15 FRONT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Vte_� ,•. Department of Public Safety
.F hu•a•1L?tate Budtling Cudel•-80 C]IR)wenth Edntun !
00 City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
t rhes S chon For Official Use Onlv)
Building Permit Number: Date Applied: Budding Inspectue i
SE N L LOCATION IPlease indicate Block s and Lot s for locations for which a street address is not available)
No •me)ltreel C m /Tutvn Zip Code Name of Budding(it applicable)
SECTION 2:PROPOSED WORK
If New Cuns_tructiun check here❑or check all that apply in the two rows below,
Exi ti �^—(:':e.:x•-/i)fawl�nd-subm u-A}�prrt
Change of Use ❑ Change ul Occupancy ❑ Other ❑ Specify:
Are budding plan,and/or construction documents being supplied as part of this permit application? Yes ❑ N
o
Is an Independent Structural Engineering Peer Review required? Yrs ❑Brief Descnptiun of Pruposad Wurk: 2e e n WlSECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDIN NDE GOLNGRENOVATION,ADCHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing UseGroup(s): - Proposed:UseGroup(s):�•
Existing Hazard Index 730 CMR 34: Proposed+Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)k Area Per Floor(sq.ft.)
Total Area(Al.t1.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 Cl A-2r ❑ A-2ne❑ A-3 ❑ A-4❑ A-5❑ B: Busineee ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: HI Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-Z❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use: .
SECTION 6:CONSTRUCTION TYPE(Check as applicable) -
IA ❑ 18 [3 IIA ❑ Its Cl IIIA 13 11180 IV VA ve ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
I
Water Supply: flood Zone Information: Sewage Disposal: french Permit: . Debris Removal:
I'ubbc❑ l heck il,nd•ide Ph+•tl Gma•O Inabc.ilr mumc,)•al❑ A trench will nut be Licrn.arf U,.p,,...I gape❑
required Our trench ,•r.pearl.
t I'mala•❑ ,•r mda•nldi Z,ina•:_, ,.r nn.,tr.r.lrm❑ permit is rnclo•eal❑
t
I Railroad right-of-way: Hazards to Air Navigation: \1%I L.0•ri, t .•„nn..•,.•n t;,„ „ ;,
\••1 \ppla.tblr❑ LIO,u:two,a.ohm eup,•rt.tppu,adian••i' Ltha•ir'C' cu onn)•IcIrJ' i
.., l-..,.a•nt u•Ikuhl vnah•.v,l❑� lt•.❑ ••r\„❑ lv-❑ \,• ❑
SECTION 8:CONTENT OF CERTIFICA fE OF OCCUPANCY
I .binm,•ll •,Ic , .__L+ l.i,•u/v.t (.pv••1l m.I n,.U..n ____ l iact.l•.111t I...ad 1-,-rlLn•a
I h•r. the hud.lu.q..•nLtm.m�pnnClor N dem' �I•rcial`Iry¢i hili"^` ..__. _—_
SECTION% PROPERTY OWNER AUTHORIZATION
tine.md .\dd ray.•u 1'ruprr t r Owner
2Pert'Met[) � r E'Qir� Xa..md ilnrl lua; linen hp.—_ .
I'rul•erll'1ha❑er(unmct In/urmalwn-
t14
eoF- 8Y,3 �C RaB. �yo. a8�o P,"R;wna��daol._
(.dr ownev� relephone No.(1Hr.+pa•.0) relephone No (c w a-mad d,lrv—
I(ap}•hceblr,:,the pn+prrlc uac ner hereby.luthantrs Celt QtarlNy+a
Tn�lit [ r�f1�i [�(-�al�yvr ,er.� GL�uc�ar� Mme• 190
\ame ?beet AddlrnV Cow Town State Lip
td act nn the •n+tart%+na ner'.behalf,m all matters n•latire w work authonnd by this buldm• •remit a + •hcauon.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
111 lanldm•is lox Ilan li,UlUcu.It.til.•ndu.aJ%un•and/or n.tl urhler Can+ntrwhon Cuulrol then check here O and-lr .5aaeun IU 11
10.1 Re istered Professional Responsible for Construction Control
eleptione No. a-mala cess R egutration Numlb
Street Address - - City/Town Sta to Lip Discipline
10.2 General Contractor
J d SC k T •
Cumpan g u s
I
Name of Pers+>n Respamsible fur unstruction License No. and Type if Applicable
�p— s( fid•
too Cs s1- a143o
Street Addresb City/Town State Zi
(�'�Q P
-- 1 {4- ad�Jolv'a1@lsnrlele hone No.(business) Tele hone No. cell) - e-mail address
-SECTION 11:WORKERS'CO ATION INSURANCE AFFIDAVIT IM.G.L.c.152. 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents mustbe comsubmitted-with this application. Failure to provide this affidavit will result in the denial of the issuance of the bu
Is a signed Affidavit submitted with this application? - Yee O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor +y
and Materials) Total Construction Cost(from Item 6)-S 0.+-a
1. Building S �� lea' BuildingPermit Fee=Total Construction Cost x /
2. Electrical S _(insert here
appropriate municipal factor)=5
3.Plumbing S -
1.ldechanical (HVAC) S - Note:Minimum fee=f (coAt�municipality)
5. Mechanical (Other) f /\''/) t -
S ,� Enclose check payable to
6. TnWI Cult - Ood (contact munici alit )and write check number here
5ECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By i-ntermg my name below,I hereby attest under the pains and penalties of perjury that all of the mfrrrm,164in"'n6imrd in this
Application is true and.rccurate to the best of my knowledgeand Understanding.
J03t126 F_ (i�__ Dale
�� �
Llo.nc pnm.in.l-ign name taste
''=f G)ouGCS ) C� It'
. d
�h rel hldre,, int: Tunas �t.tt r • —
}
i \lutwipal Inspecturto till out this section upon application approval:
I
J. �4 CITY OF SALEM
PUBLIC PROPRERTY
l �D DEPARTMENT
12C WAYMIM;I US STx ELT • SAI E.101,MAMMA II %I S 5197
fr.l.:918.745.9595 • f.ss. 979.7+C-M46
Yorkers' Compensation Insurance Affidavit: Builders/Contracturs/Electricians/Plumbers
%onlicant Information (� Please Print Leeihly_
Name Inucwcss/OrgbnintioNlndlv�duull: L� 0 S C (� FJ d rCle
Address: ACLjefo'
City'stalci%ip: dei_ siT o4 619 3d Phone ii: �l 76" �'0 — Q�l l
i%ore you an employer'.' Check the appropriate box: 'Type of project(required):
I.❑ 1 am a employer with - 4. ❑ I :un a general coutraetor and t 6. ❑-new consiruetion
cntpluycus(full and/or part-time).• have hired the sub-contractors
2.(y7 1 am a sole proprietor or partner- listed on the attached sheet. 7. (� Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working lir me in any capacity, workers' comp. insurance. 9. ❑ Ouilding addition
No workers'comp. insurance S. ❑ We are a corporation and its
10.[3 Electrical repairs or additions
required.) officers have exercised their
3.❑ I :rat a homuuwncr;Juing.all work ..... , _,right of exemption per MGL ,11.0 plumbing repairs or additions
myself.iKo workers'cunip. C. 152,§1(4),and we have no 12.❑ Ruuf repairs .
insurance required.) t employees. [No workers' 13.0 Other
comp. insurance required.]
•A�p upphama that cheeks box ill must also till uut the section below showing Ihoir wohua'cumpensation pulicy intiantatim
't I%ma,wmn who adtmit this affidavit ind;uting Ihcy are doing all work and then hire outside cumrmson,must submit a new air-davit indi"ing o¢h.
d'omrtcmrs that check this box,must attached an addaiunal.heel sh,a,mg the%nine of the sub axn ractots and their wurkers'cornp.ptdicy information.
I our un employer that Is providing workers'c•oinpen.ration insartutce fur my unployeev. Below is Ilse policy mrd job.site
iuforinalion.
Insurance Company Name:__..
Policy is or Self-ins. Lie.n: ____.. _.. .._ Expiration Date:
Job Site Address: City;State/Zip:
Attack it copy of the workers'compenxanon policy declaration page(showing;the policy number and expiration data).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal-penalties of a
line up to 51.5110.00 and/ur one-year imprisonment, us well as civil penalties in the Turin of'a STOP WORK ORDER and a fine
of up to 5230.00 a Jay against the violator. lie advised that a copy of this statementinay be forwarded to the 011ice ut'
Inv.angaunns ul the UTA for insuratxe awcruge scrilicatiun.
1 do hereby terrify under of ie painsand penal iev ufperjnry that the infurmudon provided above is true and correct.
Official use unly. Do not write in this arra,to be coutpleted by city or town official.
City or frown: Permitil.ictme 4._
Issuing.\Whurity(circle title): _
I. Board of licalth 2. Building Mparnneut 3.Cil).1'owtl Clerk 4. Llectrical lucpecror 5, plumbing Inspector
6. 011ier
Conlacl Terme Phone 1:
Information and Instructions
>lassachuscus General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,in emploree 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
d the Gxeguing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of :ah individual,partnership,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 an 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 cumpllanci with the Insurance coverage required."
Additionally. MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please f ill 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 nuniber(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 docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
-Xccidents for confirmation of insurance coverage. Also be sure to sign and date the•affidavit. The affidavit should
he remmed 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 question regarding the law or if you are required to obtain a workers'
compensation policy,please call the Dcpartrnent 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.
I'icase be.cure to till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicerse 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 due city or town may be provided to the
applicant as proof chat 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 bum leaves etc.)said person is NOT required to complete this affidavit.
I lie 0I lice tit Investigations would like to Thank you in advance for your cooperation and Should you hate:my questions,
please do not hesitate to give us a call.
The Deparunem's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OIHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
tai>ed i-26-05Fax N 617-727-7749
i -
www.mass.gov/dia
THE TRUCK
TRASH & DEMOLITION REMOVAL
HAULING &CLEAN OUTS
ALL TYPES
ALLEN G.YOUNG P.O.BOX 6084
(978)281-2773 GLOUCESTER,MA 01930
CITY OF S�UE.Nl, ,LxSSACHUSETI'S
BI;II.DLNG DEPARTM&NT
' 130 WASHNGTON STREET, Y°FLOOR
TFy (978) 74S-9595
FAX(978) 740-9846
Kimmju RY DRISCOLL
MAYOR THo.WSST.PtERaB
DIRECTOR OF PUBLIC PROPERTY/HCILDLNG COMMISSIONER
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 c 40, S 54;
Building Permit# is issued-with the condition-that the debris resulting from
this work shall be disposcd.of in a_ properly licensed waste disposal facility as defincd by MGL c
111, S 150A.
The debris will be transportcd by:
the lrvcit-
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility) .
Watureofpermi applicant
ld
° datC
I.bnvlf.law:
\lassachuuttx - Department nt Public Satoh
Board 4 Budding Re,-,ulafiuns vnif Standards
Construction Supervisor Lf,ease
License: CS 59445 .
Restricted to: 00
r
4.nF
' "JOSEPH F�'BORGE
6 EDGEWOOD RD
GLOUCESTER, MA 01930
4
Ezpiratiorc 5!5@012
(b llnikswwr .T�.26545 .
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