12 HAWTHORNE BLVD - BUILDING INSPECTION ---------------
I� ►• The Commonwealth of Massachusetts
r
j-,�,..� Department of Public Safety
11 \le..,tahu.vl
IN SI-Ile BudJtng G-Je 1:AU C% 1a•cen I Edi lu,n
Wf) City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwellin
rho Semon For OfhctaI Ude Only)
Building Perm"Numlxr: Date Applied: Budding Inepecloc
SECTION I: LOCATION lNease indicate Block It and Lot s for locations for which a stree
>3t address is not available)
i(1� s�,iyM MA c;r��c �'/�fMc�r r��✓ Nva�,s'•p
..No. and Street Cnc /ToN'n Zip Gate .Name ul Building pf.tpphatblrl
SECTION 2:PROPOSED WORK
It New Cun trust on check here❑or chrck all that apply to the twu ruws below
-- - -E:asting-Budding -- Repair -Altrritiun-0— Addirkle-❑
-Brmulili.m-O�Plaur-fil4ont-and-wbmrl-Ay+prndra_J�----_-.-._.
Change of Use ❑ Change of Occupancy O Other ❑ cpr lfy:
Are building plan+andlur construction ducuments being supplied as part of this permit application? Yrs C3 ,4
Is an Independent Structural Engineering Peer Review required? Yes ❑ Nu
Bri&Descrlplion of Pruprtsad Work: _!I-Hd
ii�e cm
SE MON 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here it an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Croup(x): ,.
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CNIR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(vq.ft.)and Total Height(ft.)
SECITON f USE GROUP ICheck as a licable)
A: AssemblyA-I ❑ A-2r ❑ A-2nc O A-3 ❑ A•4❑ A•5 O B: Business O F. Educational ❑
F: Facto F•I ❑ f2❑ H: HI Hazard H•1 ❑ H•2❑ H-3 ❑ H-4❑ H-5 O
I: Institultonal 1.1 O 1.2 ❑ 1.3 O I.4❑ M: Mercantile O R: Residential R-10 R-2❑ R-3❑ R-40
S: Storage 5.1 ❑ }2 ❑ U: Utility O Special Use O and please describe belumv:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IAO I8 O IIA rl 118 ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7: SITE INFORMATION(refer to 780 C%1R 111.0 for details on each iter")
I
Water Supply: Flood Zone Information: Sewage Disposal: Trench Penni): ' Debris Removal:
I'ubhc❑ Cltccl,d•ndtt.le I I,r•tl Lune❑ L+Jlaur mumap,tl❑ '\ bench tall not hr Ltcrnvd Unlet...I Sne❑
I',la.dv❑ nr mdvnldt Lona':_ nr un.dr•c,i,m 0 rcquucJ O ur trcoch -r
I
)'ermlt r.antak Neal ❑
ItailruaJ nght-uf-way: - Hazards to Air.Navigation: alt 1L•1.•r„ r ..,,,,n,,,,
..n
\.•1 \pphd.ddvD I•�Inidlwv.+dhtn.nrpurl.+l•),ivadt arra• Llhctr u•uctdPm •
1 Icld dl'
..r lqud.lcml+wtl❑ ..r )r. ❑ \ ❑
SECTIU.V A:IOti TENT OF CFRTIFIGI fE OF UCCCP.INCY
/ f.{•c.q l . iyrm b.nt .____ t+aiulanllyd.l lrr llrn ,
IRe'� Thr 1•wLluq ant.tm.tn�hru+Llrr>t•h•m' - _ . . '
`I'ra tat�Upulabun.
r
SECTION 9: PROPERTY OWNER AUTHORIZATION ,
\'eme,ul.l ,\.1.1 ra•.n ul I'nq+crly Owner
1��� n y 72A F1)✓Ef' S v�✓L AM vt c17r7
yv.^hl'{'NS Lg,j_r'1G/ SOCs 1 /'j'-i'YII1
\an+r IPnntl No and Nrcrl lila• Lu'n "I'
I'rnlv.rlc lhux•r Cont.10 lnlormatiun: I�
rule rvlephone No.(buema:s) reivphone No. (cell) a• mea.Iddn•..
11 apphrablr. the properl% m ner hrretw authorizes
Name Slrvel Addrrns Clt\'i Town Stale lip
In act on the propvrit ora ner'.behalf, in all m.tllrr.relative to work authontavl by this buildin•j,rfmit a + plication.
SECTION 10:CONSTRUCTION CONTROL tPlease fill out Appendix 2)
III Inuldm•Is k t;than 15•lxx)cu.It.ut m,:hwJ•ua•anJ/or not uudcr Gm>uuanon 1pnurul Ihcn chink here❑and k.+Sralum III II
10.1 Re istered Professional Responsible for Construction Control
MhRK FZ�YMEf2 &i7 ..S3 . P_ M1I rens �✓6✓a: 1
_ tcrme-tRvN_V trap rep unr u. r-mat —id cess rgutratiun Number
Street Address City/Town State Lip Discipline Expiration Date
10.1 General Contractor
M A-RK PZ&Y M EE,
Om .1 yName: a CSS
kQ• ' I�kYM•:_11Z / dC
Name u(Prrvm It"gsible fur onslructiun License No. and Type if Applicable
Street Address 0• 0 ni- yto 8 Jt7__ /Town State Zip
Tele hone No.(business) Cs� Telephone No.(cell) - e-mail address
SECTION 11:WORKERV COMINSATION INSURANCEAFFIDAVIT IM.G.L.c.152.§ 25C(6))
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submilled with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a sign Affidavit submitted with this a licationt Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(labor Total Construction Cost(from Item 6) -$
and Materials)
1. Building f Q 10 G Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical f appropriate municipal factor)=5
). Plumbing f (J !r
Note:Minimum fee f (contact�stunicipall�j,,yyy)
a. Mechanical (HVAC)5
S. Mechanical (Other) f Enchk+e check payable to (–L•�//�
6. Total Cost f (mnlacl munici alit )and write check number herr
SECTION 17:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv attest under the pams.md penalties.if perjury that all of the Information contained .n this
.Ipplic.own Is trur and accurate 1, t e brsl ul my knowledge and under.Lmding. St
i I'Ic:nv uri(and•Ipn n.nne rule rcicphonr \� Ila lc
p
�Ilrct Wdr," Cit% r roa n �fafe /Ii., --
;7,C iv Ai e 5% w' M ll � lGf /
%fum:ipal Insprour to till out this section upon application approval: -_ a f_.[ - i
\.unr LI:a• i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I til:;X:1'Y:10.11:uI 1
\111tH 12C WASHING I 5.\tp1/,MAsS.11111 It,I IsJ197J
Tal.:11711-743-9393 a p.lx. 9711-740-93416
1V'urkers' Cumpensation Insurance Afrtdavit: Builders/Contractors/Electrlcfans/Plufnbers
Wnlicant Information Aa 7 �// �jn Please Print Leeibly
V8171t:IlluanH:aygrpmtvatinNlndmdual Y. `"/ /f-/`r\ /' Ay "z-lz
vi(Iress: i�1i r�J
CitytStarc,Zip: -9.IO/w 141/,1 c'/1`17 " Thune d: i� 17- 5-,1 8909
Are you ail employer:'Check the appropriate box: 'type orproject(required):
1.❑ 1 am a cmpluycr with 4. 111 am a general contractor and 1 6. New construction
employees(full andlur pact-time).• have hired the sub-contractors ❑
yOf7. I�qq Reanodelin
I am a sole proprietor or partner- listed on rhe anachcd sheet. : yrat ft
ship and have no cmpluyccs These sub-contractors have N. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
I No workers'comp. insurance 5. ❑ We are a corporation and its
rcquircd.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 ani a homeowner doing all work right of exemption per NIGL 11.2f Plumbing repairs or additions
myself.(No workers'comp. c. 152,j 1(4),and we hove no 12.❑ Roof repairs
insurance required.) r cmpluyecs. (No workers'
cmnp. insurance required.) 13.00ther
•Any u;rphca+d that checks bus el must ahu fill wt the wetian Wow showing Their wutkas cumpensmiws pulicy inhummiva
'Itumcuwmrs who atarmil this affidavit indicting'hay:na doing all work and then hire outside eaurae Tin most.udmia a new alydavil inJiuting mach.
dbntmcan that chuck this bas mlar ataehcd an additiuwl Aunt showing the mold of the mbaoauwtoa and their wurkun'carp,policy inlhrmariun.
/ant an employer flout is providing workers'eurnpetsation insamuce jut uty employees. Beloly Is floe pulley mrd job.silt
in/arinutiun.
Insurance Company Vaine:
Policy 4 or Sclf--ins. Lia N: -__ .. .._ Expiration Date:
)tib Site Address: City/Stale/Lip:
.\teach It copy of Ilio workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverdge as required under Section 25A ul'JIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.5110.00 and/or one-year imprisumncnt,an well as civil pcnallics in the form of a STIP WORK ORDER and a fine
oftip to)250.00 a day against the violator. 11c advi.+cd that a copy ofthis statcmunt may be forwarded to the Office of
111%01hatloila JI lliv DIA for iostarance covera.,L' lel'IIIcallon.
/du hereby cerrijy under the pains mrd penuldes u)'perjury that the in/urrnulion provided above is true Burl aarrcc6
Date _2
OQiciul use duty. Oo tool mire in this area. to be cutup/eyed by city or town d/jirifrL i
I
('itv or Town: - - Permit/I.Iccnsc q._
Issuinho Aulhorily(circle enc):
i
1. lit+mrd of Ilcalth 2. fluildio, Dcpartiucnt .1.(:iey"full it Clerk 4. Electrical luspectur 5. Plumbing; Inspector
6. Other -_
C'''hef I'crwil: _ -. Phone 7:
Information and Instructions w
.\laS&lcllusctls Gcneral Laws chapter 152 1equires alt employers to provide workers compensation for theiremployees.
l'llrsuanl to this statute,an emplured is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
\n a npluyer a defined as"in individual,partnership,association,corporation or tither legal entity,or any two or more
i the t trcguing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of-ill Individual,partnership,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
all not because of such employment be deemed to be an employer."
or ell the grounds or building appurtenant thereto sh
MGL chapter 152. Q25C(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 of to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of cumpUance with the Insurance coverage required."
Additionally. MGL chapter 152, a25C(7)states"Neither the commonwealth not 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 rill 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,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
:\ccidents for confirmation of insurance coverage. Also be sure to sign and dole the uftidavit. 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'rown Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided u 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 permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/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"rill 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 now 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 dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
the 0I lice tit 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 Dcparllncnt'S address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oftice of Investigations
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax H 617-727-7749
If:cizcd i-10-05 www.mass.gov/dia
L
CITY OF S. I.&%f, .NL L-uSACHUSETTS
• BL;MDLNG DMARTMEINT
130 W.ASHLYGTON STREET, Y°FLOOR
TEL (978) 74S-9595
FAX(978) 740-91M
KIJtBHRLEY DRISCOLL
MAYORTHows ST.Ptt:aas
DIRECTOR OF FLUX PROPERTY/BLII.DLNG 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 disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
144A-PK RAVME 2
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit a licant
date
lebnal(Iw
.As11 tscachusetty DepartfnenE
Board of Building Regulations and Stentlar>#ti
Gonstructio4 Surrvisol License
f SDens}ee �,t�'102387
iB
"MS1RK RAYMIt
n',' '
(( FO BOAC 448
SALEM MA01g9�70rif ,
Expiration 8H82012* F