6 NAPLES - BUILDING INSPECTION x'12A-�► -, � � 3 CK s /(-GSC o �
The Commonwealth of"l4-s4 "I%ysf8
o Department of Public Safety
VJ4 Massachusetts State Building%eA%QI3R)P 12- 18
Building Permit Application for any Building other than a One-or Two-Family Dwelling
C._. (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official: Z (t✓
SECTION 1: LOCATION (Please indicate Block#and Lot#for locations for which a street addre'916 not available)
mf � eS SAA-eM 01�10T
_ No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used if New Construction check here❑ or check all that apply in the two rows below
Existing Building❑ Repair 19-1 Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
L Change of Use ❑ 1 Change of Occupancy 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No O'
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:R�K-U 31tc- l-3 h-V Zoo U,,: -L 2 A �
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SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Y
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5: USE GROUP(Check as applicable)
A: Assembly AA ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-t ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑ and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA 11 H3 IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 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❑
Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA_I_listoric Cwwninsiion Rgviex_Prn;L_s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes ❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations: '..
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Properly Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact hnformatlon:
7k1- C31_ Gil b U4 zs-y 7J63 �c1Rse� S74Z5(301AIX
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes aGy�
ar5f ll'�n.G4y�-r_ `730604,s, -,-t- L-YAA A (3 )5 Z
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
If building is less than 35,000 cu. ft.of enclosed space and/or not under Construction Control then check here❑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
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Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
h-1- M ty-5 2- G! _ - 3 5 7 s Pc i V%c Q)0-0 VA CA-I+. Wt,
Telephone No. business Telephone No. cell e-mail address
SECTION 11:�\lORKETdS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 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❑ No ❑
SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ 3 1., Y75,6 0 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ 2 5 OO • U' O appropriate municipal factor)_$
3. Plumbing $ Oo . oU
1. Mechanical (HVAC) $ Note: Minimum fee=$ (contact
/munici ality)
5. Mechanical (Ocher) $ Enclose checkPY'n able to
6.Total Cost $ '3 -7 . OD (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accuhe best of ,y knowledge and understanding.
L?CoP rr ctA9% rate t
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Please print and sign name Title Telephone No. Date
�3CUtl;K S St -xn ''1 MR b1�roZ
Street Address City/Town State Zip Q
Municipal Inspector to fill out this section upon application approval:
Name Date "
OTYOF SALEM, MAS AaRSETP.
BULUMDUAMM rr
120 WA90UMSVMTp31°DROOR
7kt.�➢78 745.9593.
FAX"749M
KDAEKEYMESC
M YCR 7�iLarASST
DnEcTcutcfnmucaamay/BtjlDmcammMRMM
Construction Debris Disposa/Affidavit
(required for all demolition and.renovation world
In accordanm with the sixth edition of the State Building code, 780 CIWR, Section 111.5 Debris;
and the provisions of MGL coo,S 54; Building Permit A is issued with the
condition that the debris resulting from this worts shall be disposed of In a proper#►+rkerwd
waste deposit fadlity as defined by MGL c 111,S 150A.
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
t ic> C,OM Acxc#,L$4-L.yxv. TfA145
(name of facility)
(address of facility)
•
SigKature of applicant
Date
The CommonwepWt ofMgssachuseds
Deporinient oflipdttstridiAcddertls
1 Congress S"4 Suite pe
B.oston,M.4 01114-1017
www.masagov/dia
Workers'Compensation Insurance Affidavit Builders/ContradorsAgec6icians/Plumbers.
TO BE FILED WITH THE PIRA TTING AUTHORITYAvalleard .
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Newt:(Basioess!O�ratiodlnAividual): C Y u Q �/l'A 1 vL cc) T K,t: .
Address: 3 cc) l Jos S j
CityAtate/Zip: k Y VIVk Phone M ? g S F 3 — t
Are you as employer!(heck the apptepriate bor: - .
Type of Or (re9afrgd):
l.Qtameemplorerv;m _emabyees ieit aoa�pox-mne).� -
7. 0
New construction.
1.Dlma,sok proptietormpamaahip�odhave no empfaXota wor) g fwme in g< :[ do. cling
my capacity pk wmkas'bmq%lose rapdred.) - 9. 0 Demolition'
3.0 lam ahomeoxve doing a0 wmkmywX iNo wodras comp.im�aeocertgaved]r 10 DBm7ding•sd&Yion.
4.01m a hom6owoer end aa'0 be hmtog omoaatms m cmdaa aft w"mk m my popaw. I waf -
mature that all comnorms aNahave workm'companum mstoaoce mare sole 11.0 Electrical repairs or additions
faayne"WO no emptoyea,.
12.QPlumbmg iiepays flu'addititios
5. magmeaal conmwmaod ltinetfined listed no the aturbed sheat ,s
0I7Lpe.eay-compiscowahave employers and have wor)raa•eomp.mmaace.+ 1�.�Roofrepay .
6.0%are acoryotafionaod its offi=havee iodgmirtWoof=emp6oapaMQ.o. 14.DOfber .
151.§l(4),and we haYaai employees:INo worlimV cmp:iameocereipiked.) .
•Myayp]irmtNat checks bait pl awa also®omthe aequea bekwshowtagillOW&eu eamutim Ofty4Jamadi,
txonasavaswhosubmittoweffidavfindeningthey.ndoingoDvvat Neebbeouiside nmaauhmaO t%tfavitmdastmgeach:
rCoatnctomd t check flus Joos must anchad smaddi6mal ahedidaiwmg fn nam of&.cm 4mianaon and state wbodwoi mtNcee maces kava
employees.lfd#obcm¢adwph-compluy=4tboymustpmvi*dw wa4ms'.mmP•Palih'.a�bv, -..: ..
law agWnplopwthatirprovidmgmarAm'oompeadatfvnauxuatoaefornayemplpycer. Betowisthepsileyandfabsite -
Information.
Insurance Company Name:/I q�a SOCA
T
Policy#or Self-ins.Lic.#: W e C- 5-"(9 U i $d( 2V 1 s Expiraadon Daft:/0
Job site Address: G 14.14 l 1-e s cityismaq,ip:s A(e)K i
Attack a copy of the workers'compensation policy declaration page(showing the policy number and eipinUon date).
Failure to segue coverage as required udder Mtn,'c. 152,§254 is a taunina]viohnion punishable by a fine up to$1,500.00
and/or one-year imprisomueot as well m civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the doLitor.A copy of"statement may be fo wa ded to fire Office oflnve ltigations ofthe DIA for insurance
coverage verification.
I do hereby anderthepa and penalties ofperjmry that the Jnformahvn provided above a doe and ro►red
Sum
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Phone
7Fr/ 's9 s
r
eial use only. Do nor write in this area,to he competed by city or town o,(Jitid
or Town• PermWiaeense#
Aathorlty(circle one):
ard ofHealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
her
Contact Person: Phone#:
4
Information and Instructions
Massachusens General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,
express or implied,oral or written."
An employer is defined as"an individual;partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver 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 commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally,MGL chapter 152,§25C(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 year situation and,if
necessary,supply sub-contractors)nara(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 flum the
members or partners,are not required to carry workers'compensation ianrance. 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
be retained 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 lime.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The 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 sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/liceise 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.a dqg license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017.
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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