4-6 TULIP ST - BUILDING INSPECTION Z
D The Commonwealth of Massachusetts
ffDepartment of Public Safety
`v-,,,✓� NLtss.uhusetls State Building Code(780 CMR)Seventh Edition
City of Salem
(�
Building Permit Application for any Building other than a I-or 2-Family Dwellin
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block#and Lot# for locations for which a street address is not available)
�- I P S7e-ea7- Si�-/e�, t7lq �o
No. and Street Citv /Town Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑Or check all that apply in the two rows below
Existing BuildingRepair 11Alteration ❑ 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? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? �, _Yes 11 No l�
Brief Description of Proposed Work: S%!'��7 t z Z
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): S
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: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 11H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ I-3 11I-4 ❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4 ❑
S: Storage 5-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ HA IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA E3 VB [I
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: - Sewage Disposal: qi,
it: Debris Removal:
Public Check if Outside Flood Zone❑ Indicate municipal A tnot be Licensed Disposal Site ❑
reqench or*pecifv:
I'ri ca to❑ ur induntifv Zone: or on site System ❑ perd ❑
Railroad right-of-way: Hazards to Air Navigation: .uric G,mmi.�i„n Hr.io,c I'n,rc..:
Not Applicable❑ IS Structure�cithin airport approach area? their review completed,
m C-ni1scnl to Build enclosed ❑ Yu,❑ or No❑ Yes ❑ No Q
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition ut Code: Lse Gruup(S): T_\pe of Construction: Occupant Load per Fluor:
Dues the building containan Sprinkler St Stem?: Special Stipulations:
'� �����
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name.Ind Ad res.'of Property Owner
� e ` � y-d -TIJJ , � S7 S,g/P✓�p /yr,� oi��o
Name(Print) Nu. and Street City/Town Zip
Pnt' Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to act on the pro pert vow ner'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)
(If building is less than 35,000 cu. ft.of enclosed s pace and/or not under Construction Controt then check here❑andskip 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
-y- I
rYeyrgt C, C l y n/0 J CQ,��I t✓L�i� �/7 C
C panry Name:
� ye 61,1, /VoS
Name of Perwn Responsible f ,r Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. (business) Telephone No. (cell) - e-mail address
SECTION 11:WORKERS'COWENSATION 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 17 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) =$ .S
r
1. Building $ '.i t °' Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
Note: Minimum fee=$ (contact munict alify)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclosecheck payable to �`�
6.Total Cost $ L��O-�r 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 Lind understanding.
r
Please pt and of ame Title Telephone No. Dale
Str ress p City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
\, Date
CITY OF SALEM
�.; PUBLIC PROPRERTY
.� .
DEPAKTLIENT
l�. \� \,III\ ..,":1;NII ( • 1,\II \I, \L\..0 I. .. I .._1'I .
Construction Debris Disposal .affidavit
(required lir all Jentulition and renuvatiun work)
I
In accordance \%ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit is is issued with the condition that the debris resultin.- front
this work shall be disposed of in a properly licensed waste disposal lacility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
myszl+'
manic of hauler)
I he debris will be disposed of'in
(narne of facility)
54,/?rl/J H 4 Ye
viliddres<of l icility) 1
ae a tc of prnn« .ytphcant
,late
C� - 6 TA , � ST
slk�Pt
CITY OF SALEM
, I PUBLIC PRUPRERTY
DEPARTMENT
,1111'.N 11'.lnht 1-1 1
li`•'d 13: Wa,ttl\t.ern SIR LLT • SM tit,M.trtSst tit 11 1 1 NJI`J7�
li.i. Y73-7/5-9i95 • 1'\x 97N-.'41' M46
Workers' Compensation Insurance Vffidusit: Builders/Contractors/Electricians/Plutnbers
tuplicant Information /�/ / Please Print Leeihly
Nome�li�•u ss th an✓a1inNlnJiv.luull: r 7 &a f-A 4- �/ 11% 4/9r ( ;7 fr 1 Tr✓G7/O-1 -17/14,
Address: G/! tG c��/rr�,,1r
City,State,Zip �� ,, A9 O/� /7V Phone i/: 9'?I' 9'IS - (KY 1
.%rc you an employer:' Check the appropriate box: I')Pe of project(required):
1. 0 1 am a employer with 4. ❑ I :un a general contractor and 1 g. ❑ new construction
engnloycea(full anLvur Part-time).• havc hired the sub-cuntracturs
?.❑ 1 am a sole proprietoror Panner-
listed on the anachcd sheet. 7- ❑ Remodeling
,hip and have no employees These sub-contractors have 8. ❑ Demolition
working for the in any capacity. orkers' comp. Insurance. 9, E] Building addition
I No workers'comp. insurance 5. We are a corporation and its
I required.] officers have exercised their 10.C1 Electrical repairs or additions
3. ❑ 1 ant it homeowner doing all work right of exemption per MOL I L❑ Plumbing repairs or additions
myself (Ko workers' comp. C. 152, j 1(4),and we have no 12.0 Rout'rcpuir
insurance required.] n employees. (Ko workers' 13J-] Other rr ra CSedvab-,i:
comp. insurance required.]
•lu. .yphtaW Ihsn ckccka boa 01 mow:dau till uut the wcuun l,tlow.huwina,heu w-urkv,s cunlpcnuuiwr Iwhcy mliunutium
' I lomm,wrwn who e,dtmii this aRlJavit indiculing Ihu)sue doing al work mW Ihcn Ain uu4lde cwury wn must,uhmit Anew jirdavil indiuunll umh.
-C ,ilt wwr i Ihat,hcck this bort muo.Inrhtd.m adJdiunal nisei,h,, imv an mann of the subionlracton and their turken'cutup.policy mfurmauon
/ane run emplu)•er that is pruvidit g nvurkers'evinpcnvmian in.surtutce Jur ley employees. Beloit,is the polity and fob sih'
hifuranutiam
In,uramu Company Vame: _.__ -. _ ----__—'-
I'nticv a or Scif-ins. Lic. K: __.. . . .. __ Expiration Dale:
)ob Site -Address: _-_. CIIy.SlalerZtp:
Attach it copy of the workers' cumpensatlon policy declaration page(showing the policy number and expiration date).
I�adure to sccurc cu,erage as required under Section 25A of.1IGL c. 152 can lead to the imposition oferiminal penalties of a
tine op to.S1.500J1n and/ur one-year imprlsmuncnt, a%well is cit it penalties in the furan ofa STOP WORK ORDER and a rine
of up u) )_'50.00 it day against the violator. lie advi..cd that a copy of this malcinenl may be forwarded to the 011ice of
I,%:,u,am,ro ul :hc DIA :or ut,m.ux: ,er ilit.a:un.
i du/tereby trrtiw ou -rthe pain id penu/ricc u/perjury Mut the in/'unnation pruvided{{abuve is true mrd correct.
t)/Jiriul rue only. /)u nor u•rile itis this arra, Iu br cunrp/elyd by iilp ur/diva o//iriu/. j
( iiv ur fawn: _ _ Permit/License 4
Issuing .ituthurily (circle ane):
I. Ilo.trit of IIc.dlIt 2. It uddiug Mpart ulcnl 1. Ci ).Twtit C'Ierit 4. Llcclrical Inspcc for >. Plum bin4 los pcc tar
6. Other _
GuttaO l'Lnuu: .. .- Phone it:
Information and Instructions
f.usachuseus Ucncnl Laws chapter I i2 requires ill employers to provide workers' cuinpensition for their employees.
('u nu.wt to (nis ,hatwe, an rmylucer a defined.0" es cry pclson in the service ufanuhher under any cuntract of hire,
c apress or implied. ural or written."
,\n emplap.-r is defined as an individual, partnehhhp, .Isseciailou. corporation or other Icgal entity, or any two or more
,r the t„rcgomg engaged in ajoint enterprise. and including the Icgal representatives uta deceased emplu)er,or the
rea ci%er or(rushee of a1) individual, pwinefshlp,association or other legal cnnty,employing emplo)ces. However the
Owner of dwelling house having not snore than three apartments and who resides therein,or the occupant of the
dwelling Douse of another who employs persons to do maintenance,construction or repair work on such dwelling house
Or ,a) the.round.%or budding appurienant thereto shall not because of such employment be deemed to be an employer."
NIGL 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:'
AJdiuunally, MGL chapter 152, j25C(7)states"Neither the commonwealth not any of its political subdivisions shall
enter into any contract for the performance of puhlic work until acceptable evidence of cunipliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Plcase rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)ailing 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 allidavit should
he rentnied to the city or town that the application for the permit or license is being requested, not the Department of
1 ndustrial ACCLdents. 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
l f-insurance license number on the appropriate line.
City or Town Official
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 out in the event the Office of Investigations has to contact you regarding the applicant.
plL ase be sure to fill in the penniulicense number which will be used a%a reference number. in addition,an applicant
that must submit multiple pennitAicatee 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 (o complete this affidavit.
I h.: t Mice of Iuveui.atium iwulJ the to drank you in adv;utcc fUr your COoparauon and sIIUUIJ you hale ,my questions,
please do nut hesitate to give us a call.
fhc DJ pamncnt's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.mass.gov/dia