Tr#: 13098
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