314-318 DERBY - 51-71 LAFAYETTE - BUILDING INSPECTION 3
The Commonwealth of Massachusetts
Department of Public Safety
AIassachusettS State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Dote Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
3/y- / ems S/- '21 A -� y/ /o-/- 0 q 8=
No.and Stree"t City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here O or check all that apply in the two rows below
Existing Buildings Repair❑ AlterationX I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
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? r // Yes 11 No ❑ ,
Brief Descriyti�n of Proposed Work:��L L!�/� ci�F`E T- d lrr �iJ(.0 14,
l ti�S�C. `JI Qp9O !Z
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): S
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 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
L• Institutional 1-1 Cl1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 ❑
S: Storage 5-1 ❑ S-2 ❑ U: Utility❑ . . Special Use❑and please describe below:
Special Use: -
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA ElIB ❑ IIA ❑ 1113 ❑ IIIA ❑ [JIB ❑ IV ❑ j.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❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licenced Disposal tine ❑
required ❑or trench or specifv:
Prig ate ❑ or indentifv Zone: or on site sN stem ❑ permit is enclosed Cl
Railroad right-of-way: Hazards to Air Navigation: \I:\ I Ii.G rci.:Ci�nuni>rinn Hroir�c Pn n'r..:
\ot Applicable❑ Is Structure within airportapproach area' Is their rev iemv completed?
orCnnsent ill Build enclosed ❑ Yes❑ or:No❑ Yes ❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code Use Group(z): Tcpe of Constntdion: Occupant Load per Floor:
Does the building containan Sprinkler System?: Special Stipulations
• SECTION 9: PROPERTY OWNER AUTHORIZATION 3
Name nd Address of Prop rl 'Owner -
���i/Ls1�I2CrJF
Name(Print , No.and Street City/Town Lip
Property t)wner Conla-4eZIn1A/rmatiun:
Titic `tyd/,G9li/• Telephone No. (business) Telephone No. (cell) r-mail add nss
If Lc. ni+e v otaner hereby aut rcizer
lime Street Adress City/Town State Zip
to act_un the properk owner's behalf, trial[ matters relative to work authorized by this building Lermit a p plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin •is less than 33,1N10 cu. tt.of enclos.d space and/or not under Constriction Control then check here O and skip Section It) 1)
10.1 Registered Prole r nal Responsible for Construction Control
Nc✓irti aGz
Name(Registr, Tele Shu Nu. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
CuWanyNames f �10Y/f'
CD Ed't�Oti/ �i�G✓��ry J
Name of Person sp s=r C nsuuctiun L, No. and Typeif�cable
treZ Addre �2y �� „ _ _ City/Town
4State Zip
/Telephone No.(business) Telephone-�No.'((clell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
AWorkers'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 application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6)_$ 15�0
1. Building $ • 5-00'dV Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor) =$
3. Plumbing $
Note: Minimum fee=$ 5 (contact municipality)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ pU vP (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 knot%ledge and understanding.
I'Ie.i,c pnnl and ,ign name i itle Tt •phone No. Date
I
-�Ircrl A,i.irc.. <it%/Totcn >totc ip
Municipal Inspector to fill out this section upon application approval: ^ . IU •U
\lime )a
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The Commonwealth of Massachusetts
.f I, Department of Public Safety
,•� \Lmssarhu,etts State Building Cade(780 C\IR),Seventh Edition
City of Salem
BuildingPermit Application for an Buildingother than a 1- or 2-Famil Dwellin
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block#and Lot# for locations for which a street address is not available)
NO. and Street Cit, /Town Zip Code Name of Building (it applicable)
SECTION 2: PROPOSED WORK
If New Construction check here O or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change Of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being suppliedasiparrof this permit,appiicatfon?•Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
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): t•
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
EW
Proposed
NO. of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4 ❑ A-5❑ B: Busineducational ❑F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-5❑L• institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 O M: Mercantile❑ R: Residential ❑ R-4❑S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑anow:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
[A E3 IB ❑ IIA ❑ IIB ❑ IIIA C3 [IIB ❑ IV VA VB ❑
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Information:Flood Zone Infoation: Sewage Disposal: Trench Permit: Debris Removal:
Public ❑ Check it outside Floud Zone ❑ Indicate municipal ❑ A trench will not lie Licen,ed Dinpos,l Site❑
Prnate ❑ or indenufc Zone:_ or on .ite.%,tem ❑ required Our trench ur .peclk
permit i,encluned ❑ _
Railroad right-of-way: Hazards to Air Navigation: VA Ili>nn
Gd 1pFhc.ible ❑ .tivucture �crthm airport apprnach arca' I. then rrnemm nnnpeled'
•,r lmrnl 10 BUild cnrin.rd ❑ .' 1 c.❑ or No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I.,iitir,n of ( a1.: __ lrnupr.l: fm pe of lun.trucnon: Occupant I..ad per Iluor.
l i•
=1) . the L•uildmg uumt un um, •rinklcr�c,tcm'. ,pci ial Stipulations —
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CITY OF SALEM
r , PUBLIC PROPRERTY
-N DEPARTMENT
moo.
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\lsaal 11: W,%It IINIa UN)1:4LIi I' a SA I1'14, MINN it III %1 1 I,JI`77�
'773y 15-113115 • 1 l.< 974-71�. IS 46
Workers' Curnpensa(ion Insurunce Affidoxit: Hui lders/Cuntractors/Electricians/Plumbers
%n )licant Information Please Print Le ihly
V it lnetnU,lneIs,I�rg3al r.&imm,l n J i I ,too ll:
CLly'smic./lp' 49"Vhoneit:�—�:2e,:z'. 6�11X
%, .In nu fat vmployer:'Chcck the appropriate bus:
l')PC orproject(rcyuired):
4 m a.-:neral contractor and 1 6, new construction
1. E3 1 aa1 J employer wish 1 a
❑
2. .nployecs(lull Jndlur part-time).• hate hired the still-contractors
1 .un a sole prnpriettx or partner- lismd on the attached sheet. 7. ❑ Remodeling
ship and have no cmployeas These subcontractors have g. ❑ Demolition
lc urking tier me in any capacity. workers' comp. Insurance. 1) ❑ Building addition
1 No workers'comp. insurance 5. ❑ We are a corporation and its
I re(Iuired.) officers have exercised their 10.❑ Electrical repairs or additions
}. E3 ant a homeowner doing all work right ofcxcniption per MOL I I.❑ Plumbing repairs or additions
myself.JNo workers'comp. c. 152. S 1(4),and we have no 12.❑ Ruul'repuirs
insurance required.j t employees. (Ko workers'
comp. insurance required.! 11.❑ Other
•\u. .y pkim nett checks tour,not must also f ill utn the seclmu Inluw showing 1169r worths'utnlpen W lJll puhCy mCi rn atium
' I lomcuw,wn who ud,nid this affidavit indicating 1Ae)ire doing all wvork mW thee him uulside cwurlen)n must submit a new JlGdavd mdiufmg.11.h.
-f',.nmwum Thal Chcck thusbox mtul Jaached.m ieJniunil nhael.Auwiuy Ill.n:n w of thv sub�onlractors and their wurken'comp,pulley mfurmamm
/mar an empin}•er rhul is providing Ivorkers'cua+peavarion in.<urmfceSur ury eurplopecs. Belory is (he pulicy and Job fire
infuronuriorr.
Ir.,urancc Company
11oli::v is or Sclf-ins. Lic. d: __.. .. . .. ___ Enpirauun Dare:
)oU Sita Address: _-_. City,SIJLC/ZIp:
.\trach is copy of the lvorkers' cumpenvation policy declaration pale(showing the policy number and expiration date).
Failure to secure cuserage as required under Sci.tiun 25A til'DIOL c. 152 can lead to the imposition of criminal penalties of a
tine up Io$1.500.00 Jnd/or one-year impti.s,minlnt, J<wCll JS LI%11 fXIIJI(ics in the form of STOP WORK ORDER and a fine _
Of up its S'_50 A0;t day Jgoinst file vi)laif. lic advised that a copy of this statement may be lot%irded to the 011ice of
111%t'IUl :11e DIA :o111.11enver.lge ler ilia.n:on.
Ido hereby t crrify corder r 1,411 01 renu/riev of perjury ebur the in/urination provided above is(rue uatl correct {
tl/ficiu/use only. /)u oral urirc iu rh1 urcu, ru hr ruurp/reed by airy)ur Io1vn a/liria/.
( itv or fawn: _ Per snit/License go
Issuing.\udlurify (circle noel:
I. It,1JrJ of Ile.dth ?. Ituddinq Dcpurtumut 1. l:il�.'fgnu Clerk J. L•'lectrical luspcclor S. Plumbing; lolpecfor
6. Other
Contact I'Lnun: .. _. Phone rl:
- 1
Information and Instructions
1.v s.i I,u,eiti General Laws chaprcr 152 requires a I i entplo)ers to provide workers' compensation for their employces.
Pur,u.ut to (:tis statute, in rmpruree is defined as - .ever) pci.on in rhe service of another under.illy contract of hire.
e apreNs or implied, oral or wrnten."
\n .•rnpluprr t<defined as "in individual, partnership, .sioeiatiou, corporation or other legal entity, or any two or more
.r rhe hrtegoing engaged it a joint cnierpnic. and including the Icgal representatives of a deceased enip lu)cr, or the
rccencr or trustee ul or utdrvtdual, pwincrihip,association or other legal cnnty,employing employees. However the
owner ofa dwelling house having not more than three apartments and who resides therein,or the occupant of the
,I vvelluig house of another who employs persons to do maintenance,construction or repair work on such dwelling house
JI' •1Ih the grouods; or building appurtenant thereto shall nor because of such employment be deemed to be an emplo)er."
NIGL chapter 152, i25C(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 villa has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally. NIGL chapter 152, a, 2547(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance utpuhlic work until acceptable cvidcncc ul-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 yuur situation and, if
necessary,supply sub-contractor(s)name(s), address(es)and phone ntuuber(s)along with their cerfiftcate(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 confimtation of insurance coverage. Also be sure to sign and dale the affidavit. The aff idavit should
Ile gemmed to the city or town that the application for the permit or license is being requested, not the Mpartment 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of die affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
1.1:asc be.sure to fill in the penniulicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitaicense 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)." 1% 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
(].e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lis: )bice of Investigations hwuld Ihke to thank you in adv;uicc for your eooperauoa and should )vu liasc ,iny guei(lot,
please du not hesitate to give us a call
fhc Daparnncot's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lavesdgadons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/dia
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CITY OF SALEM
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F, PUBLIC PROPRERTY
DEPARTMENT
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Construction Debris Disposal Affidavit
(required Ibr all demolition and renovation work)
In accordance \\ith the sixth edition of the Statc Building Code, 780 CMR section I 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal Iacility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
L Q�G
(name of hauler)
I he debris will be disposed of'in
(numr of Iacility)
I:\ddrcs. ur lacllity)
prnnrt applicant
late