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71 PALMER ST - BUILDING INSPECTION t 4 The Commonwealth of Massachusetts Department of Public Safety \las,.ichuwtts State Building Code(780 0\MR)Seventh Edition City of Salem Building Permit Application for any Building other than a I-or 2-Family Dwellin (This Section For Official Use OnIY) Building Permit Number: Date Applied: Building Inspector: SECTION 1:LOCATION (Please indicate Block M and Lot 0 for locations for which a street address is not available) No.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❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change ofUse ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No EfJ Is an Independent Structural Engineerin,Peer Review required? Yes 11No Ef Brief Description of Proposed Work: 2 a at„ ka Loor Zi 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): r 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-I Q A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: EducaKonaf ❑ F: Facto F-1 ❑ F2❑ I H: Hi Hazard H-1 [3H-2 Q H-3 ❑ H-4 Q H-5❑ h Institutional I-1❑ 1-2 ❑ 1.3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4 ❑ S: Storage S-i ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB Q IIA ❑ 1111 ❑ IIIA ❑ IIfB ❑ IV Q VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 11 LO for details on each item) WaterSupply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Floud Zone❑ Indicate municipal p A trench will not 6e t.icensrd Disposal Site❑ required❑or trench or,pecifv: Prlratc❑ or indentifY Zone: nr on site=)stem [3 permit i.enclosed ❑ _ Railroad right-of-way: hazards to Air Navigation: MA I Ii,Wn, Cmnni,.in+ V'ol :AppfictMe❑ k Stricture within airport appntach area' Is their Iecie+r Completed, ur CMI'Lilt hi liuild endo,ed [3 Yes❑ or.No❑ Yes❑ \o ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY I`duiom of GO,-:,-: __L,e Group(,): . Type of Coni tntcuon: Occupant Lund Per Floue D,w, the building conlainanSprinkler Sc'mlem': Special Stipulations: 0{-,m / ted SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Adu�rss �fl`Pn�fn rtv Owner Name(Print) Nu.and Street City/Town Zip ProlpvrtvQier� omactl'1 t10ation: {}� �� ".1> -- �Z3 X84 - '7S "? _ — �( v Ol wo, o Title - Telephone No. (business) Telephone No, (cell) a-mail address If applicable,the prupert.v owner hereby authorizes Name Street Address City/Town State Zip to act on the pro pert owner's behalf, in all matters relative to work authorized by this building permit a p plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (df building is lws than 35,M)cu.ft.of enclosed space andlor not under Cututruction Control then check here❑and skip Section IU.t) 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 Company Name- ,2- n wa�� _ C-s P �� 37 Name of Person Responsible for Construction License No. and Type if Applicable ( ra1 � �,>� 0245 3 Street Address75( 8 CityjTown State Zip Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'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 O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ �) 1. Building $ 3 0 Building Permit Fee=Total Construction Cost x i�—(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee (contact(contact municipality) 5. Mechanical (Other) $ Enclose check payable toter 3 cSS 6.Total Cost $ a O 0 (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 accurate to the best of my knowledge and understanding, ��, _ �v o� C7 _ . cam 701111 ( �s + _ 11 1 Please pri nl and sign name Title Tele phone No. Date wtreet address Cit%/Town ti Zip )A .Municipal Inspector to fill out this section upon application approval: T_v� l _ Name Da to CITY OF 5.1LE.�t, l�Iai,SS.1CHL 5 TI`S ,y BUMLLNG DEPART>t&NT 'fie ,r • 120 WASHLNGTON STREET,3'a FLOOR a/ TEL (978) 745.9595 F.tiY(978) 740-9846 K[.NiBFRi RY DRISCOL MAYOR DIRECTOR ST.PtERRa DIRECTOR OF PLBLIC PROPERTY/BCILDLNG CONLMASSIONER Workers' Compensation Insurance:lMdavit: Builders/Contractors/Electricians/Plumbers Anolicant Information Please Print Legibly Natnc t0usit> sUrganizatioalndividual): D,_ O+w / Address: 2�> � ----c � CitytStatc/Zip: �/^ �1 AAA 0�4 S Aone tf: 1 > ) `- $-0 — "7 S g Are you me employer?Cheek the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction sployees(fide andior part-time)., have hired the sub-contractors Z&I am a sole proprietor or partner• listed on the attached sheet.I 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me is any capacity. workers'comp.insurance. 9. Building addition [No workers'comp. insurance 5. © we are a corporation and its t0. Electrical repairs or additions required,) officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions myself[No workers'comp. c. 152,41(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' comp,insumm:o required.) I3.0 Other -Any applicatt loin stocks West must also fill cut the tylion below showing their workers'compensation policy information. t 16vmownecs who submit this&Mdays indicating they ace doing alt work and then him autsidacontrsaacx most su hmit a new sirdavit indicating such. =Cononctors that check this box must anschod an adrktionel ahrel showing the nurse of the sub nao cion and their workers'comp.policy infornution. 1 um an nnp/oyer that is providing workers'compensation insurance for my employees. Below Is the pollcy and job site information. Insurance Company Name: Policy g or Self--its. Lia M Expiration Date: Job Site Address: City/State/Zip: Atiach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failum to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 mul/or one-year imprisonmem as well as civil penalties in the form of a STOP WORK ORDER and aline of up to$250.00 a day against the violator. Ile advised that a copy of this statement may be furwardcd to the Office of Invcstigutiuts ul'the DIA forinsuranct coverage verification. - I de hereby cerrf^fyunndder the pains and penaides of perjury dial the information provided above is true and correct. Si;P_ Phone 1: Official use arty. Do not write in this area,to be completed by city or town affhlat i City or .. . Permit/t.lcenseq _.._— ._.� Issuing Authority(circle ane): 1.Board of health 2,Building Department J.Citylfown Clerk 4. Electrical Inspector 5, Plumbing Inspector 6.Other Contact Person: _. . __. Phone tl: [ Information and Instructions Massachuscus Ucneral Laws chapter 152 requires all employers to provide workers' compensation titer their employees. Pursuant to this,i4tuie,an emplgred is defined as"...every person in the service of another under any contract of hire, kpress or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more a the laragoing engaged in a Joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee ul'.m individual,parmership,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 maintenunce,construction or repair work on such dwelling house or on the.rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, v+'_5C(6) also states that"every state or local licensing agency shag withhold the Issuance or renewal of a license or permit to operate a business or to coostruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of cumptlance with the Insurance coverage required." .additionally. MGL chapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acccptablc evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if . necessary,supply sub-contractor(s)nume(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 alf idavit should he 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 a space at the bottom of the affidavit for you to fill not in the event the Office of Investigations has to contact you regarding the applicant. 111:ase 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 peraio'licetsc 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 tilled 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he t)Ilice of Investigations would like to thank you in advance for your cooperation and shuuld you have any questions, please du not hesitate to give us a call. The Dcparnncm's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Me of Investigations 600 Washington Street Boston, MA 02111 Tel. k 617-7274900 ext 406 or 1-877-MASSAFE lt:: .cd i-'6-05 Fax N 617-727-7749 www.mass.gov/dia CITY OF S.U.E.NI, 1�L-ISSACHUSETTS 8LILD LNG DEPA RT.%ONT 120 WASHNGTON STRErLT, Y°FLOOR TEL (978)745-9595 FAX(978) 740-9846 KIJIBERLEY DRLSCOLL 1�1AYOR I7tOMU ST.PtERRs DIRECTOR OF PUBLIC PROPERTY/BCILDLNG 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 I 11.5 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 wilt be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant date i.nwird,�