18-20 MASON ST - BUILDING INSPECTION i The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1-o - mil wellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: 3 Building Inspector: �07
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available) //
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No.and Street Cit.v /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 Buildin Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? YesW No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Ffr-pR(IQ StIq I(1S Q(2A 11. k4t% �Lj
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) O
Existing Use Group(s): Proposed Use Group(s): 1'
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(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❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 O
I: institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage Sl ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
required 11 or trench ur specifv:
Private❑ or indentify Zone: or on site system C3hermit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \IA I listoric Go nui> on Rrc i,-rc Pn+1011:
\ul Applicable ❑ Is Structure within airport approach area:' I, their review completed'
nr C onNenl to Build enclosed ❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: L.e Group(s): Tvpe of Construction: Occupant Load per Floor
Docs the building contain an Sprinkler System?: Special Stipulations: `T
�v V
SECTION 9: PROPERTY OWNER AUTHORIZATION f
Name.md Address of Propertv Owner
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Name(Print) No.and Street Cit)/Town Zip
Propertv(-)%%tier Contact Information: �g)
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town Stale Zip
to act on the pap perp'o)yner's behalf, mail matters relative to work authorized by this building permit a . lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor 22
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Company Name: kCt (,
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Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address-r C Snro2. City/Town p State Zip
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Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidentsmustbe completed and
submitted with this application. Failure to provide this affidavit will result in the denial ofa issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$ $00 .O U
1. Building $ S OL1• Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ KO o, ('0 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
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Please print and.ign name Title Telephone No. Date
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Street Address Cit)'/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
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CITY OF SALEM
lmay., PUBLIC PROPRERTY
i .'` !,
DEPARTMENT
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Construction Debris Disposal Affidavit
(re(luired for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section I 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris iesultin- front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
7c) LP �1R
(name of hauler)
Ilse debris will be disposed of*in
(name ul facility)
S Qv G&j Q T-1
(address ul larility)
vcnawrc of pcnuit applicant
AL2 �� 9
date(
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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fiLi. 'P8-715.93"5 • 1:%.x 778.74, 1.146
Workers' Compensation Insurance ,lifftdosit: Builders/Contractors/Electricirns/Plumbers
itpDlicant Informrlion Please Print Leflibly
%y
Name Inuvite%sa�r;;anvatinm•Indnnluull: tily & iri o 13
vi lido .
Address: 2 Utij /I V,( p
Ciry,Slare.%ip. !/l Q)FyCd Ah 02/k Phone
.\re %ou all employer' Check the appropriate bus: Type of pntjeet (required):
4. 1 tun a general contractor and 1
1.❑ I um u cmpbyer with ❑ 6. Q New construction
unployces(lull unlL'ur part-time).• hate hired the sub-contractors
?. I .un u sole proprietor or partner- listed on the attached sheet. C] Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
%wrking for me in any capacity, \workers' comp. insurance. q. ❑ pudding addition
No workers'comp. insurance 5. ❑ We arc a wrponation and its
I
required.]
officers have cxcrcised their 10.Q Electrical repairs or additions
3. ❑ I ant it homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.(No workers'comp. C. 152, j 1(4),and we have no 12.Q Roof repairs
insurance required.) r amployccs. 1No workers' 13.❑Other
comp. insurance required.)
•%m .yplicavt Plitt crocks box 01 must:dwo tilt oto the•ecbon Iwiow.howiny rhaa w'urkas'cumpunution lwticy mhomation.
' 11omco.mrs whu submil this artidavit indicaiiny ttwy are doing all work mol then hire w,side caumetun must nubmil a new a1'Qdavii indiukiny w,h.
d'•mrcwll,n that heck this box mtYl anachal an aedaional nlwet%Auwiny tlw u:wu of th;sub- cintrwickrs and their workers'cutup.rsdicy mfurmanon
l ant un employer that i.s pruvidin•q rvurkers'eumpenwntimt insurance fur ttty employees. Below is the pulley and job sire
hrfannution.
In,urancc Company Name' ---__—.—'_—
Policy is or Self-ins. Lic. 0: __.. .. . .. .__ Enpirulwn Date:
Job Site Address: _-_. city,Slale/"Lip:
Attach it copy of the %workers'compensation policy declaration page(showing the policy number and expiration date).
I;aduic to secure co%emge as required under Section 25:\o1'\lGL c. 152 can lead to the imposition of criminal penalties of 3
rine op m]1.511010)unLVur une-year imprisonment,us %well us ci%il pcnulltes in the furan of a STOP WORK ORDER and a fine
1(kill to )'_50.00 a Jay .tgauul the violamr. He adv rad that a copy of this matcment may be lures arded io the 01 lice of
Im.eu�aa rats ullhc DlA icaLun.
l Ju ha•rrhy lcrtifv under dor pains and pumlticw of i erjury that the infunnallon provided above is true and correct.
N1, 1.11w Dire
r)/jiriul me dilly. Do not wrist in thi.v area. to be rmupletrd by city ur town a//ic'ial. I
('Iry or Town: ... _ _ PcrmitiLiccnse 0
1%%uing .\ulhority (circle nuc): i
I. II,,.IrJ of 11vallh t. lluddin , Dcpartutcul 1. CitCfuun Clerk J. Electrical Inspector i, Plumbing lu%pcctor
b. 011ier _
Cnnta❑ l'c non: .. _. Phone it:
Information and Instructions
t•r 152 lcquires JII cm rlo ers to provide workers' compensation for their employees.
V.usachusets lacncral Lawi chap t 4 I ) .P .
Ptirs❑.ua w dlis statute, an empluree Is defined as- .e%cry pclson In the service of another ouder my contact of hire,
e%press or implied, oral or winter."
\n r,npJuprr is defined as"an Individual,partnership,ssocwuou.corporation or other legal entity,or any two or more
,.t the h,rewmg engaged in a pont enterprise, and including the Icgal representatives of a deceased cmplu)cr,or the
receiver or trustee of.m wdrvidual,paruefship,association Of other legal cnnty,employing employees. However the
owner Of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
,Iw.•Ilmg Iluusc of another who employs persons to do maintenance,construction or repair work on such dwelling house
or 011 the.rouacb or Mudding appurtenant thereto shall not because of such employment be deemed to be an emplo)er."
.%.IGL chapter 152. §25C(6)also states that "every state or local licensing agency shall withhold the issuance or
rencwul of u license or permit to operate a business or to construct buildings in the commonwealth for any
applicant wIto has not produced acceptable evidence of compliance with the insurance coverage required:'
.\ddiuonally, MGL chapter 152, g25C(7)sides"Neither the commonwealth nor any of is political subdivisions shall
,anter into any contract for the performance of puhlic work until acceptable evidence ufcumpliance 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 nu mbef(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 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 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
•If-insurance license number on the appropriate line.
City or'fown Official
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
I'I:ase be sure to till in the permit/license 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"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by de 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 dug license or permit to bion leaves etc.)said person is NOT required to complete this affidavit.
I ho I)I the ,I hiveHl.atiunb would line to thank )'ou til adv;Mice fur your cooperation and should Yllll Ila\c :my questions,
please du nut hesitate to give us it call.
fhc DJ p• rimcnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMCC of Investigations
600 Washington Street
Boston, MA 02111
Tel. 11617-727-4900 ext 406 or 1-877-MASSAFE
Fax p 617-727-7749
www.mass.gov/die