38 WILSON STREET - BPA-11-485 The Commonwealth of Massachusetts
Department of Public Safety
I� F' '.' % \Li..adnneUsStale BuddingCode 1.,80CMR)SeventhEdition
Iu I City of Salem
•J•1'
Building Permit Application for any Building other than a I- or 2-Fimily DwellingI
I Phis Section For Ofticlal U,e Only)
Budding I'll.Number: Dale Applied: Budding Inspector
SECTION I: LOCATION (Please indicate Block 0 and Lot It for locations for which a street address is not available)
�$ bi?/sc, ,n.A P14C55 0J970
x� \o.and Street C itr /r,nvn Lip Code .Name ut Budding lit.ippitcable)
SECTION 2:PROPOSED WORK
If New Construction check here❑ur check all that apply in the two rows below
Existing Budding❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are budding plans and/ur curutructiun documents being supplied as part of this permit applicauun? Yes ❑ No ❑
Is an Independent Structural Enginrrrin•Peer Review required? y� J Yrj ❑ Nn ❑ y
Brief Description of Prupovd Wl�rk: Ls-�v-..s-� �C✓1��1 +�e-f r �i0i0� )✓ U/G/C?/r 1N lin,�oi�e5
tit ! ✓c 11��c i n jy e Nn ✓) �t I✓
K B
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 Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area idol. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applivable)
A: Assembly A•1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A•S❑ B: Business ❑ E: Educational ❑
F: Facto F•I ❑ F2❑ H: High Hazard H-I ❑ H•2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1.1 ❑ 1.2❑ 1-.l❑ 1-4❑ M: Mercantile❑ R: Residential R- R-2❑ R-3 Cl R-4❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use O and pleasIe describe below:
SF,rnal Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
. IA ❑ Is 13 IIA ❑ 1180 IIIA 13 1118 C3 IV C3 I VA VO (3
SEMON 7: SITE INFORMATION(refer to 780 CNIR 111.0 fordelailson each item)
i Water Supply: Flood Zone Information: Sewage Disposal:
French Persil: Debris Removal:
Public❑ (heck,I,nn>ide flit,-d Lone❑ InJic.ilr mumiipal❑ A french ,,It not be, Licrmed Ui.poal Site Cl
❑
„r nd
«•quucd❑ur trench „r.recd c.. _
I'ri v.i 0.•❑ icnldl Zone:_ nn,n.dr.c•frm
I pc•rmlt i.cnclomJ ❑
I Railroad righGof-way: Hazards to Air Navigation: �I l l l,.l,.r�. l ..,,,n,........ ,, 1'.• •.•,:
I
\ol \i'rh..ildc❑ L�Innnuc,.�Ihm,nrpurl a)•ilodih,in•.i' Llhcu irl ic„ :,antd.Ir.l' i
, , 1 n•rnl b. Ilio III oud,wl ❑ I h•,❑ „r\o❑ lr. ❑ \„ ❑ _�
SEC"rION 8:CON TENT OF CFR"TIFIC,\fE OF UCCL'P.1NCY
I .Ilh,91 ,• ( i ,IC _ .___ L•c lJ,q�t,ly __ I,i•C ,II „n.IrU.ln ilt ____ Ili itlF•.Inll „J,I /•.'I Ili , , .-_.__ __._ __
li„r. Ihr 1•w Lho.:.,,n1.un.u.ci,nnAlcr�l .lam'' _ `irnal�upu .iuon. ____ I
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Nome.0 d .\dJn<.e of 1'rul+erre Owner )
\.unr il'rint) _ Nu.and Slrvel Clts; rusvn
Pri,pert%Uu tier Contact Infurm.mnn:
role reiephime.No. (bu..me>x) rviephune No. (cell) r-mad add n•..
If applicable, the properly uu ner hereby authorizes
Name - Street Addreas CItY/Town State Zip
of act on the +n.,vrlc u..nvr,behalf, mall matters relative it,work a lthunzed by this •buildin ernnt u + +bc., it
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(11 huldm•is los than li•tXX)cu, n.tit.ndo*vd• iev asidlor not i G...urul Ihvn check here❑.rod .kq +,•.bun IU 1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone Nu. e-mailaddress Registration Number
Street Address City/Town State Lip Discipline Expiration Date
LWorkers'Compensation
al Contractor
amr: XRd LI"4- �y
UrG S
Nameram��R�__r.��nsrblIr fur Construction �j� Lice sr No. and Type if Applicable
S70ess 4p City/ owner State Zip
�z'o1 S'!—• `?- 7Go.(business) Tele hone No. cell) e-mail address
SECTION Il:WORKER 'CO E S N INSU ANC AFFID VIT(M.G.L.e.152. 25C(6))
ers'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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =S
1, Building 5 BuildingPermit Fee=Total Construction Cost x
S _(insert here
2. Electrical appropriate municipal factor)=5
3. Plumbing $4.Mechanical (HVAC) 5 Note:Minimum fee=5 (cont snicipa it )
S. Mechanical (Other) 5 Enciusr checka ible to
fi. Total Cost 5 P•ya
�OUDr v4 (contactmunici alit )and write check number er��
' SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
HY entering my name below. I hereby attest under the puns and)+rnahirs of per)ury that all of the inhumation o ontmned in ihie
ipplicalum is true.nd accurate to the best of mY knowledge and under.landmg.
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I'Irgi.v pnra ain't.ign",line �^ � elate
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\luniripal Inspector to fill out this section upon application approval:
\am u
I•.uc
CITY OF SALEM
DOW
PUBLIC PROPRERTY
,_.
DEPARTMENT
.i,nc N:I'Y JNI<C,-11.
\1+1v lit 12^.WA+MIM;I JS SIXEL•T a S.UL•.U,M.+SSM.In sl.l as5197^�
1'1%1,WS-74i9595 •1'.+x. 97111•7+0•9346
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben
\nniicant Information Please PriintALecibly
Name tnucmesi0r;aniratiiirdlln-dlviduull: /� t��l�U r'/K. �GLL r✓G7(,Ly° �-fi vr�
Address: /S S1 L2`G•� �.y�✓ U e
City,starcizip: 01�'/ S
:Sreyou an employer!Check the appropriate box: 'Type of project(required):
4. Q I ;an a generacontractor and d 1
L❑ 1 ;un a employer with G. ❑ New construction
unploycas(full antUur part-tiole).• have. hired the sub-contractors
_.C3m I aa sole proprietor or partner. listed on rhe attached sheet. : �• C] 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 or additions
3.drequired.) officers have exercised their
I ant a homeowner doing all work right of exemption per MCL I LE] Plumbing repairs or additions
myself.(No workers'comp. c. 152,j 1(4),and we have no 12.Q Roof repairs
insurance required.j r employees. LNo workers' 13.Q Other I')'I 15C f&p0. I VS..
comp. insurance required.] . —
•!1ny a;gtheam that chucks box dl must:dao sill Lan the stearal huluw showing their rurkus'compenwion pulicy intiaourirae
'Ilumcuwoun whu mdtmis this amdavit indicating they are doing all work ante then him outside caurxton must•uhmii a new arfdavil indieaaints ouch.
-Conirnt,"thus check this box m+at attached in additional alu.;et.hawing the name of the suis conuwtan and their wvurkun'comp.policy infurmatiun.
/run un tospluyer thuf fv pruvidinX workers'c'ontpeusnlion inturnncc jot uty eurployecs. Belnly is the policy and job.site
lnjortnutiva
Insurance Company Name:—.. .. AAAA
Policy 4 or Self-ins. //"C
Lie.it: _ ___ Expiration Date: / A /',�
Job Site addrem—TY I"Wro-4 -� r�`�-` City;Stateizip: 5C6' ESS 01f 7 6
Attach it copy of lite workers'cmnpensution policy declaration pale(showing;the policy number and expiration date).
Failure to sccuru coverage as required under Section 25A ul'`IGL c. 152 can lead to the imposition of criminal penalties of a
tint up to S1.500.00 andlur one-year imprisonment, as well its civil penalties in the furor of a STOP WORK ORDER and a fine
of up to i250.00 It day against the violator. Be advi:rcd that a copy of this soticment may be lurwarded to the Office of
litYcangaaons of tete DIA for imurarce coverage\erilicahun.
/do hereby terrify under the pains wed penaltles ]perjuryebur rhe injurrnudon provider/above is true and correct.
�i�•:t:nttre: � [�,Gliiq bzf, / Date' OcuculRj 2-4 2- 10
OQiciul use only. Dol not tvrire in this arca,to be catplered by city or to o/JiriuL
City or Town: ... PermittlAvirse 4_
hsutng Authority(circle one): i
I. Board of Ilvalth 2. Iluildiog Department J.City(fowo Clerk 4. Electrical Inspector 5. Plumbing; Inspector
6. Other
Contact Pk"011: .. Phonc tl:
Information and Instructions t4'
.Massachusetts Gcncral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant (u this itatWC, in emplurea is defiled as"...every Pelson in the service of another under any contract of hire•
capress or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
or the Giregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
(CCCIVCf or trustee UI :Ill individual,pwmership,association or ocher legal entity,employing employees. However the
house having not more than three apartments and who resides therein,or the occupant of the
owner of a dwelling g
dwelling 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."
MGL 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, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of eunipliarlce with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)namc(s),address(es)and phone nuniber(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 au 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 confimtation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retuned 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;rad printed legibly. The Department has provided u 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.
Please be.cure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that in"submit multiple pcnniulicetsc 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 roof that a valid affidavit is on file for future permits or licenses. A new affidavit must he tilled out each
IPI P
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.
I he 0I lice 111 Investigations would like to thank you in advance fur your cooperation and should you have any quebtlons,
please du not hesitate to give us a call.
The UcParunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OR1ce of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Itcvi>cd �-'_6-(15
www.mass.gov/dia
K
is 9
CITY OF S.U.E.NIs .LxSSACHUSE-rrS
• BI:II.DL`1G DEP.iiRT.%0NT
120 WA SHLNGTON SMLM, Yo FLOOR
TEL (978)74S-9595
FAX(978) 740-9846
KIJIBERLHY DUSCOLL
MAYOR 'IHou►s ST.Plxaas
DIRECTOR OF PUBLIC PROPERTY/BI:ILCING CONNISSIONER
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 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
I 11, S 150A.
The debris will be transported by:
.(`
(riline of hauler)
The debris will be disposed of in 0,CSL 1 A 50 (—� {d ^ lA 4P—1 S
Q
��51/ (�-e .
(na a of f facility)
7 DaAau f" Tt✓wC (TLLc 5th �4& V3
(address of facility)
�iG�O /X�i ti
signature of permit applicant
date
Icbna,if J.►