21 GOODELL ST - BUILDING INSPECTION 1
The Commonwealth of Massachusetts
r Department of Public Safety
-It State Budding Code 1•,SO C\Ili) *,-%vnlh Edit I"n !
City of Salem
Building Permit Application for any Building other than a I-or 2-Fimily Dwelling
Ji�sv
(Thi,1rcnon For Ufbcod U.r Only)
Budding Permit .Number: Deli Apphrd: Building Inspector:
i
• SECTION I: LOCATION (Please indicate Black a and Lot a for locations for which a street address is not oval la ilei
-2-1 !�aodeh aaaa Salco,, (7tggo j
\o.and Street Coc /T,.%,it Zip Code .Name ul Building pf.tpphcahle)
SECTION 2:PROPOSED WORK
If New C, tructiun check here❑or chrck all that apply In the two rows below
-- -- --Exr..cmg-Burldinh EI-- lemulititt C-(Pleas ill jul�pd-::ubm+t-Appendix-1-)
Change of Use ❑ Change of Occupancy Q Other ❑ Specify: 0_1�fb"� s�.Z'` Q y t"A 11 4Z &-, )%
Are budding plans and/ur construction documents being supplied as part of Ihis permit appiica lion? Yes ❑ No GY
Is stn Independent Structural Engineering Peer Review required? _ l Yes ❑ No ❑�
Brief Description of Prupowd Work: s Q- t/�i L d, 1 Li r n
(Lc�P/Air Fxiff nq Gia)gT v s'w;(� FS "7�a
•n�-'r-P- rc�;f ncl
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): f
Existing Hazard Index 790 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA -
- Existing Proposed
Nu.of Floors/$furies(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 q'-_A-3 ❑ A4❑ A•5❑ 1 B: Business ❑ E: Educational C1F: Facto F-1 ❑
F213 H: Hi Hazard H-1 ❑ - H-2❑ H-3 ❑ H-4❑ H-5❑
1: Instilutional I-1 Q 1-? Q 'I.3❑ I.4❑ M11: Mercantile❑ R: Residential R•i❑ R-2 ❑ R-3❑ R-4 ❑
S: Storage S I El
S-2 ❑ U: Utility❑ Special Use❑and lease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB [3 IIA ❑ 118 IIIA ❑ -1110 1IV ❑ VA CI V8
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
-Debris Ii<muval:
Water Supply: flood Zone Information: Sewage Disposal- Trench Permit:
'
Put+hi❑ � l'ha'ik d,ndrida•Il.x,d Zune❑ Indir.tlr mumapal❑ A Trench wdl not he Liicmed Un)+a•,+I dila•❑
•
required ❑or trvoch .,r
I'nralr❑ i.I ,„r 110cnl,1% Zone:_ ,.r on•dr•corm Cl hermit n rndn•rJ ❑ _I•
Railroad right-of-way: ffatards to Air Navigation: \1\ I L•L•n. t ..,nnu.......R,..,,, ;•r--
\,.I \f•yl.'A'le cl 1•struatuie a tlhm.urpnrl.q+prnaih sura' 1•Ih"r iva ie.+ c.anl•I.IcJ• i
.., l .•n-.•nl b, Ittu 1.1 ona6,•c I Cl I No•❑ ,.r\u❑ Nr•❑ \„ ❑
—JI
SECTION 9:CONTENT OF CERTIFICATE OF OCCUPANCY _J
I .idbnl .•Il qlc __ L-c ldniif9.1 ___ ft l`a'.q l•.n•Irlli h..n -_ t'iiUl`.1111 I,,.NI f•rr L.,a ._.. __.__ _._.
16.r.dtc i`w l,hoq.,nn.un en shnnAlcr�t.I a•m' - `I•n ial sliprd.t lion•
SECTION 9: PROPERTY OWNER AUTHORIZATION
\'sone end .\d d rias ul Fr, pvrly Onner
'
n A/AGA- ks Pollcom6sT. se-/-n_ aq o
\,m+r J'rmtl No.and Sircel l il+ , Gnyn !'1.
I'rnperlr sh.ncr(••entad lnlurmauon:
� �rcr n )1�hrfl�Rlti ����5"g'yS� ,WILA Comefi6l- P f
rrtlr rete+hone No.Ibustns:s iiia •hone No ak�1
F 1 F lirl4 e�muil .t.IJ rt•.. i
II al+phioblr,the pn+prrty uw nrr heretw outhontrs t
F:
\.Ime Street %Jdreas City Town Slab Gp
b•ad,es the *rc+•c•rtc•nyner'%behalf, m all matters rclatne to work authorized by this budJm • 'rrmlt a + ,lies 5 n.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) ✓�
111 bwldm•is lo.than 3i.0tit4u.Ir ut endussJ +ar¢.utJ/ar nal undvr C•maruchun Conlml then check herr incl mak+ +\vlum to II
10.1 Registered Professional Responsible for Construction Conlrol
• hes •ni) I rep one No. a-mat ad rens Registration Number
Stunt Address - City/Town State Lip Discipline Expiration Dote
10.2 General Contractor
Company Name: -
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents mustbecompleted 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 application? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1. Building s –76c)
Building Permit Fee-=Total Construction Cost x_(Insert herr
2. Electrical s r QO appropriate municipal factor)=s
3. Plumbing s
N. Mechanical (HVAC) s Note:Minimum fee=;s (contact municipality)
5. Mechanical (Other) f
Enclose check payable to
6. Intal Cost $ bd
(contact munici .Jit )and write check number herr
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Hy mining my name below, I hereby attest under the pains and penaltle,of perjury that 611 of the inhumation - nLimed in Ihn
.tpplicalwn is true and accurate ht the best of me kpuwledgaand understanding.
(�dt3EnT /�lalt�a�n� �� Ow/�ei� ��� • 5/s"�ys�'
I'Iedv hint,and 11gn Mimeftl __---- —r--,--_—
iy it ephon
rel 1 ddrr..
('m: fats n
1
Municipal Inspector to till our this section upon application approval: -__ (•Lr7Y�� __ �(
l
\,nnr
CITY OF S.0 E.NI, Uiss kaius=s
BI;MONG DEPARTMENT
' 130 WASHLYGTON STRM.Y°FLOOR
TEL (978)715-9595
FAX(978) 79846
KIM BERMY DRISCOLL
MAYOR THO.NA.4 ST.PtERR6
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG 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 l l 1.5
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 disposed of in a properly licensed waste disposal facility as defined by MGL c
(11, S 150A.
The debris will be transported by:
RpPe- -F Akrirhrim G Ylie//0
(name of hauler)
The debris will be disposed of in
G - MCI is
(name of facility) '
(address of facility)
signature of permit applicant
k 7,12 e/ / -
date
Icbnadf Jk
CITY OE S:1LE\1, , LS,SSACHL;SETTS
BUILDING DEPAM.I&NT
120 WASHINGTON STREET, 3aa FLOOR
• 11Fs.. (978)745-9595
Eta(978) 740-9846
Iu\jBERt Ey DRISCOLL T tOFLUST.PIERRE
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING COILMMEONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.. � licant Information / Please Print LeeiblY
Valve(Busickyt.Organizatiorvindividual): RO�rri" 1 !A/L IV)
Address: ys r�/yltewlkl r'47<_-s5F
SNIev t Vif_ 011219 0 Phone M: ��" 7y} 'q3r_)
City/State/Zip: r
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
ells to les full and/or part-time)." have hired the sub-contractors
p Y ( 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet.:
ship and have no employees These sub-contractors have g. ❑ Demolition
workers'comp. insurance. q. Building addition
won ang for me in anycapacity. ❑ g"
[9,'��workers comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
.equircd) officers have exercised their
,�,/ right of exemption r MGL 1 I.❑ Plumbing repairs or additions
3.1y1 1 am a homeowner doing all work b P per
myself[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' I3.❑Other
comp.insurance requin:d.l
'Any apphc:un dun logics box rl mass also fill out the sections below showing thea workui compenWiun polity information.
t I l.neno mn,who submit this affidavit indicating they me doing all work and then hire outride contmctom mast submit a rurw afndavit indicating well.
:Cummusm that chak this box main anxhcd nsn additional shat showing the name of the subsonnra0M and their workers'romp.policy information.
I am as employer that is providing workers'compensation insurance for my employees. Below Is the poUcy and job site
information.
Insurance Company Name: _.._
Policy 4 or Self-ins. Lic.t✓: Expiration Date:
Job Site Address; qEwjle)[ S City/State/Zip: c19k- A4 M,CI
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL 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 tine
of up to 5250.00 a day against the violator. Ile adviacd that a copy of this statement may be forwarded to the Office of
Investigations uPdrc DIA For insurance coverage verification.
/sins lrereby c errtif/t corder pulns nmrd p nalllu ujperjury that the information oa provided above true and correct
skmaItre li & l..t 4 p/n/A„.—//l/ Dour. Z_/ ]Z/?,1 / I
Phone
O/ficial use only. Du not write in this ureas to be completed by city or town afflivial
i
City or Town• _--
Issuing Authority(circle une):
I. Board of lieahh 2. Building Department 3.Citylfuwn Clerk 4. Electrical lnspector 5. Plumbing Inspector
6.Other
Contact Person: _ . ._-- -- Phone tl:
i
Information and Instructions
Massachusetts Gcneral Laws chapter 1 i2 requires all employers to provide workers' cuirpensatnon t6r their employees.
I'ursu:ult to funis.unite,an rmplured is defined as"...every person in the service of another under any contract of hire,
c%press Or implied.Oral or wriuen."
An employer is defined as"an individual,partnership,association,corporation or tither legal entity, or any two or inure
d the foregoing engaged in a joint enterprise,and including the legal representatives or a deceased employer,or the
receiver or trustee ui .tit individual,ptutnership,;usociatioa or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartment and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenunce,construction or repair work on such dwelling house
or in the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, ¢25C(6)alio states that"every state or local licensing agency shag withhold the Issuance or
renewul 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 comptlance with the Insurance coverage required."
.additionally. MU chapter 152, §2517(7)states"Neither the commonwcahh nor any of its political subdivisions shall
crier 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."
Applicant
Please fill out the workers' compensation affidavit completely,by checking ilia boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificatc(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
he retuned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accident. 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 cotnpanies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete;ted printed legibly. The Department has provided a space ut the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Plaasc be sure to fill in the permiulicense number which will be used as a reference number. In addition,an applicant
hat must submit multiple pennitllicense applications in any given year,need only submit one affidavit indicating current
policy infra oration(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 flnture 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
t i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he 01lice tit Investigations would like to thank you in adv:mce fur your cooperation and should you have;any questions,
pleusc du not hesitate to give us it call.
fhe Ucparmnent's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Iovestigatlons
600 Washington Street
Boston, MA 02111
"Pel. N 617-727.4900 ext 406 or 1-877-MASSAFE
Rc.iscd �-_'G-(IS
Fax M 617-727-7749
www.mass.gov/dia
I