80 WHARF ST - BUILDING INSPECTION I�
The Commonwealth of Massachusetts
Department of Public Safety
\I.t,adiu•vits$kite Building L ode(.-8U C\Ili)h•cen I Edi lion !
I City of Salem
Building Permit Application for any Building other than a I-or 2-Family Dwelling
(rhe Sra'lwn For Official Use Onlv)
lludahng Vermll Numtwr: Date Applied: Budding Inepeaur:
SECTION I: LOCATION IPlease indicate Block s and Lot s for locations for which a street ddress is not available)
\o. and Street C ilc r rulvn Zip Cede Name of Building(il applicable)
SECTION 2:PROPOSED WORK
If New Construaum check herr O ur check all that apply m the two rows below
"- .. EArcting-6uilding- -Repairrraltiun-0 -rlddiFHm-f]--Drmulitiun-a4Pleas"ill,)ut-and-submit-Appendrx-
-
ChangeofUse ❑ Change of i)-.... cy O Ulhrr ❑ Specify:
Are building plan.and/ur construction documents being supplied as part of this permit application? Yes ❑ No ry
Is an Independent Structural Engineering Peer Review required? Yrs ❑ Na C
Brief Description of Prop,e-d Work:
7!
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERC ING 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): t
Existing Hazed Index 780 CMR.34: Proposed Hazard Index 780 CPAR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft)
Total Area(.sq.ft)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Asstmbly A-1 ❑ A-2r O A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ H: HI Hazard H-1 E3 H-2❑ -3 O H-4❑ H-5❑
1: Institutional 1-I ❑ 1.2 O 1.3 O 1-4 O M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4 ❑
IS: Storage S-1 ❑ S-20— U: Utility❑ Sp_ecial Use O and base describe below:
Special U.sr:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA O 118 ❑ IIIA ❑ 1118 O 1 IV O VA O VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR I I I.0 for details on each item)
French Permit:
Debris Removab -
Nater Supply: Fload Zone Informalion: Sewage Disposal: { Un m-.d Suc CO3I'uhhc� ('heck 7l nulade rL.,d G,nv ClIn.hcale municipal 11 :\ trench will nul he Licrn,ra L
� I'ncalc
❑ „r unlenliK Zone:_ ur nn.ate•%stem❑ required Cor trench ,a.perrth.
prrmrt i.anclu.r.l ❑
I Railroad righbul.way: Hazards to Air Navigation: \I-\ Iba,.n, l ..,u..... .,i 13•,,,,,
'\rl \L•{diaal•le❑ I.�Irualmr a,lhut.nrprrl apl•inddt an•a' I.lhru ra•t ica o•m{ Icl..t'
w 1(udJ cnal,,d❑ I Ie.❑ ❑ ❑
SECr1O.N 8:CONTENT OF CERTIFI, %rE OF OCCL'PANCY --�
1 .1,lu ql '11 •.1l' ___ L-c lJq `4.I — It F`c •I(• I,�IrN 1p 91 _– ltrlll)•.Illl l •.Id L'ol I ,i.q
14 ,-. ih,•b,nlAu,,:.,•nl.int,tn�I,rmklor?t.tom' _ �L•rrial�lipulahum
SECTION 9: PROPERTY OWNER AUTHORtZATtON i
V.ut+r perty Usvner
\.ton=tPnnq \o ttx!?Iraet lth•-(ot.•n ''P i
I'n,}+cele lh+net Contact lnlurnimion: /A"IG) 7d4 SO
rnlr Frlr}+hunt Vu.Ibu�mr,•1 rrle}+hi�nr.Va. full) .•-tnatl .t J=Ire��
If a + phcabte,the n.pert%usv ner herrn%authorizes
Name 1�1reel AddreN, lits'i Town dale Zip
,pact un the rtu pvrh-=,t.net,behalf, m ail matters rvlati%e to tvurk authanzed by the.building +emit a + +hiatn+n.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
lit Nuldm.is Fns than notxf cu.it_of emloxJ +aiC andfor nut water Gertanrchon i+nllml th,n,heck here Q and 4,y ti=•.tuus IU 1 i
10.1 Registered Professional Responsible for Construction Control
;V-;TrnCytti�tia7Tt) eep one Nu. e-maitilrr5s eyistration Number
Street Address - City/Town State Zip Discipline Explr.uwn Date
10.2 General Contractor
Company Name. 100.714/ r -
Namr Pers.sn Re,}xrnsible krr /Construction License No. and Type if Applicable
A-t_gj , J�QQrf if Whi f�/60 7
Street Address City/Town State Zip
7 03
Tele hone No.(business) Tele hone No.(cel! e-mail address
SECTION 11:WORKERS'CO' ION PIS RAN E 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 si ned Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building S d f d Building Permit Fee=Total Construction Cost x_(insert here
2. Electrical fAe/ int;y =d0 appropriate municipal factor)=s
3.Plumbing "c I s a .DD
J. tvkehanica (H AC) I s Note:Minimum fee=$ (contact municipality)
S. Mechanical (Other) I 5 Enclose checkp'y's tble to
Ay F-Prie, --
6. Total Cost - s 7KQCi, _ {contact mu»ici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Be vntrnng my name below. I herebv attest under the p.nns.md penalfie,of pequry that all of the infurmotion cunt•fined ,n th,e
.tpplicalnm r,lnie.md accurate ht the beet of my knowledge and under,lan prig.
iI'le.ne}•rut(and"gfl n.ime rule 1 a0,ph, c• ).ne
r} I
Municipal Inspector to fill out this section upon application ipproviL•
CITY OF SALEM
PUBLIC PROPRERTY
� o DEPARTMENT
�Ls Ys'a 1 \t AiHI.\G ION 51 ELT • SA11A.M,t YSACI II it cls 0197
I'ra.: 08-745.9595 • 1'.tx. 979-74V.)S46
Yorkers' Compensation Insurance :'l'ftdavit: Builders/Contrac torsi Electricians/PIumbers
konlicant Informulion Please Print Leeihiv
Verne(0uu ncsvOr6an,y4linn1 lndrv,duob:_A—m
Addfess: R RiD/ t S2E
City,Slarci%ip:� 14k Qh� Phunefl:��7
Are you an employer! Check the appropriate box: 'Typo of project(required):
4. ❑ 1 am a.cnoral contractor and 1
L El I am a employer with 6. 0 New construction
employees(full andlur put-tine) have hired the sub-cumractors
2 � un a tole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
' ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
No workers'comp. insurance 5. ❑ We are a corporation and its 10.[] Electrical repairs car additions
required.] officers have exercised their
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers'comp, c. 152,¢1(4),and we have no 12.0 Roof repairs
insurance required.j t employees. (No workers' 13}.0 011ier
comp. insurance n:quir-ed.]
-nny appllcaul Ihm chuck*boa MI mu*t also till aur rhe section buluw slowing rheic wo(lui cumpensaliott pulicy inliomatitnt
'I lumvuwnen whu submit this n171davit indicating they arc doing all work mW then hire outside etvnractors must auhmil a new alydavil iodic lmg amh.
-Con¢mb,n
that thcck this box mlun anwhtd.m addiriuwl sheel showing lite namo of the sub.ontrulon and their wurken'cornp.("they information.
l run un eaq)loyer flint Lt providing)vurkers'compensation iuturance for aty eatployeet. Below is the policy and job site
information.
Insurance Company Name:---
Policy
ame: __Policy g or Selr-ins. Lic.t+: ___... . _.._._ Expiration Date:
Job Site Address: _ City;State/Zip:
Attach it copy of lite workers'compensation policy declarulion pulse(showing the policy number and expiration date).
Failure insecure coverage as required under Section 25A cal->1GL c. 152 can lead to the imposition of criminal penalties of 3'
file up 10 51.5110.00 and/or one-year imprisonmt:nr,as well as civil penalties in the furm of a STOP WORK ORDER and a fine
of till u))250.00 it day against lite violator. lie advised that a copy of this statement may be furwarded to the Ol'tice of
lit% gaunns ul the DIA for insurance covcragc tcrilicaliun.
/do hereby certify under/thl pjtrr�iin�s�and penalties ofperjury that the infurmution provide/qd�above is true and Correct.
til�''f 11❑I'C' _ _`/Y r/-"'- � DatC' V/ r oC. �' �t-✓�/
791 -c0
Official use wdy. Do not rvrile in this urea,to be ctmnpleted by city or town officiary.
I
Ging or'fown: Permit/License 0.-.
Issuing Aullturily (circle ouc):
1. ntsard of Itvallh 2. Building Dcparnncut 3. Cilvr Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Conrad I'cnuu: _ .. Thune tJ:
Information and Instructions X
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enmployces.
Pursuing to this matute, in emplorea is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An empluyer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
,a the foregoing engaged in a joint enterprise•and including the legal representatives of a deceased employer,or the
receiver or trustee of :m individual,pmmership,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
.Iwelling 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."
%IGL 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. NIGL chapter 152, §25C(7)stades"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public 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 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 does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
-Nccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit 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 question 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 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 not in the event the Office of Investigations has to contact you regarding the applicant.
Please 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 pennit/licetse 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 ilia 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this afftclavit.
I lie 0ifiee td Investigations would like to thank you in advance fur your cooperation and Should you have any questions,
please do not hesitate to give us a call.
The Deparuncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Otflce of Investigations
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Iteviscd ;-'ti-U5 www.mass.gov/dia
CITY OF S'UE.NI, NL-uSACHL'SETTS
SUILDLNG DEPAR- ENT
120 WASHLNGTON STREET, Y*FLOOR
TEL (978) 745-9595
FAx(978) 740-980
KI.-,jBgRr FY DRISCOLL
MAYOR THows ST.ParsRs
DIRECTOR OF PUBLIC PROPERTY/BC[IMG CONNIMIONER
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 It 1.5
Debris,and the provisions of MGL c 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 I50A.
The debris will be transported by:
rlUz- T p
(name of hauler)
8
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
dale
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