BUILDING JACKET (002) Q
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The Commonwealth of Massachusetts
* Department of Public Safety p(�l MAY 3 I P �2 5tl Massachusetts State Building Code(780 tlGi )
U Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official: 71 V
- SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address r not available)
e
No.and Street City/Town Zip Code Name of Building(if applicable)
tf� SECTION 2:PROPOSED WORK
I^ Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
I Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other q0 Specify:—1 ftsQ 1'�1 G-f�N
Are building plans and/or construction documents being supplied as part of this permit application? Yes tb No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: \6aa o xN,-k W L L1- � r)Wy c, t cAn
r9.crx Ir aJJ
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
Existing Use Group(s): Proposed Use Group(s):
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-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ 1 E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ I-3❑ I-4❑ M. Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 17 IB ❑ IIA ❑ IIB13 IIIA 17 IIIBO IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
•i Permit- Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
Private❑ or indentify,Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Informatiogn:�,
1 1 D -_?4q-q
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
305e- nrl , S 1c93 wCN-C rn pt, c
Name Street Address City/town State Zip
to act on the property owners 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 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
�our�.,c�e c ,slla+{ R V?3Iosn
Name(Registrant) Telephone No. a-mail address C-°'� Registration Number
a l i t 12d 51 C Aa P_ynhcr1 1�1W" 8
Street Address City/Town State Zip Discipline Expira ion Date
10.2 General Contractor
An0L.e_ C ,-% C' .ilf�.i r,j -CTc.Vw�d1c��jrC
Company Name
3 —V 1 V-4 ctn 101: 3
Name of Person Responsible for Construction License No. and Type if Applicable
!a UA-), ryl.t.1},v. s+. Nkik- '1 V41LACLL 9Qd, K M1Ps fA_l_Y.o
Street Address �� City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVTT 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 l7 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 $ 35 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to owledge and t (b o y kn understanding.
Gk Lrw,- fte`T 111Q_-5ft&7105 - ice
Please print and sign name Title Telephone No. Date
9CA eAw, (�iw l ✓11Y} olgdt4
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
,
fL-MSWWT9E fMgE94MG OWPROVED BY T44E
A pXl; 1B pWOR TD A.PER1F AFJNG GRANTED
CITY OF SALEM
N0.121-z�6 \ Data
Is Property Located in / Location of
slat H Loft Distdct? Yam No V 1nilAlnv
Is Pmpwty Located in
I*Conew adon Area? yea_NO
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) f Reroof, Install Siding, Construct Deck, Shed, Pool,
RepaidUplace, Other: A A 'c
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
spedfications:
Owners Name Albert C I C� cti o ilf
Address & Phone l t,-P) Q r re a p L3+ sa/?!24 �'If} j 97e )
Architect's Name YZ2
Address & Phone j )
Mechanics Name A111 '
Address & Phone
What is the praposs a boild ? T r.k,Ic IR AhJ
mderlai of bt~ a a dwaYNq,for tow many lamYba? o�
Wo bri ft cwrdorm to law? Xe C Asbestos? L)0
Wonted coot ° cuy Lkenw• N A she umm e
same Improvement
Lic. ,� X
Ignature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE 1
RfWA0VQ o1CA (�IaP. r t,iC11S ih Aw(, T.Y.S o,-H , Skfe4/oclt .
Pc�;nyt a'\el �r�loce �locrl
MAIL PERMIT TO:
No.
APPLICATION FOR
PERMR TO
nD�
LOCATION
l 5-9 r
PERMIT GRANTED
INSPECT INSPECTOA OF BUILDINGS
l
•
pL.*1SV1 T.KfM.{-� AfPROVED BY T44E
Jy;� l Pt310R T0.A.PEM17 BEING GRANTED
CITY OF SALEM
—�; Date V
No.
W Property Located in Location of
dw Historic District? Yes No hd ding
is Property Located In
ow Corwerwulgn Amur? Yee NO
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Sidin , Construct Deck, Shed, Pool,
Repair/Replace. Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owners Name o a
Address & Phone
Architect's Name
Address & Phone f
Mechanics Name
Address & Phone 4 ( t
wtw Is Qw Purpose d bWldinp?
mom"d buldrtp? UI Bi9Tit H a dwsdit,for how many lamilies?
WIN bWk*V cordorm to law? Asbestos?
Estimated Oast cJ OD City Ucaroe r N A State L low" R
am* Lpro.eant X
7-19Z
I , Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
c-
MAIL PERMIT TO:
.t
NO.Z
APPLICATION FOR
PERWr TO
LOCATION.
PERMIT GRANTED
�� Zo 2dD,6
APPR VED
1 PPOTOR OF BUILDIIYGS
no Coewtostp eM oj3f4sswhUsel18
Deparlatem ojlfrdtrsMd Aeaddutfs
l$df
6at
BOW4 MA M11
tt+wtraressdott/dQtt
Worker'Comptensadon Insurance Afiidavib RWMen1ContradonMedridsxW?hmbere
Avpdcm t bf�rma ttln Pidse Print Ldo+t
Name 6GrN is 7 S
Address: 4 q iD,7
City/StatdZipe ,Soil// aS'7o�: ':, Phase th 0 �� �328�
Any as em"ert Mck thttsoMrIste bast' type Of project argdred);
1. am a ea�ph>yer wind 3 I am a small cootraclor and I 6. ❑New jest 00 dam
®plcy'�(stn se wlor psis- ' bave bind as 06komaaow
2❑ I am a sole prapriettir or parloeo- listed on do aMuW sheet 1 7.
Ship and bm so empkryees These sd-.c trubn bave ti. ❑Demoll"
watift ib<im i•nOlespeci4l. /'=W m* nc mua 9. [�Hn>7dioO addition
vtt ofileealr ye 1&0 ElWWMI mpaas
m igbt
or addition
3.❑ I a a bomeowner doing 4 Sark rof MGL' 11.0 Pbmtbisg npain or addition
myself(No wod<W comp. c. 152.f 1. tui�i+te bav>s'm 12Q Roofnpafir
maaesoce tees t. IN° �r 13.�Other
•Any.pp8maliMcbui.box0lnwaWwfillgt4[•• bebrdwviga.k,r.e13P'aongemtaaoaPolleymb;mrtloa
tHadmWomWARobooit"m id vitadkAftOftadofma.pwkEdtbsWiid e.00.tiirefonafntt.abmit.o.w.®dtvitt .00h
tCOM&W*M dot cb.dc d*bu mnt.nttb.d a.ddatoad.bet d oviea as==benYnie.nht���e.mid"woef r.'cw*policy b bnnedm
IOasgremplvrdrantlrprovf&vg wrdtrr'eoaepaesdleabWanprotfnagaitpfijeert BdottArdltpoftWdMS&P
NfM"dm6
Innsance Companyxame %RAl✓yl
Policy N or SelTriw Lis Expnation Date: v 'iS— d 7
Job Site Addreat_ i�A' A n h z— 3 7 Ohl : 2� 19 1 71 7 L
Attack a espy of the workers'compensation polley dodaratlon POOR(showing the Policy somber and expiration dad@)6
Pailme to sears coverage at requh under Section 25A of MGL a 132 can lead io the imposition ofaimiod penalties of a
fin up dD$',Soo.00 and/or one-year hWi1Oomem,swell Me civil penalties in 60 form of a STOP WORK ORDER and a fine
ofup to$250.00 a day against the violaw. Be advised that a copy ofdtb smtemew may be forwaded b the Ofte of
htvadgitions of the DIA for iosmaoce coverage verifiptios.
I Ap Isembl"no wider At ptbu Saul ps tfpaja7 tANfAAe kfffmWkapvvWd above Is true and rawest
sianaeme: �� Date• ;����/y 6
Phone0: kz C/7 Z411
OPWRMOIROL DORM*Vft a rbb ana,n d<caa'pfeWiy eAryrain+t r a�Id@e
City or Town Pernift eense b
Iaaisg Authority(cirde one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical ImpeXtor S.Plumbing Inspector
6.Other
Contact Perton: Phone M•
t
Information and Instructions
(,,eoaal Laws tb*W 152 requim an emRlaprmV Pro
an it defined as"...every yasos in the saviee of
wider my
p�q t6v atatnse. �or implied'oral of wnlga"
assoelstim►corporation fir o&er legal entity,or a°Y two or more
An sir PWN is de ned as�n individeaL parts hj *a legal refs of s dmassd emPWM a the
Of the foregoist��19 ti joist aterpriss, a office lea�tY��PieY�[emPioYers arwevQ the
receiver or trustee Ig o iadividoal,ptrgashiP. and who resider&agile6 or the o�of dtiF
owner of a dwemoi house baviot tat mere dtaa am aparmab ao a repair oa such dae>>mibom
dwellmt borne of tmotha wb0 emPloya pat0ns q d0 otbecause . be deemed to be an etaploya."
or an the i�of buildmi >saeq:ban� of saes empby�
Mtff.�132,12SC(�ale°sum that"eves?Stare or teeal teeeft att�eY am withiold the ionaaoe or
renewal of a neeata or Permit to opwale a bedans err is eattatrwA baillgn0 V the twmMMraatlh fa*tre4"
with the Inanranee maw req "
apps. a wM has net prodaecd MM ptabh svideace d as of ilt potidal ssbdhrittions shall
Addidall ,MM clapter 1A 12XV)states"Neils dw wmmonarabb�of oamP>taaea w�the inaataace
enter ho say cc'
tgct Sur the cfpnbNC wow tmtid atxeptsble
ie4aIIcumn of this cbaPset boo boo presented to the
colllmft "
` by dw mig Sabottes that 201Y q Y�won&'d
Please fM out the wodr�sco��addr .(ea)aaai PbM mmt.*)along wilt their caoi8casda)of
noccsswyt men L�imt�ted LiabitetY ComPanim(L Q a Limited I.iabriny Puitesshipa wt&no anpdow b odiive dun the
uonbers or PaAaaa,are not rogoited q any�' bm="- if as LLC a I1,P dos brave
emPldY P°bCy' Be advised dill Ibis.Mdytvjtmay be mbmu0ed q dx Dcpartmai of Industsial
Arts tion of bye�'� �b:We to dip Ind date the affidavit. 1La atHdavit sboald
be returned to dte city or tows that&a apptiadm for the penuR a hence f heist e04�sot t ah
b�any yuesti m ngardiet the taw a rfyon an rego;red q attain a workers'
Mkwlad0in'� � me II�e D eq at dw>m�bea pt0ed belaa'. Self-imarad"oompa>r�s M earoer thdr
P�
iota on>be brae.
_insm�e Bceata
seY
Cky or Two 01 cish
please be sore that the affidavit it complete and printed lc&l'' The Department bat provrded a space at lbw bottom
of dte affidavit far you q fill out in the event the office of tuvestiptions bas to contact you regarding the aPP
please be sure q M in the pa rArdeente number wbich wOl be used as n re only s tttmit o a addition,an applicant
that milt submit Wa tiPle pamwficim a apP in any given Yeai sad only ° one affidavit indicating tatrent
policy iefteestion(if oecmary)and. "lob Site Addreta"the applicant to write"all may p —(city to Of
town)"A caPY ofthe stlfdavit dW bra bsW odkia�r s�d?L' by_ . Ott)'
enm venom
at ptnotthat a valid af9davh is on&le for&dare permits or&cum A sew a�davit aostbe MW art each
applicaUlt year.Wbae a borne Owner or efdaea is obbh&g a Hotatae a permit not related q say busittaat a commaevenom
(Le.a dog home Of permit to burn lava eta)said person is NOT required to complete this of ldwit
would lilte q thank you in advance fayour coopaatioa and should you bave any questions.
The Office oflavestitatioaa
please do not betitt W q ns a pn
'ha Depa laces addrM telephone and fax nomba
The Commonwealth of Massachusetts
Department of Industrial Accident
Office of Inveattgedons
�. 600 Washington Steed
Boston,MA 02111
TeL #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
` CITY OF SALEM# MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WAsmINOTON STREET, 3R0 FLOOR .
SALEM, MASSACNUSETTS 01270
9TANLCV J. USOYICZ, in. TELEPHONE: 978.745-9893 EXT. 380
"Aron FAX: 979-7409046
Salem Building Demrhnent
Debris DLqmwW Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
W`� A (Location of Facility) & �-
"A4
Signature of Applicant
Date —,
I
f1*116ii1116t�E fKAW*NrD OkPPROVED BY T44E
JNSPPE =PLilOR MDA.PEAW AEING GRANTED
CITY OF_SALEM
No. \ D"
IsProwwwcamin 14"tt" of
IIM FilMotb OIMdw Y«No ftu"m
b Pe* Mty LooaMd In
Im CMrMwaon Am? Ysk,_No
BIALD" PERMIT APPLICATION FOR:
Pormu to:
(Circle whichever apply) Root Roroof, Install Sidin% ConWW Dell. Shad. Pool.
FW0awVAwIm. Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the follwaing
speodicatiom
Ownses Name OrGZiO OCC 1,�P rh � � .
Address a Phone 0 k R(AgS S�,• A kfw\ L 1
Architects Name IVA
Address & Phone _ N1AJ j 1
Mechanics Name ��?
Address & Phone 41-14 L 1
whirl Is rw purpose of oirldtrp7
mmum of pfldkip? U a dwW".for how mrny ImMu?
wo bA*q mdolm to low? Asbsstos4
EWknWAd cost 3$�, ply UW=r N �` stair Uarw r
t
uc. Il IXoaWm 3a
X ,�
of Applicant
SW = UNDER THE PENALTY
OF PWUURY
DESCRIPTION OF WORK TO BE DONE
2-ePIriCe
MAIL PERMIT TO:
r
No.
APPLICATION FOR
PERMIT TO
P�-/jvaF
LOCATION
/6' SemL 4 S77
PERMItGRANTED
APPAOVFD
Oq OF 8UI S -