0005 DERBY SQUARE - BPA-11-614 d
The Commonwealth of Massachusetts
Department of Public Safety :
%L1,1dnuctts St.,(e Building Code(,80 C\I R)Seven l h Ed I hon !
City of Salem
Building Permit Application for any Building other than a I- or 2-Family Dwelling
(rhes Som-tion Fur Official U,e Only)
Building Permit Noon Dula Ahpllyd: Budding Impactor:
SECTION 1: LOCATION (Please indicate Block s and Lot s for locations for which a street address is not available)
No. and Str t . Clv /Town Zip Code Name of Budding(It.tpphcabla)
SECTION 2:PROPOSED WORK
It New Cunrtrucliun check herr❑or cheek all that apply In the two rows below
-- Exr ting�mlding�--Repair-❑ -Aller ttfun-❑--Addili<an-❑ �rmuliliun-0 -FleasrTill.rut�na�-.ubmu-Appvndix;l4---
ChangeolUse O Changeof0ccupancy ❑ Other ❑ Specify:
Are budding plans and/or cumtructiun duatmrnls bring supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Enginrerin4 Peer.Rev w required? Yrs ❑ No
Oriel scnption of Prupo. d
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 Croup(s): f
Existing Hazard Index 780 CMR,34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business CI E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-I ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
T: Institutional 1.1 ❑ 1.2 0 1.3 R: Residential R-1❑ R-2 ❑ R-3❑ R-4 ❑
S: Storage S-1 ❑ 5-2 ❑ U: Utility❑ Special Use❑and (rase describe below:
Special Use: -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 118 ❑ IIIA ❑ - (IIB ❑ IV ❑ VA ❑ V8 ❑
SECTION 7:SITE INFORMATION(refer to 780 C\IR 111.0 fordetails on each item)
Water Supply: I Flood Zone Information: Sewage Disposal: Trench Permit:
Debris RemoraL•
Public❑ Chick If oubLle I I.,I Zunv❑ Indicate mumapal❑ A trench will not be Llcrmed Unpu"II ?"le❑
required ❑or trench ,r.peep%
I'ncate❑
or mden Ulv Zone:_ nr..n,dr•cerin ❑ F•ermn I.enc lord ❑ _
Railroad rot
ht-of-way: Hazards to Air.Navigalian: \L\ I bd..n, t .......... R,
\.d \pph,.Ildc❑ 1,1Irmlu1µ-+,,thut.urpurl.Ippu Llch arra' 1,their l'c, . ...n+t•lolod'
:+ Itud.l on, "10 I Vc.❑ ,-r.\n❑ lr.❑ \11 Cl
—�
SECTIU.V N:CONTENT OF CF.RTIFIC.\rE OF UCCCP.\NCY
I .Inu,il •I l .-J, -_ L-c l.I. upl•I r+1•r.q l� ny nl+lp nt t VC%1)'alrt l n.al torr l lion
II,•,. ih.•I,wl,Lnq.,n+um,tn�pnnAlrr?t.tam >pn'Ial�upul.lhw+� __ _...__ __-_____ i
I
SECTION 9: PROPERTY OW ER AUTHORIZA"r10N
\'.un• w 1 A.Idn•a.ul Pr t •rty O„'rare
\tour lPnitU N,r..uxt.” cel Cih; town Lilt I
Pn! .• % 0%,ner nt.t❑ In r .till, A
idr reiephone No.Ibu.anr•.) rely+hone Na. Icell)
If a(+phi 1,V.thele rnrely oanrr hrrrbv authoners
\'.tmr ?tn•rl.lddrrs - Clivi T m is ?Sate zip,
w act nn the +ra +vele o„ner'.behalf, In all matters relati%e to work .lulhurltrd by this(wldln• •rrmrt.t t -hcaiwn.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) -
I II l•uddm•u lo.Ifun li,tXx)cu.fl.,d o loa J>lace and/or o,tl under C.nulni,hon Conlml Ihvn check here 0.1... .k, +1•.h,m 10 I)
10.1 Registered Professional Responsible for Construction Control
I
r rp n
e-mall a esi egistration Number
Street Address City/Town State Lip Discipline Expiration Dote
10.2 Central Contractor "
Nam of Per.rm R",Mnsiblrjoil Cunslructiun License No. and Type if AppIible�
Sts Addr � - /�r ty/Town — State Zi qpermit.
Tele hone No.(business) Tele hone No.(cell)SECTION Il:WORKERS'COMPENSA ON INSURANCE AFFIDAVIT(M.G.L.c.152. 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be complesubmitted with thisapplication. Failureto provide this affidavit will result in the denial of the issuance of the buildi
Is a signed Affidavit submitted with this application? - Yes O No O
'SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
1, Building S BuildingPermit Fee=Total Construction Cost x
2. Electrical E — _(Insert herr
appropriate municipal factor)=$
3. Plumbing $ —
4. INechanical ("I"AQ S Note:Minimum fee=$ (contact municipality)
S. Mechanical (Other) 5 Enclose check payable to
6. Total Cast 5 D. (contact munici alit
)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Hv entering my name below, I herebv olfest under the puns and penalties of pequry that all of the nformatinn n mt•imed in this
ap)+licaf eon n tole•rad accura�iL��bvfof mvpnuwlyd• and underst.mding�a �1�/�l��r
title I ,Ic h,mr V, U.ile
Itrrrt IJ.Ira•" llh: Ln`tt �Ll to LiFt
� \lu m:ipal Inspector fn fill out this section upon application approval:
- amr I l.i;c
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CITY OF SALEM
PUBLIC PROPRERTY
o DEPARTMENT
.I Ur.:N:1'Y:)XINCA I1.
Ls rs'It I WA\HINt;l ON S I IELT • SALEM,MA&SM.Ill il.I ISO 07C
11•.i; )78.'43-9595 • h.sx. 978.740•7346
Workers' Compensation Insurunce Affidavit: Builders/Contractors/Electricians/Plumbers
\pnlicunt Information Please Print LeCihiv
Na Int: l0uunessi OrganbmioNl nJmduaO:
Address:
City,Slaw,Zip: Thune
Are you an employer!Check the appropriate box: 'Type of project(required):
L❑ 1 ant a employer with 4. ❑ I :un a gencml contractor and 1 6. ❑ new construction
cnyslJyccs(toll and/or part-tine).` have hired the sub-contractors
2.[�I am a sole proprietor or partner- listed on the anachcd sheet. 7. remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
No workers'comp, insurance 5. ❑ We aro x corporation and its
required.)
oBiccrs have exercised their 10.[]Electrical repairs or additions
-
3.❑ 1 ant a hltlmel MInCr doing all work right of exemption per NIGL I I.❑ Plumbing repairs or additions
myself.[Ko workers'comp. c. 152,¢1(4),and we have no 12.0 Ruuf repairs -
insurance required.] t cmployccs. (Ko workers' 13.❑ 011ier
comp. insurance required.]
••toy aylhca t that chucks box 01 must:Jae till our the scaimt Wow showing their w•urkws'cumpcn a iou pulicy iolunruuiun
'I lom.uwnun whu smhmil this atlldavil indicating Ihcy are doing all work and then hire outside cwuractors must suhmil a new alydavit indicting.rich.
d\,ntra,urr that check this box rtrt anachcd an additional sheet showing the rant¢of the sub-conuwlors and their worker•comp.policy infurmatiun.
I mn mt employer drat ix providing workers'c i pen.vntian insurrntee jar osy enaployeec. Below is the policy and jab.vile
injarmutiaa Q /j
Insurance Company Name: /^ _.....__......-._----- �+r
11ohev 4 or Self-ins. Lic.0: o1 aoo,/ _�a __._ Expiration Date:
Jobitc :\ddress: t coy;Statcizip
Altuch it copy of the worker cum •n.sation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A uf.%lGL c. 152 can lead to the imposition of criminal penalties of a
fine kill m 51.500.00 and/ur one-year intprisomncnt, as well as civil penalties in the furm of a STOP WORK ORDER and a fine
of up ms 1250.00 It Jay against the violator. He advised that a copy of this statement may be furwarded to the 011ice of
Insranguunns ul'the UTA for insur:uxe airouage sen hcatlun. '
l da hereby certijy under the )a/tinmay'/mldd p7enulties ufl icHury that t/a injurmullon provided above is true and correct.
Official use only. Do not Ivrite in this arca, to be rouapleted by city or town official
City or l'own: _ Permit/Licensc0 _._.
Issuing Authority (circle one): i
1. Board of lieallh 2. Building I)cparttucul J.Cily/1'uwu Clerk J. Electrical inspector 5, Plumbing Inspector
6. Other
Contact Tenon: __ .. Thome:
Information and Instructions
.Massachusetts Gcncral Laws chapter 152 tequires all employers to provide workers' compensation for their employees.
Pursuant to this statute, in empforee is defined as"...every petxon in the service of another under any contract of hire,
cypress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
d the 60reeoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of :m individual,piumership,assocmtioa 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, v+25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of it license or permit to operate a business or to construct buildings in the commonwealth for any
:applicant who has not produced acceptable evidence of compllance with the insurance coverage required."
.additionally. NGL chapter 152, sv'25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ul'public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till 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, ore not required tocarry 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 Departrnent at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Ofnclals
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 till in the permitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicettsc applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and ander"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 cite 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 hone 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 burn leaves etc.)said person is NOT required to complete this affidavit.
I he Ol hcc 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 Dcparnncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of lovestlgations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
Itcviscd i-20-05 www.mass.gov/dia
CITY OF SALEM, .8LvL-kSSACHUSE-rrS
• BUILDING DEPARTMENT
110 W.1.iHLNGTON STREET, 3e FLOOR
TEL (978)74S-9595
FAX(978) 740-9846
KI\BERLEY DRISCOLL
MAYOR THo.+us ST.PtFRRs
DIRECTOR OF PUBLIC P1tOPERTY/B1:nDLNG CONNISSIONER
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 # 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
111, S 150A.
The debris will be transported by:
Q�/�/f'1;I' Gva/Jrlair'�l
(name of'hauler
The debris will be disposed of in
(name of facility)
/(address of facility)
J'
signature of permit applicant
(late
Iebnailf J.k