City of Salem Permit Application 25 LyndeKIMBERLEY DRISCOLL
MAYOR
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 W ASHR•IGTON STREET, 3"D FLOOR
TEL, (978) 745-9595
FAx (978) 740-9846
THOMAS ST.PIERRE
DIRECTOR OF PtBLIC PROPERTY/BI:ILDtNG CO'L.tISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information !n l� Please Print Legibly
Name (Business.Organizatiorv(ndtvidual): � r i4 �/7 Lt/tyP 1�
Address: (7 / -tr - /e# 2 A 4,4(,e-
cat6yVV
City/State/Zip• S/4/e l4 p 6 f' 7 0
Phone ##:
Are you an employer? Check the appropriate box:
1.0 i acmployer with 4. ❑ I am a general contractor and 1
tployees (full and/or part-time)." 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 MGL
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.)
•Any applicant that checks box 01 must also till out the section below showing their workers' compensation policy information.
T I fomeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
:contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp. policy information.
I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.)
3.0 I am a homeowner doing all work
myself. [No workers' comp.
insurance required.) t
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. [] Demolition
9. El Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.0 Othrr
I am an employer that is providing workers' compensation insurance for my employees. Below Is the policy and fob site
information.
Insurance Company Name.
Policy # or Self -ins. Lie. #: Ft'piration Date -
Job Sire Address:
City/State/Zir•
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGG c. 152 can lead to the imposition of criminal penalties of a
fine up t•. S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 150.00 a day ag inst the violator. 13e advised that a copy of this statement may be forwarded to the Office of
lnvestigatt ns ol'the DIA r insurance coverage verification.
I do hereby c
Sir'nattire:
Phone #:
Ins and penaltle f perfusy that the information provided above Is tru and correct.
3//9 010
(k6
Date:
iOfficial use only. Do not write in this urea, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other _
Contact Person:
Phone #:
[
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code (780 CMR)
Building Permit Application to Construct, Repair, Renovate or Demolish any
Building other than a One- or Two -Family Dwelling
Code and Other Requirements for Building Permits
The Department of Public Safety has issued these building permit application forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in order to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the building permit application, that no outstanding property taxes, water fees,
etc. exist.
Filing Instructions
1.Please contact the city or town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done.
2.All applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3. Please include a check for the Building Permit fee. The fee may be calculated using the information to
be supplied in section 12 of the Building Permit Application. The check is to be made payable to the
local city or town where the work will be done.
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)
Buildmg Permit Number. 1 Date Applied: _ l Building Official:
SECTION 1: LOCATION (Please indicate Block # and Lot # for locations for which a street address is not available)
I — VW) c. Jo,I Gott D t L9 -'an" 121'rh
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 CI or check all that apply in the two rows below
Existing Building 0 I Repair 0 I Alteration 0 I Addition l0 I Demolition ) ` (Please fill out and submit Appendix 1)
Change of Use as 1 Change of Occupancy ❑ I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0
Is an Independent Structural Engmeer• eer Review required? es_kTa No❑
Brief Description of Proposed Work.
Y` Mt1 e or 4 kf e a1 d�G�' o r �acr e 14 of hrl� ;n
f01A4 Sr LLAP ;fr -Cf'Or o i-c/hotinle✓' booitt i4a.
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) ❑
Existing Use Group(s): Proposed Use Group(c\•_
SECTION 4: BUILDING HEI HT AND AREA
Existing
Proposed
No. of Floors/Stories (include basement levels) & Area Per Floor (sq. ft.) 4 J)
Total Area (sq. ft.) and Total Height (ft.)S V i (A (./ f O
4,-
SECTION 5: USE GROUP (Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 J B: Business 0 L E: Educational 0
F: Rai" F-1 0 F2 Q _H: High Hazard H-_ ❑ El H-3 -4 0 H-5 ❑
I: Institutional I-1 0 1-2 ❑ I-3 ❑ I-4 ❑ M: Mercantile 0 I R: Residential R-10 R-2 0 R-3 ❑ R-4 I]
S: Storage S-1 0 S-2 ❑ U: Utility 0 I Special Use 0 and please describe below_
Special Use:
IA ❑ IB ❑
SECTION 6: CONSTRUCTION TYPE (Check as applicable)
IIIA❑ IIB❑ IIIA❑ IIIB❑ ) IV I] IVAEl VB
SECTION 7: SITE INFORMATION (re er to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information:
Public 0 Check if outside Flood Zone ❑
Private 0 or indentify Zone.
Sewage Disposal:
Indicate municipal ❑
or on site system ❑
Trench Permit
A trench will not be
required 0 or trench
permit is enclosed ❑
Debris Removal:
Licensed Disposal Site 0
or specify:
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 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
me an Address of Property Owner
-.� —i c £fig.7,)-)- 4i,,uil14,24(4 4, 4 iica,,, .,fun )7 lc, 0 I� 7D
Name (Print) No. and Street City/Town Zip
Property Owne Contact Information:
1 kt, 14 fiu k od, Pfr q=_ �yo q 4/
Tide Telephone No. (business) Telephone No. (cell) L, `(.t�'Lf ej� it ddress / �j,
If applicable, the property owner hereby authorizes f `� iti Lv (9 0 i 14 04 8 , t, 04,2
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 check here l7 and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
1 h o Nc o f44 VO c>s ,boo D64ar /oarrh.ifer;
/AL
ame Re trant f le ne No. e-mail addre
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
:ST,,,., 14 ft \i
Company Name
��ni►tx . Vilet LVV4
Name of Person Responsible for Construction
a7 Q_A v►a N 9 <n 9et AVM
Street Address
egistration umber
License No. and Type if Applicable
,5 Ie _ "NA o/970
City/Town State Zip
97f y20' 1 q6 3c1-tialue Woo . con•
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 Indusirial Accidents must be completed and
submitted with this application Failure to provide this affidavit will result in the denial of the i5soance of the building permit.
Is a signed Affidavit submitted with this application? Yes PJ' No C
SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
and Materials)
Item
Total Construction Cost (from Item 6) =
i 1. Building $ Ai 0, 09 0 i Building Permit Fee = Total Construction Cost x .� (Insert here
2. Electrical $ I appropriate municipal factor) = $ .
4 3. Plumbing $
4. Mechanical (HVAC) $ I Note: Minimum fee = $ (contact municipality)
15. Mechanical (Other) $ S Enclose check payable to
II 6 Total Cost $ 60, ° V O I (contact municipality) and write check number here
1
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I her by attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate tole befit of n1yy\nowledge and understanding.
'0L \ y j
6'fyb 3//
P ease print and sign name Title Tele o e o.
t_NAve.�� A ik�e , C1lklp w•- ; �,� o
eet Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Date
Name Date