B-20-533 - 0100 BOSTON STREET - Building Permit LO
I! co
The Commonwealth of Massachusetts
Department of Public Safety
�a Massachusetts State Building Code(780 CMR)
,Q 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 Offici<a1:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
/Od 43,osTyiv 5T 51-Vr�,j t)/9,7,0 New /'iyGZ4,vd 512Rksay
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK.
Edition of MA State Code used If New Construction check here O or check all that apply in the two rows below
Existing Building at Repair K Alteration O Addition❑ Demolition``❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy O 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No O
Is an Independent Structural Engineering Peer Review required? Yes O No ❑
Brief Description of Proposed Work: a,F_ o c% /,/vCr FL oOnj*jy& , Ff2l�IaM.,,,,U
Q f►T f//too✓P�1 I�U l,v t4 L 1-���st,T i N G—
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): IProposed 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 ❑ A4 O A-5❑ 1 B: Business 0 E: Educational ❑
F: Facto F-1 O F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5 O
I: Institutional 1-1 O 1-2 O 1-3❑ 14❑ M: Mercantile O R: Residential R-10 R-2 O R-3 O R4 O
S: Storage S-1 O S-2❑ - U. Utility O Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA O Ill O IIA ❑ IIB O [IIA ❑ 1118 O IV O 1 VA O VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone K Indicate municipal Al A trench will not be Licensed Disposal Site O
Private O or indentify Zone: or on site system O required O or trench or specify: UL7t ter►i iG
permit is enclosed❑ Tic
Railroad right-of-way: Hazards to Air Navigation: 41,A I I toric-Comm igsion I'co'%J t%',"1'rocc,s:
Not Applicable 0- Is Structure within airport approach area? is their review completed?
or Consent to Build enclosed❑ Yes O or No®' Yes O No K
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?:, /'n Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Alf-V/ C- n ivd f3/a Tell / I 0 0 56)5;V V t1 SA�gam(
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
F6m'0 (o4ad950 4,L - -- _ rFd �G,ti�i coi
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' ix 2)
f buddin is less than 35,60Q cu.ft.of enclosed space and/or not under,Construction! then check here O and skip Section 10.1
10.1 Argiotere0rofes Wonsible for Construction.Control
-�= Y3.3 o Sa® �t+ ' p gt
N. ( istr ele one D41o. a-m drest Registration Number
Street Address City/Town States Zip Discipline Expiration Date
ff
10.2 General Contractor
U/lrt'TF_cl �;��'NG �iaiNTl,✓� /n�
Co u►y Nam
Name f Person Res Bible f onstruction n License No. and Type
�iif4A,p�plicable
14
Street Address Ci /Town State Zip
�� _ s 0 S _ - Urur .:a 5r�d�-6,12&vri�✓& �CMlpr.� co tit
Tele hone No. business Telephone No. cell e-mail address
SECTION 11:WORKFRY CONIPI:NSA110N INSURANCE At FIDAV14, 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 O No 0
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE'::
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 671 •00
1.Building $
Building Permit Fee-Total Construction Cost x_(insert here
2.Electrical $ 5',D CO 0 appropriate municipal factor)_$
3.Plumbing $ 0 0
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 6 (, pp O (contact municipality) md write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering any name below,I hereby attest under the pains and penalties of perjury that all of the information contained'n ths
appl' lion is tru and accurate to the best of my knowledge and understanding. ] 5
Pie! s' n na Tie Telephone No, Date
Street AAldress
city/T n tale Zi
Municipal Inspector to fill out this section upon application approval
Name Date
1�® Commonwealth of Massachusetts
4� Division of Professional Licensure
Board of Building Regulations and Standards
Cons r '
o. isor
CS-088520
� g MARK A ING �cpires: 11/29/2021
.�, �-- ;
53 EAST MAMA STA
AYER MA 01 2
o
Ir
SS"1_io
Commissioner �•.c
The Commonwealth of Massachusetts
Department.of Industrial Accidents
I Congress Street,Suite iff
Boston,MA 021144017`
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers...
TO BETILED WITH THE PERMITTING AUTHORITY.
Applicant Information_ Please Print Leldbl
Name (Business/Organization/Individual):
Address:
City/State/Zip:. A3 . . Phone#: t3-3 0 5 d2 C)
Are you an employer?Check a appropriate box: Type of project(required):
1. 1 am toyer with employees(full and%or-part-tone).• 1. New c nstruction
2. am a sole proprietor or partnership and have no employees working for me in $ ernOdehng
any capacity.[No workers'comp.insurance required.]
3.Q i am a homeowner doing all work myself.[No workers'comp.insurance required.]
9. ❑Demolition
[] '
4.❑i am a homeowner and will be hiring contractors to conduct all work onmy property. l will 10 Building addition
ensure that all contractors either have workers'compensation.insurance or are sole. 1 L.[a+leetncal repasts or additions
proprietors with no employees.
12.�uP`tubing repairs or additions
5.a I am a general contractor and'I have hired the sub-contractors listed on the attached sheet:
These sub-contractors have employees and have workers'comp.Iinsurance.: 13.0 Roof'repairs'
6Q we are a corporation and its officers have exercised their right of exemption 1e MIGL c. 14.EJ Other.
152,§t(4),and we have no employees.(No workers'comp.insurance required.]
*Any applicant that checks box ql must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are 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 sub-contractors and state whether or not those entities have
employees, If the sub-contractors have employees,they must provide their workers',.pomp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company.Name:
Policy#or Self-ins.Lic.nn#: Expiration Date:
Job Site Address: ���L l/Y` City/State/Zip:.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is.a criminal.violation-punishable by a fine up to$1,500.00,
and/or one-year imprisonment,as well as civil penalties in:the form of it STOP WORK ORDER and a fine of up to$250 00 a
day against the violator.A copy of this statement may be.forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby eer ' er the ains,a d of perjury"that the information provided ab ve.is true nd correct.
Sign ture: Date:
Phone#: r�3
Official use only. Do not write in This area,to be completed by city or town official
City or Town: Permit/License#
issuing Authority(circle one)0
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other -
Contact Person:. Phone#:
i
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
98 WASHINGTON STREET,2ND FLOOR ,
TEL: 978-745-9595
KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for.all demolition & renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris,
and the provisions of MGL c40, S54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,S150A.
The debris will be transported by:'
CLL,T- q 7r LuA/9 Tt-12 S
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
,r. y #at a p p'l 5ant j
S Z.2 7
(today's date)