10 1/2 LANGDON ST - BUILDING INSPECTION t. The Commonwealth of Massachusetts
(,r�,.•�' Department of Public Safely
\la.•odmnvll.dale 01ddrng Code 1%90 C\114)Savenlh Edm,.,
- City of Salem
Building Permit Application for any Building other than a I-or 2-Family Dwellin
I rhtn Semon Fur Dlfaaal U•e Only)
(asp Building Penna Numlx•c Dale Applied: Building In pact r:
SECTION wN 1 LOCATION IPlease indicate Blackill andt Lot
�111 for loci lions for which a street address is not avidablel
`ANI Jl = G 4 / /�
i LArUGvr, SrS�C�✓'m
No.and Streal Calc /rowan zip Gale .Name ul Building pt.ipphcat•le)
SECTION 2:PROPOSED WORK
It New Cunetrucltun check here O as check all that apply in the twu ruws below
" - - Eatating-Building' - Repair - -Alleratiun-0--Addi/nnaO
-O�muliliun-❑-({rlraseIill-.w I-and-.ubmws-Aypendrx-i} ---_---
Change ut Use ❑ Change of Occupancy O Other O. Speedy: L, •j
to
Are budding plans and/ur cunstructiun ducuments being supplied.0 pan of this permit app icaliun? Yes O -INU ❑
Nan independent Structural Engineering Peer Review required? Yes ❑ N ❑
Bra!(Description of PruPat Work: �. 1S'Y)A i
SECTION 7: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) O
Existing Use Group(s): Proposed Use Croup(s): r
Existing Hazed Index 7110 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
Nu.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION f USE GROUP(Check as applicable)
A: Assembly A-1 O A-2r O A-2ne O A-3 O A-4❑ A-513 Bl Business ❑ E: Educational ❑
F: Facto F-I ❑ F2 O H: HI Hazard H-1 O H-2 O H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1.2 O 1.3 131.1❑ M: Mercantile❑ R: Residential R-10 R-2 O R-3❑ R-4❑
S: Storage S-1 ❑ 5-20 - U:-'Ulilily O' •- - - Special Ust O and Elvase describe beluw:
Special L'..r: i
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA O IB ❑ IIA ❑ 118 O IIIA ❑ life O IV O VA Cl ve O
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
I
lvaler Supply: Flood Zone Information: Sewage Disposal: wench Permit: ' Debris Removal:
Public❑ l'hv�k J oulada•IL.ni Lona❑ Inwbc.wle mumop.d❑ '\ Trench wall nut be Lacen•ed Ua•po•ul time❑
I',1%.1Ia❑ or mdcnblw Zama: ..r nn.ale• requued❑or lrvilch --r•Irak.
I — vtrm❑
)`armtt a.cnclu•aal ❑
i Itailroad raghP0/-waY: fluards to Air Navi anion: ll\ I L• ---
ll L•n, a .....liar......I: '
\ I \pphw.abL'D 1•11ruwluav ulllgn.)I rie.n.apl•tnach,an•.a' I•thcu ra.lea :.an)•Icla.l'
..r l .m•cnl to llud,l
.,,j 13 )c•❑ .•r\o❑ Cl V. ❑
1w•
SECiIU.N 8`C ON TENT OF CERTIfILA iE OF UCCL'P,\IVCY -�
I .I d I•n a. I ( -J, an•u
.__ L-cll a. __ rw y' q l „nyrlh In nl 1
i ___ t afra)•.uu I ••.a.t ice I L.,n
I by- Thr Dud,hnq.,nn.un.rn �l•nnLlrr?a•u•m• •paaaal•Ilpulala.m• ... _ -.. I
dr C
SECTION 9: PROPERTY OWNER AUTHORIZATION
V.ut .ui.l ,\.LlreI Vrol crly Owner I 0!9110—D
3�i4 ' r,r, �y t�J 10An� OG71S� �m — 1-
\.mer Il+n'10 .Nu.and Nrerl lett , r,,%,n "I+
I'n,l+crh'lltt ncr l „nl.tcl In lurmdllun:p ) )(t /� /r J./f
.,�ct/N ay_ 91L. 1-L.11.• l / V N
rairTelephone Nu.Ibuans:sl Telephone Na. (Cell) C-mad .tJJ n•.•
pr ,ert% +it,neer herietw.mlhurites ply/
Name Street Address Civ/Town State lip
to.10,ns the ro carts +n,net behalf, mall mallara relaucr to work.rulhnnted by Iht.buthhn + permit.t + plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
in l•uddm•is lt•+a than Ji.011aICu.It.of cnck,v I ace and/or not under Condrudum Gntlrul Iha•n check nice❑and 4-v Se.mm 1011
10.1 Re istered Professional Responsible for Construction Control
.- Mmmr-f{Yrgrtran i rp tine u. ti-mala cress egutratian Number —--�
Start Address City/Town Mate Zip Discipline Expiration Date
10.2 General Contractor
=, PQfrl+ T
Company Nam : C56a9
Name of Perste Rerlxnsible for Constructiun License No. and Type it Applicable
t/ Qom'� h 5 'f' L dig.
Street Address City Town State Zip
Telephone No.(business) Telephone No.(cell) email address
SECTION 11:WOR SATM [NSUANCE AFFIDAVIT(M.G.L.c.132.4 25C(6))
A Workers'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 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).f
1. Building f U Building Permit Fee a Total Construction Cost x _(Insert here
2. Electrical f appropriate municipal factoi)=f
1. Plumbing f
a. Mechanical (HVAC) f Note:Minimum fee.f (contact muni ality)
5. Mechanical (Other) f Enclom check payable to
6. Total Cost f J (; (contact munici alit )and write check num er herr
SECTION IJ:SIGNATURE OF BUILDING PERMIT APPLICANT
Re vn tering my name below, I herebv cutest under the pains and penalties of perjury th.lt all of the in forma tion..in t.r mrd in Ihis
.rpplicatu,n ie trite,nd acn+rate to the bed ui my knuwlrifgr and undrritendm�.
_ ThLL1AriP
iI'Ir.i..•peel .m/dr•�pn n.unv / y-- rale It ph„nx•
._- / �/'r'.3 N L/ /_,//1v/ I�/�- ,([.per; �•�'
—�—v--�-•—• --�-s-•--ter
�licrl \.f.lre.. lift: Lnvt �t a Lip
\lunicipal Inspector to fill out this section upon application approval: -__ �. )�1
Jr.
Van r / �
CITY OF SALEM
; I� PUBLIC PROPRERTY
DEPARTMENT
.iw:l aI 1'Y UnlXa.11
\[%1t nt 12^.WARnMi I t^5T8 ELI'* inlp\1,M.cw.u.l II iP.I IN J1.)
l-e.l.+973-713-9595 a F.tx. 979-74;2-'M46
workers' Compensation Insurance affidavit. Builders/Contractors/Electricians/Plumbers
kofilicant Information Please Print I-eeibiy
Nil Inc t Ijim livvs/Orgrmralian/1ndivlJuul l:
Address: it/% SCP S�
City,Starci%ip: P74 . 6 130"ct 2 Thune ii: 7i?1 � s`S�l— t/Ris�/
�you an employer:'Check the appropriate box: Typo of project(requiied):
I I.1J t am a empluyur wish_:� 4. ❑ I :un a grncni contractor and 1 6. ❑ New construction
employees(full undlur port-time).` have hired the sub-cuntracturs
2.❑ I ant a sole prnprictor or partner- listed an rhe arched sheet. 7• ❑ Remodeling
ship and have no omployces These sub-contractors have 8. ❑ Demolition
working lin Inc in any capacity. workers'comp. insumnce.
9. ❑ Building addition
I No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10•❑Electrical repairs or additions
3.❑ I ;un a homeowner doing all work right of exemption per NIGL 11.0 Plumbing repairs or additions
myself. [Ko workers'comp. c. 152,q 1(4),and we have no 12.❑ Ruurrepairs /
insurance required.) t employees. (Ko workers' 13,❑011ier l /..
comp. insurance required.)
•any:gga'ca l nwt cheeks bol ill must also Jill out Iha v ction Wow a'owing'heir wutko i cumpamatioa policy imiomation
'Ilumuuwmrs-hu""mit this anldavis indiutina Ihty are doing all work and then hire outside courncroo must.uhmii a new at'rdavit intli"ing such.
4'.,nmxutn'hal check this box mum atoehof an additional short shuwinx Iha 113ma of the sub.conuwtors and their wurkad comp.ptdicy information.
/dor un employer that Lr providing lvorkera'rumpcn.rnrion insurnuce for lily employees. Below is the polity and fob life
infuriation.
Insurance Company
Policy is or Sclf-ins. Lic.d: _.. .. .._ EApirulion Date:
Job Site Address: ` 6 i2l, O
a Ci-State/ZIp: a I �
Attach it copy of ilia workers'cumperssafion policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required uodcr Section 25A ut'.%IGL c. 152 can lead to the imposition of criminal penalties of a
fele tip rop S1,500.00 and/or one-year imprisontnunt,as well as civil penalties in the form of a STOP WORK ORDER and a rine
of up In 1250.00 It Jay against the violalor. Be advi.icd that a copy of this stntcmcnt may be forwarded to the Office of
luvahgounns ul'Ihe DIA (or insurance coverage cetificanon.
/i/o hereby terrify under the pains ratd pritalrier u(perjury y that flu information provided above is true and correct.
11✓:CII"I'e' O '_ 747 /r / /§ds DAIc'
Phut•a
Of/ftial use only. Do not irrite in this area,to be coupleted by city or town njjieiuL i
'
City or fawn: Permitil.ICtnse s
Issuing Aulhority(circle nun):
I: Board of Ilcalth 2. 1luildin., ilcparunenl .!.fityi Ibnu Clerk a. Electrical luspcetur 5. Plumbing luypcclor �
6. Other
C,titlacl I'cnuuo _ .. I'hunc 7:
Information and Instructions
�I:us.tchusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to(itis suture,an emplga•ee is defined as"...every person in the service of another under any contract of hire,
cypress or implied, oral or written."
An employee is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
,d the fortgolng engaged In afoint enterprise,and including the legal representatives of a deceased employer,or the
recciver or lrublee of an 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
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, y+'25C(6) also states that ,every state or local licensing ageacy shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings is the commonwealth for any
applicant"Ito has not produced acceptable evidence of compliance with the Insurance coverage required:'
Additionally.SIGL chapter 152, a25C(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 rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s) narne(s),addresses)and phone numbers)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 does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for continuation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed 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 low 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 thea roriatc line.
City orfown 0md315
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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license nuntbhr 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 inrormation(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 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 i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
the (),lice of lnvestigations would like to thank you in advance fur your cooperation and should you have any quebtions,
please do nut hesitate to give us a call-
rhe Ocpartmcnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of fuvestlgsdons
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
Rc ,.iecd 't;-us www.mam.gov/dia
CITY OF S.3I.&M. 1.L-kSSACHusETTS
BUILDLNG DEPAXIMLI NT
' 130 WASHLNGTON STREET,3 °FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJBERLEY DRISCOLL
MAYOR THo..%us ST.PmRu
DIRECTOR OF PUBLIC PROPERTY/BI:MDLNG 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 It 1.5
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:
ka I K hill„ �T&U. /<
(name of�r)
The debris will be disposed of in
(name of facility)
C Q /�irrCG�'y0 l✓ ✓ L � "
(address of facility)
1
signature of permit applicant
date
kbnvif J,k .