86 WHARF ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts '
rDJI fi ., Department of Public Safety
-:.,-,,.✓ MasSaCh U5el is State Building Code(780 CMR)Seventh Edition "
00/I City of Salem
Building Permit Application for any Building other than a 1-or 2-Fami wellin
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block A and Lot k for locations for-X.:�ch a streeA a d ess 14 n t ail bl )
<Z& Wy Wrz:e S T tj !l 3qle
No.and Street Citv /Town Zip Code Name f Building (i it e)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in t two rows below
Existing Building❑ Repair 11 Alteration. ❑ 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? r Yes ❑ No ❑
Brief Description of Proposed Work:
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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 Evaluation is enclosed (See 780 CMR 3402.0) ❑ -
Existing Use Group(s): Proposed Use Group(s): a•
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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 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 O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB0 IV VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zohe Information: Sewage Disposal: F
Permit: Debris Removal:
PF y Licensed Disposal tine ❑
Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ will not be
or trench or specify:I'riva[e❑ nr inden[ily Zone: or on site system ❑ nclosed ❑
Railroad right-of-way: Hazards to Air Navigation: %1A I h,hmi<C.nninia�iun Ravirc Prom.:
Not Applicable ❑ la Structure within airport approach area? Is their review completed'.
la C onsent In Build endoa'd ❑ Yes ❑ or:No❑ Yes❑ .No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Cse Group(.): Tcpeof Construction: Occupant Load per Fluor:
Docs the buildingcontain an Sprinkler Scstem?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION \ E
Name and Address of Propert�wner
Name (Print) No.and Street City/Town Zip
Pru perh Owner Contact Information: Ici
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner herebv authorizes
Name Street Address City/Town Stale Zip
to act on the pro ierh 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 cit.ft.of enclosed s ace and/or not under Construction Control then check here❑and skip Section;10.1)
10.1 Registered Professional Resporisible for Construction Control
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Name(Registrant) Tele shone No. e-mail address Registration Number
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Street Address - City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
Company Name:
Name of Person Responsible for Construction License No. and Typejf Applicable
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Street Address City/Town State Zip
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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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ "e-lOm (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.
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['lease print and zign name Title Telephone No. . le
\moi \ Lan+l�A�t A�/ W�z't�1.a�r /��1 m\QQi
titreet Addles. Cih/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
IK CITY OF SALEM
PUBLIC PROPRERTY
DEPAR'CNtENT
III 9�BVi.'I i : � I C •i'N �J: viJ
Construction Debris Disposal Affidavit
(required litr all demolition and renovation work)
In accordance �%tdt the sixth edition of the state Building Code, 780 CMR section 1 1 1.5
Dcbris, and the provisions of MGL e 40, S 54;
Building Permit K is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of*in
Ululnr ul lacihty)
I ndJrea. u(I�cllilyl - '
HellaluC Of pCnntt .q+phcant v
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IJ1�•
CITY OF S .M
.UsE . Axss.-1CHUSETTS
BUILDING DEPARTI&viT
• • I 120 WASHINGTON STREET, 3w FLOOR
TEX_ (978) 745-959S
FAX(978) 740-9846
K1,.,tgFRt FY DRISCOLL
MAYORDR THows ST.PrExxnB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%USSIONEA
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / \ Please Print Leeibly
Nalne (Busing Or6.sniratiomindivtdu l):
Address: 1a
VAe
Cit /State/Zip: J1JN � \JNA /�� Phone#: �� �'l4ig y%,r76-
Y C �,
It y n employer?Check the appropriate box: Type of project(required)
I. 1 am a employer with�_ 4. ❑ I sera?a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).• have hired the subcontractors
I on attached 7• Remodeling;
e a uhed ❑ g
2-❑ 1 am a sole proprietor or partner sheet
ship and have no employees These subcontractors have s. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
INo workers'comp. insurance S. ❑ We are a corporation and its )0.❑ Electrical repairs or additions
required.] officers have exercised then
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
c. 152 14 and we h
myself No workers'com . .4 ( ). have no
Y i P 12.C]Roof repair
insuranceuired.) t employeos. [No workers'
rc9 13.0 Other
COMP. insurance required.]
-Any applicanl tial checks boa Of MUNI antro fill out IM scum below Showing their worker'compeustimu Policy information.
I I Lvtwuwuan who submit This afRdNrk indicating they as doing all work atd then hila outside centrupen,must Suhmil a naw affidavit indicating such.
{,Mursrron thus cheek this box Most anwhed an a.lditiorml ahss showing an tome of the S,bc trsctory and their workers•comp,policy infomumhm.
I am an employer that Is providing•workers'compensadon Imutranae far my employee. Below is rhe polley and/ob illi►
information. ..•�- '
Insurance Company Name:
Policy p or Self-ins. Lie.N: Expiration Date: t_> .'CCS C
Jab Site Address: $Lo City/StatdZip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration data}
Failure to secure coverage as required under Section 25A of MGL c. 132 can lead to the imposition of criminal penalties of a
rine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invcaogmiom ollhe DIA for insurance covarago verification.
I do hereby certify under the pains and pep Ides of perJary that the informadoa provided above is true and carnet
ore: tea— ��O]III® Dote:
Phone d: Ick q<z — A-J Laq
iO1rie•ial use arty. Da nor write in this area,to be cump/eted by city or town official
City or ruwn: _- Pcrmit/Llccme N
Issuing Authority (circle one):
1. hoard of health 2. Building Department 3. Cily/fowa Clerk J. Flectrical Inspector 5. Plumbing, Inspector
6. Other
Cuntact Pcrson. _. -. -_. _- Phone N•