74 LEAVITT ST - BUILDING INSPECTION The Co mon we
b alth of Massachusetts —
a3 Department of Public Safety
,. % \Lr..odnna•1 Me Budding Code 1,80 C.MR)'a•rrn I Ednlun !
City of Salem
l --� Building Permit Application for any Building other than a I-or 2-Family Dwelling
1 rhes Semon For Official L'<v On IV)
Building Permit .Number: Dale Applied: Budding Impactor
SECTION I: LOCATION 1Please indicate Block s and Lot s for locations for which a street address is not available)
L
7building
treet C civ /Toon Lip Cuda Name ut Budding III•ipplic.4,10
SECTION 2:PROPOSED WORK
If New Conmructiun check here❑ur check all that apply In the two ruws below
- ------ ildin); --Rrse ❑ Change of Occupancy ❑ Other ❑ Specify:
g plan,and/or cumtnrctiondocuments being suppliedas pan of this permitapplicatiun? Yes No ❑ndent Structural Enginee inti P r Reviewsluirc ? Yespti. of Pruposa• Wo itMos ko
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): 1�"Existing Hazard Index 780CMR 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(x).ft.)and Total Height(ft.) t ZII t "I a Zu
SECTION 5:USE GROUP(Check as applicable)
Jet
A: Assembly A-1 ❑ A-2r ❑ A-2ne❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 O H-4❑ H-5❑
1: Institutional I-1 ❑ I-2 ❑ I-.l❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2 ❑ R-3❑ R-4 ❑
S: Storage S-1 ❑ - 2 Of U: Utility❑ Special Use Nand please describe beluw:
Special Use: C,
SECTION 6:CONSTRUCTION TYPE(Check AS applicable)
IA C3 10 IIA ❑ IIB ❑ IIIA ❑ 1118 ❑ IV ❑ VA ❑ V8
SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water 5u ply: Flood Zone Information: Sewage Disposal: Trench Pennit:
"Debris Removal:' -
f'ub Lc l ('hviA drndvdc PL+nl Gnn•❑ Indicate mumci)tiIX \ Irenchyyw, Il not he Lrcen.ed [),Mira...) Situ
Ih.la.Ile❑ err mAnbh'Zune: nr r,n,,te 1%Item❑ required yy or trench ra.pcalc.
— i,ermn r.enclo,ed O _
i Ridmid rightuf-way: Hazards to Air Navigation: \b\ I h.b•n. 1 ..nrnu,.,•.n IL ,., "•.
'\rl \1•I•bc.ddv� LVruallnr oohin,nrpnrl.rp)gn,rih an•a' Llhcrr n•a ica oanl•Iclr.l' I
•a l ••rr•vnl lrRud.l cnan•cJ❑ I lc.❑ rr\u lr�❑ \,r ❑ I
— J
4fC"TION 8:CONTENT OF CF.RTIFIC.\rE OF UCCL'PANCY
1 .ldinn.d l ••Jc __ L•r ldnupr•i _ f�)c• I l .m-Irm lien, ,___ l4iuF•anl l� e.l /.r ll ,.r _._ .__.. __... '
IIq,ihr prwklvr T%,tvm' _ >irvoollupulalwn`
r
)) SECTION 9:` PROPERTY OWNER AUTHORIZATiONs
',imr and r\.1 rr.,ul�fi rt��)r7L � ifll C�..v�N�{tAR ��...t7.XF,.:�`'— ___-_ //�� V�j�-�•')t
N.u^e tPnntl No.and street ot, ro,n
I'n+l+vele U+a nrr Contaq Inturmatwn:
(ide reiephune No. (busm"s) (viephune No. (celU
tt a)+phc.tbtr,the praprrN'nxnrr hurt»•.u^honcrs
Name Strad Address Cit%-/Tuwn S1.1tr Gip '
tae alt ext the +n++ret\.n.ner .behalf, moll matter%relanre kr work awhurnta•d by this building pi a + ItcaUun.
r
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) -
tit Ntuldrn•1,is.s than 35,txa0 i if.of rneh+sad s:aa-e and/ur not urxler Crmatnu hon Control then check here O amt>k.,\•aieru 10 1)
10.1 Re ;.toed Pro(esston.I Rss onsible for Construction Control
,+la-ma-{Re};tstran r rF unr�'Nu:—r-mat as ress eg�tiunNum- ber
Street Address City/Town State Lip Discipline Expiranon Date
10.2 Central Contractor
ol
Name f P Its, In. le for CunstructionLicense No. and Type if A licab!
,$t1t�pddress &I e za- City/Town State�J V-6\ t1A�T,La _
Telephone No.(business) Telephone No.(cell) email address
SECTION 11:WORKE 'C.O. 'ENSARON INSURANCE AFFIDAVIT(M.G.L.c.152.6 25C(6))
A Workers'Cumpcnsation insurance Affidavit from the MA Department of Industrial Accidents must be completed
submitted with this application. Failure to provide this affidavit will result in the denial o(the issua a of the building permit.
_ is a si ned Affidavit submitted with this application?
Yes Q No
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(tabor
and Materials) Total Construction Cost(from Item 6)=f
1. Building f Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical f appropriate municipal factor)=f
3.Plumbing f
�. Mechanical (HVAC) f Note:Minimum fee=3 (contact municipality)
S. Mechanical (Other) f Enclose check payable to
P•Y•
6. Total Cost - f (contact munici alit )and write check number here
SECTION 17:SIGNATURE OF BUILDING PERMIT APPLICANT
Hy rmrnny;my namebelow. i herebv attest under the p.pns and penalties of perjury th.rt all of the Information o,nimned in this
}+hcauun t I cru rur.or t e bra ul I, kne rlea 'e and undenLInd Int;.
I'I nc
pri'll '.170 1,qn n.n filly f,Irpnv G. 1),rtc
' �Inv9 lahlra•�. ( tl_\: Ginn Sldlr Gip
i 5fuIII,IPA Inspector to till out this section upon application approval:
l v7
CITY OF SALEM
,,' , !, PUBLIC PROPRERTY
7. r,
�o DEPARTMENT
toM 1-11
1^�WASHING I U\STAELT 0 SAI BN,MA!L1.\(.1II ili 1'11 61972
11.1.: 08-70-1595 • P.\x.978J4C.yg46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
y tlicant Information Please Print Le ihly
V8n1d lnuwwsslOr�mintinNlndtvnluull:
Address-
Cily;Starci%ip:
Arc you an cutployer!Check the. luired.j
'Type of project(required):
1.❑ 1 am a employer with ra a gcn I contractor and l 6. ❑ New construction
employees(full andlurBort-time) e hit the sub-contracturs
_.❑ 1 :un a solo pmpricnx or partner-
ed i the attached sheet. �• E] Remodeling
ship and have no employeese sub-contractors have S. ❑ Demolition
working for me in any capacity. kers' comp. insurance. 9, Q Building addition
No workers'cum insurance : , a corporation and its
I P• l0.❑ Electrical repairs or additions
rcquircd•] CCfx taVl'CSCI'Cixed Ibl•Ir
3.❑ I ,rat a homeowner doing all workt of ex option per MGL 11.Q Plumbing repairs or additions
myself.(No workers' comp. 52,q t(4),and we have no 12.❑ Roof repairs
insurance required.] t ployees. (No vorkers'
13.❑other
p. insurance uired.]
•Any:yrpLeunl thut chucks box dt must also till out ih waion W.uw slowing their workw 'cumpen>Wiwt puricy inliumatiun
'I IWncawdin who udtmil this anWavil indicating rh y are doing all work and then him ootsi ewurnelors must suhmil a new alydavil indicating such.
('anrnwwn that check this box marl anschod an ad iioa al shcct.hawing me mmue of IM sub< traelo s and their wurken'comp.gndicy informants".
/nm rat map/uyrr that Ls pruvidinx Ivor era'campcn.cnrinn incuaulee jar wry eu loyeea. Beloly is the policy and job site
injunnution.
Insurance Company Name: -
Policy 4 or Self-ins. Lie.i3: _-__. Expiration ate:
Job Site :\ddruss: _ C ilyi StatciZip:
Attach n copy of lbe workers' ompens'atgun poficy'declaration page(showfnl;the policy numbe and expiration date).
Failure to secure coverage as r wired under Section 25A uf.`.lGL c. 152 can lead to the imposition of en incl penalties of a
tins up to 51.5110.00 and/or of year imprisonment, as well as civil penalties in the form of a STOP WO
DER and a fine
of up to)?50.00 it day rgalll the volamr. Ile advlicd that a copy tlf this ilulement may be forwarded n1 the Olfice of
III\'i.Ntig lUllY UI the DIA l0 nliurarce diveragu \en'Iflcation.
I du hereby certify under i ne pains+ntd pentddirs of perjttry that the injorinulion provided above is trite and correct.
tii�:rwtre: -._ . Date:
Of
ichd use duly. Dd not Ivrite in thiv area, to be completed by city or toivn official.
City or Town: PerinitiLicensc h._,
Issuing;Authority (circle nuc): I
I. hoard of Ilralth 2. Buildim� Dcpartmcnl ). City/fowl)Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
l',nllael l'cnun: .. Phone:Y:
Information and Instructions
\I assachusetts General Laws chapter U2 requires all employers to provide workers' compensation for their employees.
I'ursuau to[itis statute,an empitivee is defined as"...every poison in the service of another under any contract of hire,
c%press or implied.oral or written."
An employer is defined as"an individual,partnership,association,corporation or tither legal entity,or any two or more
d the tbregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
recciver or trustee 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, §+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 commonweallb for airy
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, &lGL chapter 152, 325C(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 fill 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
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be tenured 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 Town Omcials
Please be sure that the affidavit is complete;rad printed legibly. 'rhe 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.cure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pernitiliceace 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 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.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I'lie [slice of luvestigations would like to thank you in advance fur your cooperation and should you have:my questions,
please du nut hesitarc to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlee of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
R:':ucd J-?G-Us
www.mass.gov/dia
5 CITY OF SAI.E.NI, NL-kSSACHUSETTS
SUILDLNG DEP.IRTNEONT
130 WASHLNGTON STREET, 3�FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
mmBER RY DRISCOLL
MAYOR THC.+as ST.PMM
DIRECTOR OF PUBLIC PROPERTY/BOIL ]ING 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 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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
I 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
S C,
(name of facility)
f 6.�
(address of f cility)
signs re 6fpermitapplicant
date
a.nn�,ird,R
OWNER CONTRACTOR AGREEMENT
The Parties, Palmer Cove Yacht Club Inc(owner) and Roger Boucher (contractor) hereby
contract and agree as follows:
1. That Roger Boucher of 11 Linden &V Salem, Massachusetts (contractor) is an
independent contractor engaged in the business of carpentry.
2. That the Owner and Contractor have contracted for the performance of remodeling (the
work) by contractor at 74 Leavitt St. Salem, Massachusetts.
3. That un preparation for "the work" it is anticipated that individual members of the
"owners" will perform certain demolition or related construction work on the site.
4. Itis agreed that the "Contractor" shall not be responsible for the supervision, inspection
or any other involvement in the Activities of the Owners members on the work site and
the owner shall be responsible for providing any liability and or workers compensation
insurance for any person(s) other than Roger Boucher during and in connection with the
"work".
5. The Owner agrees to indemnify and hold the "Contractor" hannless from any injury,
claim or other liability relating to the activities of the owners members on the worksite.
6. Furthermore the Owner and Contractor recognize that during the remodeling work
certain hazardous materials may be discovered at the worksite. In that event the Owner
shall be fully responsible for the identification, testing, removal and lawful disposal of
such materials by its own independently secured contractors and the owner hereby agrees
to indemnify and hold the "Contractor" harmless from any liability, fines, or costs arising
therefrom.
Signed this / _day ofG[+ or
..kms
Palmers Cove Yacht C Inc. og r Boucher
Owner Contractor
4
t
4
Existrrg Acces.able Frort Errty
' s Mean of Egess
•,( 5,6, ��-0• I6•-�. b'2• b•5" 9.6• y:'_I' 3•-4• _
SCOPE OF APPLICATION:
rr,ra ra,r.• ra,..•.•a•...•.•ra,.•r W
,.a 4 SCOPE: The purpose of this project is to renovate Q
3'6• 650 Sq FT of an EXteting 5050.Sq Ft Glub Nouse.
Alterations will convert storage, lounge and shower Iq
W M i areas to new shower 4 lav areas, Improved rear egress D
Office Ent Storagel.9 Storage Utility Q W
r'y and new Ward Room with Comodore Locker < Storage, � z
i
D
N
a
USE CLASSIFICATION 4 OCCUPANCY Q
"' .• r.• ry USE GROUP: A-3 ° Q n
Wmo
= r-2• ^ w
o N D Main Brailce CONSTRUCTION TYPE: 5 combustible U W n
5• 4t•_l0° .. 3•-46'" 0 41 D -
3"' BUILDING AREA: 5100 Sq Ft 0 j I W m
r..• ,.y. a'a' N
FW Q < u m
OCCUPANT LOAD: 306 persons U t11 n 4 n
Restaurant 4 Lounge: 4500 SF/ 15 net= 300 N s a
o 7
Y T y Bar 5-r Kitchen: 6 SF/100 groes • 6 <
DESIGNER
r Gomodor 3•-� Galle
W I Fridg. ° EXIT DOOR CAPACITY: 306 occupants x 0,15"e 45"/ 3 exits= 9„2"<36"Cmir)
m
' -----------"`-----•-- -- CORRIDOR WIDTH: Varies: Min. V(provided) > 3'(statutory)
MAX TRAVEL DISTANCE: 60' < 200' (statutory max,)
1,
GENERAL NOTES 4 SPECIFICATIONS C
m
- I, All work is to be performed to accordance with the Maes State >$uilding Code
v ITH Edition and Local Ordinances.
�
Function Hall ;: Lounge R 2, Discrepancies and Contradictions In these documents should be: brought to y
the attention of the architect at once. A
3, All deviations from these plane are the responsibility of the corntractor, 00
O g
4, Dimensions may vary In construction. All dimensions are to be Reid checked A
prior to ordering stock, -�• '
n _ _ _ _ _ _ _ _, 5, All "systems" provided for the project are to be complete systems with all BUILDER
I 1 manufacturer's specified materials and warranties, .
3/37
I I I-0y"
6. Provide all maintenance and operations data for systems included In building.
I ra u . 'a vo• 'a• ..
's
o He Lav p M h �.,Ah, Exi.tlrg Aeesasabls like new,"All materials Included to the work are to be new or may be," liknew," only If
a
I s 6 6• 36• ' 4 Storage p P °r�'"°' - approved b the architect, .4
Gommodor's —� Sm ker Loum a pp y
I Locker I 9 • ..
1 ___ _-_____-__-- 8, All contractors 4 labor provided will be experienced help norfmally employed U
.-. _-_____-_____-__---_ sa, I,�, s'o•,.'s• va•',rr ra•.e'+•
in the given trade with proper certifications and licenses,
0 Lav/ 1 1•A.
Shower ? Wada Room 9 I S. All lumber provided for the project to be appropriate species and grades O
as specified by the American Institute of Timber Construction, current edition. m �
C
o i 59
10. All steel provided for the project to conform to American Institute of Steel •��• U b
I Construction Standards, current edition.
HC Shower q I
Ih All work affecting the occupied portions of the building, If an shall be �/
9 p p g• y FYI a s
I rQ.yYe. I coordinated with the occupant at least 48 hours in advance of the
Rada dcen 1,12 EXISTING DECK
operation In question, PROJECT
l
- I New es ac=*.able Mears or Eqe I 12, All glass and glazing to conForm to performance criteria of the ACTION
I Massachusetts State Building Code,
I Lleult or Project
. _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ � 13, Submit evidence ofgrade stamps for all graded materials to a "
architect prior to including materials in the work,
FLOOF PLAN OF MAIN BUILDING
slwwlrg uniw or project are overall egrew rout... 14, Contractor shall provide building permit and submit evidence thereof before o?
va•.t _ - commencement of work, _ F
L
(�
Facility Plan 15, Substitution of materials will only be considered at time of bidding. T'T9'
r3vi 00.!03 N011072 !C., Jen ary 11,201F, Ti?',�,y .`:' IRir'4 TO of
54"d M Exi.Eirs Oerdltion
as of April 20.2010 +•.r.+e l !
__ o r 16, Contractor will provide all necessary temporary facilities and controls to w/` j
�IAILMII FDA-k
TZ complete work and blend the various pieces together. u a-
. 5i.191ca` `
t'' 11. Contractor is to maintain a safe and orderly site, and provide removal of "
wadi"S'b'm'IV3 +0 ` construction and demolition debris 1n a safe and legal manner.
cni8a�aq
z::--a Lim Sq IrAo3Cdn
G
LD E
qP
5 9 t
�• _ c 0 y
N �a
- y�l°gl FN OF N'�e
_,T
c
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
Great Hall I I FINISH NOTES:
New pass thru window O ( All finishes are to be Class i commercial grade except:
I ® I Shower Rooms, Lave, Closets d Mechanical areas may be Class 2, s
3'-0" 3•-0n
0ro2x2-6 5'-a0" F
HC Lav O 4 MIN O Mech ® I All Spaces to have commercial grade vinyl composition the or
sheet floring with a T 6 slip resistance or better, o :
N
Nelb casement ?;, S i Storrs e I n a
4 O mmodor s Sm ker All walls are to receive min 1/2 GW5 except both sides of pwi ow Corridor walls will have 5/8" Type-X GWE3.cker o
O LLa
- - - - - yb• - - - - - - - - - - - 31-0II O
- - - - — - — —
H W o N
0 C w m
i.
NeLb casement4 r ; I ~ W m
`ee I N
win0ow _ " Lav/ ; ; ;I; = O m m
-1• (� I U In J m
r " Shower ; ; u1a� l Room 4 ' CASEUJORIG SPECIALIT'P NOTES: Q N n P
` New pass thru window I DESIGNER
} ; I 1. Cabinetry in Commodor a Locker to be per Commodor s
I I I I
i I I
specifications.
. 2, Specialties In Showers Lav areas to have Stainless Steel
I I I I I I
Ell
finish,
I I ; I 3. See details for placement of Accessability requirements.
�p HC S#lower 52"
(� . I
7
Vif
I I
I 31'0" I
2'-0" x 2'-0" 51-0II X 41-0II I d
1 New casement O I q
window New Slider window
1I�II p - EXISTING DECK I
Ram down 1:12 A
Flat landing JL— I F,
29'-6"
� i I
BUILDER
Limit of Protect ENLARGED PLAN e AREA TO BE RENOVATED v4" = r
L — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — J
DOOR NOTES: .a
I. All doors will be 20 min, rated. WALL KEY Fire Detection KEY V
2. All exterior doorsto be insulated units w/weather striped frames w/Lockeets. 4-a
3. All exterior doors and Door *1 to have push/pull hdwr, kick plates d closersO smoke Detector v
* Existing wall to remain
4, Door 3 to have Panic Device w/ lock from outside onl . E
D P D
y 9
O
5. Doors *5, 06 d *9 to have dead bolt locks Worn t Strobe Light .*.�
6. Doors *1, 04, d *8 to have Privacy seta _ '"`' 7` C �
New wallp
Pull station
O
DOOR SCHEDULE - `----- ---------' ® Illuminated Exit Light .~ U y
Existing wall to be removed p
PRODIUCT CODE SIZE HINGE DIRECTION REVERSED TEMPERED GLASS 1=5 aeIF Powered Emergency Light
C c
36X80 COLONIAL 3'-O" R NO - WALL NOTE: g y g �� a+ p=+ �
Remote £merens Light AES AiN�
su
Wall heights controlled by existing roof frame. n p PROJECT
2 36X80 COUNTRY 3'-O" L NO YES o, 93 r
ON. y ACTION
NMS
3 36X80 COUNTRY 3'-0" L YES YES �yFFtrHroe'� F
4 30X80 COLONIAL 2'-0 R NO - FIRE PROTECT ION/DETECT ION NOTES :
rj 30X80 COLONIAL 2'-6" R NO -
L Extend existing systems to protect all new spaces.
6 -( 36X80 Match Hall 31-0" L No - 2, All work to conform to latest MARC and NFpA standards.
3. Place additional fixtures where shown on plans. Januar l
36X80 COLONIAL 3'-O" L NO -
t1, 20
8
4. Submit any and all shop drawings and specifications for review.
C 60X80 Match Hall 5'-0" LR No - 5. Provide maintenance and operation information to occupanit. ® g
i,
fi
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` The Commonwealth of Massachusetts
Department of Public Safety
/ /J / v,�,,.T Nlaasuihu.a•tls Stale Budding(,'Ode(780 CNIR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1• or 2-Family Dwe
(This Section For Official Use Onlv)
Budding Permit Nombre Date Applied: r Building Inspector: NA
SECTION l:LOCATION (Please indicate Blocks and Lot N for locations for which a street address is not available)
Qwr_q( F$S SOO-1.1 11A 010 (ir (!(-Qlri ILNCr✓1' rit)(K
\'o.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here O or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ ChangeofOccupancy ❑ Other Specify:
.Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No ❑
Is an Independent Structural Engineering Peer Review rluired? j q Yes ❑ No�
Brief Description of Proposed Work: I.-�TF2tG+L I F-lin:-� ,�N Vp ON J] �L, 7 z , ]�GLv�4h �-
fJK STotRd d�fIG�SFNc� (i�ro� i5vru�m r IC k1t W IT ;pppa
T-A"ANTF17_11P E�
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): rt Proposed Use Group(s): KJO
Existing Hazard Index;oe-9,.iR-34-. 30z.3 I L0Proposed Hazard Index F89 GNIR 34. l✓a LboWi ji,
SECTION 4:BUILDING HEIGHT AND AREA a
Existing �rL Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.) 7 bQ p,/0, G (QE—
Total Area(sq.ft.)and Total Height(ft.) dy� 4
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5 11B: Business I E: Educational ❑
F: Facto F-1 O F7X H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 O 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 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(Checkas applicable)
IA ❑ IB ❑ IIA ❑ 110 ❑ flfA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Infomaation: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ C beak if uul.nk� 11111111 Lunn❑ Indieue municipal❑
:1 trench will not be Ucemad Ui.po,al Site❑
reyuirad Cl or bench
I'ncah•❑ ..r mJcnulc Lune: ..r un ate>c.trm ❑
permit in enelu.rd ❑
I Railroad right-of-way: I Hazards to Air Navigation; \I:\ I li.b ae 1',•nuu........ R•,i,„ ('n....
\nt \ hi.ddc ❑ k tilfnCILlrC\\ thill.111plIrt a r +ch ama' I.thcu rc+ie+i nnn ICICd'
•.r 6.1111Tt o. Build rnd"'Vd ❑ l r.❑ 1-r Xu❑ ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I ..tom Id ( dr -...__ h�rl�rni pi.c __._—.__ fa pv,n l •m-Ina:uun: _-_._ ticcu pull l� ea par l-I , r __
Ih•,. thebui 1,1, n I,)I n.an Spn n k ler icnt''. SF+vno l Sl i pula un n, _
ly) 2
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name T and r\ dress of Property Owner
� G3G�`�
Name(Print) No.and tilmrt C it�Gnvn Lip
P.ruperly O(v ner Contact Irix"n.tlion:
Au, Lexi; �(r y l�n-Fc ,w S VD- -7 1)b5_ ae . �0;5011t e �s��G/.�or
Title Telephone No. (business) Telephone No. (cell) a-mad addre.s
If a1I�rbluhL rI.prof+erh owner her'eLbGv u1PtchAo�ri�z'e �� p \
1X-11—
Name
Name
Street Address City/Town State Zip
to act on the pop rorty oay ner"s behalf, mail matters rvl ati%e It)work authorized by this buildin • permita p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If t•uildin•is Iess Than 5,(xlVyll.it.of:nclosad s iaca•and/or not wilder Constru tion Gnptml then check here O and>lu p Safi lion ILLI)
10.1 Re istered Professional Responsible for Construction Control
ci Di�(,j 010_9st1 NIhIVJ
Name(Registrant) T Iephune No. e-mail address Registration Number I
qS yn e H s7or Na^+J a2Zl b ci+P�srovyrrs72l - >
Street Address City/Town State Zip DisciplineExpiration 31
Date
.
10.2 General Contractor
Company Name:
r s pan `L Y,oL,4j
Name of Person Responsible for C,u�j struction License No. and Type if Applicable
42") oruq
Street Address ity/Town II ZiRR
17'--k- �� Z� _ �TSCu rp 1G5 @ rM C"I/T.
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'CONVENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25061)
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❑ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$_9 p li V f
1. Building $ ppp 7— Building Permit Fee=Total Construction Cost XII (Insert here
2. Electrical $ ^—{ 1 1 Vo appropriate municipal factor)=$ q9l�Q.
3. Plumbing $ UD
4. Mechanical (HVAC) $ H) Note:Minimum fee=$ (contact municipality)
S. Mechanical (Other) $ s Uo Enclose checkP Y•a lble to
6.Total Cost $ :1121- 2 (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Baentering my name below, I herebv attest under the pains and penalties of perjury that all of the information containedj1hisappT111 ueandaccurate to the bestof myknowledge and understanding.
i U �V\j r � ? IlAtl - �I 4 3D 0e.i,c pit t ,rod�ipn name title Telephone\o.
� --- mai t�.�•�„ `��_------ ��>7�h� , M� 15
?creel Wdre"s lty;'Toun GLIt Lip
j Municipal Inspector to fill out this section upon application approval: _ ( ` 14,
\ame Dole
a CITY OF S. ., %Lxss xCHusETTS
BUILDING DEPARTSIENT
120 WASHINGTON STREET,3"FLOOR
TEL (978)745-9595
FAX(978) 730-9946
K1t[BERL F-Y DRISCOLL THOMAS STTIERRB
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDNG COXMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
APplicant Information J! Please Print Le ibl
Tattle (Businessiorganiration/Individual): �"'� ` 11 Cf
Address: ���✓ f , j
City/State/Zip: bar 1 Phone #:1r{�1/
Are you an employer?Check the a opriate box: Type of project(required):
l:?t am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner. listed on the attached sheet.: 7. Remodeling
ship and have no employees These sub-contractors have $. Demolition
working for me in any capacity, workers'comp.insurance. 9• F1 Building addition
[No workers'comp.insurance 5. We are a corporation and its ME]Electrical repairs or additions
required.) officers have exercised their
3,0 I am a homeowner doing all work right of exemption per MGL t I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152.§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.LNo workers' 13 C1 Other
comp. insurance required.)
'Any applicant thatch Vks box NI most also na out the wctiuo below showing their worker'compensation policy information.
11 kwneowrns who submit this affidavit indicating they alt doing as work and then hire outside commetors must submit a naw affidavit indicating such.
:Contractor that check this box must attached an additional sheet showing the name of the sub-comm tors and their worker'comp,policy information.
1 um en nnployer that is providing svorkers'compensation insurance for my emplayees. Below is the policy and Job site
information. a,
Insurance Company Name: �~ p QT j
Policy#or Snit-ins.Lic.#:7f f l`sl Expiration Date:
Job Site Address: 2 / S7L! — —_City/State/Zip:
Attach a copy of the workers'compen ation 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
finc up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
i
Investigations ol'thc DIA for insurance coverage verification.
I do herebycertif r the pains art ! ee r,jperJury that the information provided above . truue o ]correct
P t
Official use only. Do not write in this urea,lobe completed by city or town ofciaL
City or Town: PermitR.icense
Issuing Authority(circle one):
L Board of Iieallh 2.Building Department 3.Cityffown Clerk 4,Electrical Inspector 5. Plumbing Inspector
6.Other
Phone#:
Contact Person:
CITY OF S�nEm, TANSSACHUSETTS
=; BUILDING DEPARTNfE.�T
120 WASHINGTON STREET, 3'°FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJffiERL F-Y DRISCOLL THOI.W ST.PMPRE
MAYOR
DIRECTOR OF PUBLIC PROPERTY/9l:tI.DLNG CONINtISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 784 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:
(name of hauler} (V}
The debris will be disposed of in ''JT
i
name of facility)
(address of facility)
signature of permit applicant
1
-Z2 !
date
JcbrisutLJcac