72 WASHINGTON ST - BUILDING INSPECTION �. The Commonwealth of Massachusetts
Department of Public Safety
\la..adtu,rtb Skits lluddm ti• ails
l' 1•'8ULAIR)Sa•tenthE.htum
City of Salem 1
Building Permit AERlic4tion for any Building other than a I- or 2,Fjmily Owellin
t Chu Srrtum Far Offtnai U,r UnWi
0uddmg Prrmil .Vumlxc Date Applied: Building tn.prcau:
SECTION 1:LOCA rION IPlease indicate Block s and Lot s for locations for which a street address is floe available)
UP �
\o.,utd Select Ctty /town Lip Ctafe Name cat Budding itt appiicsbir}
SECTION 2:PROPOSED WORX
It New Catnseructiun cher rry O or check all that apply in the twu ruws below
-Exi ting-Building O-- -Repair.0---Altieralw ..
n --AdwnClm
di -Gkuletiun-C}{Please-fill.tuaand-nubmlt Appendix-14---. _... ..
Change of Use ❑ Change of Occupancy O Other 0 Specify:
Are building plans and/ur construction documents being supplied as pin of this prrmit applicattun? Yrs 01 Nu O
Ian Independent Structural Engineering Peter Review,retluired? Yrs ❑ Ntj
Brief DtNcrt}'tytnof Pruposad Wurk; eC :h�'E'_i,J�(V1 1Ct� �� J h " At LA 1� fit S/aaf
SECTION 3:COMPLETE THIS SECTION/F EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an tsling Building Evaluation is enclosed(See 780 CMR 3402.0) O
Existing Use Gruup(s): i 4 Proposed Use Croup(s):
Existing Hazard Index 780CMR 34: iq 0 in Proposed Hazard index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(s+ft.)and Total Height(ft.) �.(� /
SECTION!:USE CROUP(Check as applicable)
A: Assembly A-1 O A-2r O A-2nc O M3 O A-4 O A-5 O 8: Business dK E: Educational ❑
F: Facto F-I O F2❑ I H: High Hazard H-1 O H-2 O H-3 O H-4 O H-5❑
I: Institutional I.1 O 1-2❑ 1.3 O 1.4 0 Mt Mercantile Cl R: Residential R-10 R-20 R-30 R-4❑
S: Storage S.! 0 S-2 O U: utility❑ Special Uss❑and pleaw describe brluw�
Special Use.
SECTION b:CONSTRUCTION TYPE(Check as applicable)
IAO too IIA ❑ 118 O 111A 0 I118 0 IVO VIA O ve
SECTION 7:SITE INFORMATION Ireferto 780CSIR 111.0 fordetails on each item)
IVaerr 5uppl Flood tont Information: Sewage Disposal:
french Permit: o:4:1
Pubbv Chral<tl.mt,lde Find Lone❑ Inabcatr muniapal a lunch tet In (+r Lticn.rcyutrad car lrcnch rr.j-Vt
I'rtt air❑ ,+r ut.lvnbn Luna• _ or on,dr,r,trm❑
I 1 ('remit t.a'nalawKi❑ _
Itailtoad right-of•wa Hazards to Air Navigation: al t I t,.t.•.,, t ..,,,,„„-„,,,r,,,,,., I,
\.d tpph.abM i.�Iru.tute tt tlhm air)a nl.+i CM dfr.l L Ihcrt rot'v” Panl•Ic .W .
lluJd c+h I""l❑ !r.❑ .•tA,+ Ta•�❑ \ , -__-�
SECTIO.\8:CONrENT OF CFRTIFICA TE OF OCCUPA NCY
7 ,66nrt..tt ,..tc .,-_C-r t.n.ut•+,t �—_ f+i•c. 11 ++.lfa+,fern , ,-- 1+(Cl+f.�nllndd �rr ll , .r .. _ - '
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t-- SECTION 9: PROPERTY OWNER AUTHORIZATIONo},{'n.Cd Q 1rr, Z
\.tete.+�al .1.rlariryta•�t(l/'�n,,,.,(t,t'rt�t pt.att'('n�rr U)�} t�. 1V` {t�• (jai _ ��' f'3k( -)0
\�L..M A.\(•y r`Tl.l.�t-- (V h tf/t't*"') J. `j' '.•� 1 �C.1i l I
\anivil'nnit No.and 14rvet Cut, rown
Prupvric Uta nvr Cun61ct LUurm,Ilion
Ge-oy-�at
rule reiephorte No.ibu.mr..) relephone No (tet!) a• m.o!.LLlrra. ("
ILt •pht.lblr{{��thr praprrI% ott net herr/bv.iu1'o"trr fa��,,� /�� �j
Q_ ! C t Q f — AV,6`W t��C\ i I I L�
\'.line Street Addre>, 610 Town Smite ZI}+
h,alt ,n the properte tett ner'•beha1f. In.dl matters Mao cr it,worit aut h+trterd by Thi.bud.bn• permit a • +bcatnm.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
111 huddln•Is It..Than 3i.otW cu,n.of enclawJ.+ate anJ/ur mrt under C.nulnttnun Cun1MI then ch"k here O and•kl.Fav eon fit 11
10.1 Re istered Professional Responsible for Construction Control
"-�—-Vhrnv tRygistrent 'uT'rlrphunr"Nu-" ter-mai(id3�ei� egiilratiunt umber
Street Address City/Town ?tote Zip Discipline EApirauun Date
10.2 Crneral Contractor
t y Namr: CSS b�q b,? a4 RIS 7W/
""',s n
�PLvc�4TIr r
Namr tt r�min Lpo/l.{ble her CunstructWn License No. and Type if AD livable
Street Address City/To State Zip
�- .i^U1D Glcr.s9c- � ` r� delu�a4 of /a�easi t�dP�
Telephone No.(business) Telephone No, cell e-mail address
SECTION 11:WORKEW CCOKWV AUM INSURANCED V (M.G.L.c.1S2.§ 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents mustbecompleted and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance v building permit.
Is a signed Affidavit submitted with this application? Yes O No
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=f
i. Building - f Q-4:10 Building Permit Fee-Total Construction Cost x_(insert here
2. Electrical - f appropriate municipal fictor)-f
3. Plumbing f
3.Mrcltanical (HVAC) f Note:Minimum fee-f (contact municipality)
5. Mechanical (Other) f Enclow check payable to
6. L+hd Cost f f(}„(jt3 (amtnt munici alit-Wand write check number herr
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
K%
rntrroh my name below, I hereby attra under the pains and penalise.of perjury that all of the Information.unialned in 1h1.
.tp}*hc:trnn r+true and accurate tuhe be, of my kis 4ttilgeand understanding.
pr Z11 Intl .Ipt(y"emv E3 Tale f c}' n • \,t U.rty
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1 Municipal Inspector In till out this section upon applitvtion approval:
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CITY OF S.U.E.NI, 1.LxsSACHUSETTS
OUILDIING DEPAR'I11EVT
130 WASHNGTON STREET, Y°FLOOR
TEL (978)745-9595
FAX(978) 740-9846
Kn(BER RY DRISCOLL
MAYOR THovAs ST.PmjtR8
DIRECTOR OF PUBLIC PROPERTY/BCILDIING 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 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 will be transported by:
(name of hauler)
The debris will be disposed of in :
LA" I� ��
(name of facili y)
(address of facility)
licant
signaN[eofpc it pp
datC
•I.bnvlf Jew
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CITY OF SALEM
PUBLIC PROPRERTY
' T
DEPARTMENT
1 2,^.WAitti-\s;14$57ACLT a SM E N,MAWS ri.l It it.'!a l Qi97^
JM,7$3.9393 a F.sx. 979-741,0-9346
Workers' Compensation Insurance affidavit: UuilderslContractors/Electricians/Plumbers
tnlslicant information Please Print tecibty
V;11T)C{HucntesYt)r2annntioNlndovt.laa)): ��� ��Ly��
Address:
City'smic;/.ip c a Le-,.gr-. '.JW. ja =-/S Phone il: �'/ 9-- `7Y � 57-D o�
:\re you in employer!Check the appropriate box: 'Typo orproject(required):
1.Q I an,a employer with 4. Q 1 ate a general contractor and t (e Q r5eve construction
s(full and/or art-tinic). have hired the sub-contractors
7. Renodeting
2mP tao cce
proprietor or paAner• listed on rhe attachctt short
ship and have no utnploycros These sub-contractors have S. Q Demolition
working for me in any capacity. workers' comp,insurance. 9. Q Building addition
ilio workers'comp. insurance 5. Q We are a corporation and its
required.] Of10.0 Electrical repairs or additions
Ticers have their
exercised
3.Q I ant a horacowner doing all work right of exemption per MOL I I.Q Plumbing repairs or additions
myself, [Ko workers'comp. c. 152,§t(4),and we have no 12.Q Rtwf repairs
insurance required.j t employees.tNo worker13.0 Other
comp. insurance required.]
-Any;ypluCatt that checks tial pI mtua also njl nut the ecnion 4dow stowing agar warkas cumpuntai iutt pulicy inhamaliun
'1 tum.o even who c,dtmit this a davit indicating lines Age doing all work and then hire alkide caurxtws mage suhmit a new alridavil indicating such,
d".mineitxa that chuck this bmt meat attached an additional sheet.hawing the nate of the sutt.camratvan and their working'camp.policy inrwmatiun,
/oat all r+egrluyer Noor tt providing tvarkrrs'rurnprteratian fnxaranec jar my tmpluyerx. $elegy is the polity and Job.rite
�, fujaraeuflorr.
Policy 4 or Self-ins. Lic.ins: __ Expiration Date:
lob Site Address: calef5lute/Zip:
Attach a copy of the workers'clnnpensation policy declaration page Ishowing the policy number and expiration date).
( Failure to secure coverage as required under Section 25A cat'LlUL c, 152 can lead to rite imposition of criminal penalties o(3
tine up to S 1.5110.00 and/or ane-year unprisunmcnr,41 well as civil penallicy in the Turin of a STOP WORK ORDER and a fine
.rf up to i?30.00 a day agailud tete violate. Ile advi.+ed that a copy of this stutcaunt may be 1'urwarded to the OITce cat
In%cahgaunns ol'the DIA Ibr insurance covcragu scrilicuuon.
da hereby certify leader rbc a x oiled penohle.s of pe ry their the hefur+nudan provided above is true and correct
rai'dedL [)Age,
1,11"rc
Official res'e only. Do nal it-rite in this area,to he cuntpleird by city or tonin offieiaL
t
City or'fnwn: Pcrtnit/Lictnxe is
Issuing Authority(circle etre):
I. hoard of health 2. nuildiu; Ocp: erincut .1. t:ityr'i'owo Clerk 4. Llcctricll lnspattfur 3. Plumbing Inspector
L.Other
C'slitact I'enots
information and Instructions
tai,.ichuscus Gcneral Laws chapter I i2 requires all employers to provide workers' compensation for their employees.
I'ursuwit to this statute,an rmplgyee is defined as"...every person in the seryice of another under any cuntnct of hire,
express or implied,otai or written."
.\n rnployer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
,d the ttxegoing engaged in a Joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ul'•m individual, partnership,ussoctanoa or other legal entity,employing employees. However the
owner of a dwelling house having not more than three aparonents and who resides therein,or the occupant of the
,five fling 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."
NGL chapter 152• @25C(6)also states that"every itaute or local licensing agency shall withhoid,the issuance or
renewal of a license-or permit to operate a business or to construct buildings in the commonwealth for any
applicant rho hos not produced'acceptable evideace'af com plianer with the Insurance coverage required."
! Addinunelly,MGL chapter 152,4, 25C(7)states"Neither the commonwealth not any of is political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence ufcompiiunce w ith the insurance
requirements of this chapter have been presented to the contracting authority." i
Applicants
Picase fill 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)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLA)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,u 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 atfidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Dcpwtment.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 OMcfals
Please he sure that the affidavit is complete and printed legibly. The Department has provided u space ut the boutons
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 till in the permibiicense number which will be used as a reference number. in addition,an applicant
that must submit multiple pennitilice:se 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 dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
111%; of ti,:c of Investigations would like to thank you in advance for your cooperation and slwuld you have any questions,
please du not hesitate to give us it call.
The Wparnnew's address, telephone and fax number.
The Commonwealth of Massachusetts :.
Department of Industrial Accidents
Ofilce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
,c,•:i,ed ,.'ri-us www,mass.gov/iiia
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