49 Federal St Building Permit App (Addition)The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code (780 CMR)
Building Permit Application for any Building other than a One- or Two -Family Dwelling
(This Section For Official Use Only)
Building Permit Number: I Date Applied: I Building Official:
SECTION 1: LOCATION (Please indicate Block # and Lot # for locations for which a street address is not available)
46 Fepeca, St. SG d em (YliA 014no
No. and Street City /Town
Edition of MA State Code used
Zip Code Name of Building (if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here ❑ or check all that apply in the two rows below
Existing Building 0 Repair ❑ I Alteration 0
Addition 5" I Demolition 0 (Please fill out and submit Appendix 1)
Change of Use 0 Change of Occupancy ❑ I Other 0 Specify:
Are building plans and/ or construction documents being supplied as part of this permit application? Yes '® No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No Y'
Brief Description of Proposed Work: (( X `7JL to tfiTY)I't(0n
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) 0
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4: BUILDING HEIGHT AND AREA
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 0 A-2 ❑ Nightclub 0 A-3 ❑ A-4 0 A-5 ❑ f B:
F: Factory , F-1 0 F2 ❑ H: High Hazard
I: Institutional I-1 0 1-2 ❑ 1-3 0 I-4 ❑ M: Mercantile ❑
S: Storage S-1 0 S-2 0 U: Utility ❑ 1
Special Use:
Existing
Proposed
shirt -
Business 0 I E: Educational 0
H-1 0 H-2 0 H-3 0 H-4 0 H-5 ❑
R: Residential R-10 R-2 0 R-3 0 R-4 0
Special Use ❑ and please describe below:
SECTION 6: CONSTRUCTION TYPE (Check as applicable)
IA 0 IB ❑ I IIA Cl IIB ❑ IIIA ❑ IIIB ❑ I IV 0 I VA ❑ VB ❑
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply:
Public
Private 0
Flood Zone Information:
Check if outside FIood Zone 12(
or indentify Zone:
Sewage Disposal:
Indicate municipal 6�
or on site system ❑
Trench Permit:
A trench will not be
required 0 or trench
permit is enclosed 0
Debris Removal:
Licensed Disposal Site CaP
or specify:
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 0 or. No Ed Yes 0 No 0
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
_
4 I� fied.c)e Lt Z2, irta Drne 3___1-v t_ G , f �_ (VViT7o
Name (Print) No. and Street City/Town Zip
Property Owner Contact Information: ,rye
Cho c 'U r-I 17- (41-0Y ` -5 - o` �11 01Cd,Ptlf CO4,11�'+CJt`4^ �i11n
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property 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 cu. ft. of enclosed space and/or not under Construction Control then cheek here ❑ and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name (Registrant)
Street Address
10"2 General Contractor
Telephone No. e-mail address
City/Town State Zip
Registration Number
Discipline Expiration Date
Company Name
CS093 2 0.6
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. (business) Telephone No. (cell) _ e-mail address
SECTION 11: WORKERS" COMPENSATION INSURANCE AHIDAVIT (M.G.L. e. 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 17 No 0
SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Mechanical (Other)
6. Total Cost
Estimated Costs: (Labor
and Materials)
Total Construction Cost (from Item 6) = $
Building Permit Fee M Total Construction Cost x (Insert here
appropriate municipal factor) w
Note: Minimum fee = $ (contact municipality)
Enclose check payable to
(contact municipality) and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below. I hereb
application is true and accura t
PIease print and sign name
JV Enin CA
Street Address
attest under the pains and penalties of perjury that all of the information contained in this
bit of my knowledge and understanding.
Title Telephone No. Date
City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name
Date
JeUO,ssiwwo0
0
KIM[BERLEY DRISCOILL
MAYOR
CITY OF SALEM, MASSACHUSE. '1'S
BUILDING DEPARTMENT
120 WASHINGTON STREET, 314' FLOOR
TEL. (978) 745-9595
FAX (978) 740-9846
THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPER.TY/BCILDLNG COM M SSIONER
Workers' Compensation Insurance Aiiidavit: Builders/CunfrnctorniEiectriciansiPi umbers
Applicant Information .. .Please Print Legs,
............. .
,L /,, ,-e y
Nellie tE3usiness;Organizatioct/individual):
Address: 7 v /A/ 1JI fi
City/State/Zip: SeDvhone#:
Are you an employer? Check the appropriate box:
4. ❑ 1 am n general contractor and I
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per 1vMOL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
army applicant that vheeks box ill must also fill out the section below showing their worker$' compensation policy information.
t I tram:owners who suhuti4 this affidavit indicating they are doing all work and then hire outside connectors must submit a new affidavit indicating such
={:antracsots that check this box must attached an :additional sheet showing the name of the sub -contractors and their workers' cotup., policy information.
1 am an employer that it providing workers' compensation insurance for my etttployees. Below Is the policy and job site
information.
Insurance Company Name:.
1.0 I am a e player with
en 'yees (full and/or part-time).*
2. atn a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3, ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
Policy # or Sell ins. I,ic. ll:
7, cot06"VYe;
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
3. [] Demolition
9. [] Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
Expiration Date:
Job Sire Address: „City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy tatumlaetr and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year iirnprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to S250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
lnvcsti,gatillt%s ul'the Dt fr insurance coverage verification.
f do hereby
Si zna Lure:
Phone #:
rains and penalties o perjury that the information provided above is true and correct`
Date: .4)
Official Official use only. Do not write in this area, to be completed by city or taws official,
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitytThwn Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Outer
Permit/License 4
Contact Person: Phone #:
MILEY DRISCOLL
MAYOR
CITY OF SALM0.4 MASSACHUSETTS
BUILnNIG DEPARTMENT
20 WASHINGTON STREET, r FLOOR
TEL. (7) 745-955)S
FAX (PPS) 74
THOM S ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/51,3113NG COMEISS!ONER
Construction Debris Dispose Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
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 150A.
The debris will be transported by:
et, (0 h O ii
(name of hauler)
TIxe debris will be disposed of in :
eh/AmilOr
(name of 1'ah' lity)
(address of facility)
tIlltisaffds�u
Vetgy
. A ill 7-N
signature of permit applicant
if
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