B-19-199 - 0106 BRIDGE STREET - Building Permit The Commonwealth of Ma"chuses ;
Department of Public Safety
Massachusetts State Building Code�(780 C
Building Permit Application for any Building other than 6�3 or�fiwo-Familj Dwelling
(Thus Section For Official Use Only)
Building Permit Number: Date Applied Building Official:
1 O � 0 T
SECTION 1:LOCATION
No.and Street City/Town Zip Code Name of Building(if applicable)
1 Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition '(Please fill out and submit Appendix 2)
Change of Use ❑ Change of Occupancy, ❑ r Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ No Or
Brief Description of Proposed Work: -.DPtit& dq/Ld,'LS
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(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❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
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:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION Q
Name and Address of Property Owner
o6 13/(. v s'f LAC /D
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
,�, y 7ZWy5 - - 97 02-.ifs
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 apply for and 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 Appen4*1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O.
Otherwise provide construction control.fonns see section 107 in the code as fie uired.
10.1 Rekistered Professional Iesonsible for Construction Control(the rofessional co ordinatin' document submittals).
LtD�-rfts 1 C S -1,2.5 G�
'
Name(Re istrant Tel hone No. Registration Number
,� e-mail address
tr/• � o�_3T /��n�G all _U
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
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 AFFIDAVIT 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 0 No Er
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 $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Please print and ign name Title Telephone No. Date
• ✓
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval:
Name Cl Date
CITY OF SALEM� ti SSACH S]ETT'S
"p a HumDLNG DEPARTMENT
i 20 W.-,sHNGTON STREET,r FLOOR .
TES (978) 745-9595
Fax(978) 740-9845
Kj.\jBERL FY DRISCOL L
MAYOR 'THoms ST.�RE.
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWISSIONER
Demolition Permit Sign-Off
(Supplement to permit application)
I,_ D L �� hereby supply the following rele Xl
a part of the
application for a permit to demolish the structure located at /06 u4-=
and shown on the Assessor's Maps
of_ as being on Map # Block # Lot#
The 8'h Edition of the Massachusetts State Building Code, 780 CMR,states in part: "A
permit to demolish or remove a building or structure shall not be issued until a release is
obtained from the utilities, stating that their respective service connections and appurtenant
equipment,such as meters and regulators;have been removed or sealed and plugged in a safe
manner."
Utility to be Notified : Notice Received b Date Received
Gas
Telephone.
d Electric
v Public Utilities Munycip7.1) 2- 2
_.-
Health Department_- ) ) z )
Fire Department
Other -
Other- _
Demolition debris hauler:
Location of licensed
demolition debris landfill:,
Signature of Applicant - Date: ALph C1
Signature of Owner Irate: 1
This sheet must be returned to the Inspections Department along with a completed
application for a permit, a site plan, and any other applicable information and fees..
]�c,iioperm.dcx:
.1. .,: CITY OF SALEM
SALEM 1r1ASSACHUSETTS
ENGINEERING DEPARTMENT
120 WASHINGTON STREET 4TH FLOOR
SALEM,MA 01970
Phone: (978) 745-9595 x5673
Kimberley Driscoll Fax: (978) 745-0349
Mayor
DAVID H. KNOWLTON, P.E.
CITY ENGINEER
October 25, 2011
Water, Sewer and Drainage Requirements
Regarding the Demolition of Structures within the City of Salem
In accordance with the provisions of the General Laws of the Commonwealth of Massachusetts
and the Salem Water and Sewer Department, the following regulations governing the demolition
of structures within the City of Salem shall be followed.
This regulation is made in the interest of protecting the city's water, sewer, drainage and public
way infrastructure at each connection located within the City of Salem, as well as to prevent
conditions which may cause danger to public safety, result in water loss, or damage to city or
private property due to water or sewer loss or back-ups, or cause pollution of the city's.storm water
receiving waters.
1. Prior to demolition of structure, a licensed plumber shall ascertain where all water, sewer
and drainage lines are located entering and leaving said structure. The plumber shall make
a determination of existing or prior use of each line, including,.but not limited to domestic,
commercial or industrial use; irrigation; fire suppression; sewer, storm drain or septic
system; roof drain; or sump pump. After all lines have been located, the plumber shall
make a formal written report with plans of all lines found to the City Engineer.
2. Once the plumber's report has been reviewed and approved by the City Engineer, a
Registered Professional Civil Engineer (hereinafter referred to as "the Engineer") shall
make a determination of the point of origin or discharge on each city main, for each line
identified in the plumbers report. The Engineer shall also ascertain the location, use, and
point of origin or discharge of any other lines on the property that may or may not be
affected by the demolition or connected to the structure. The Engineer shall provide the
City Engineer, for review and approval, a stamped plan of the property and adjacent City
utilities, indicating the'results of his investigations.
3. A request to the Department of Public Services, for assistance in shutting down any water
main, prior to cutting and capping it, shall be made only after the City Engineer has
approved the written reports and plans described above.
Water, Sewer and Drainage Requirements Regarding the Demolition of Structures October 25, 2011
Page 2
4. Prior to demolition of the structure and immediately following item #3 above, a City of
Salem licensed drain layer shall cut and cap the water, sewer and drainage lines at the city
main and arrange for an inspection by the Department of Public Services prior to backfill.
Backfill, compaction, temporary and permanent paving will follow to current city
standards.
5. In the event that the lines will be used immediately after demolition for construction
purposes, a set of plans and/or drawings, stamped by a Registered ProfessioraI Engineer,
describing the lines to be used during construction, must be provided to the City Engineer
for review and approval,prior to obtaining a building demolition permit. Prior to receiving
approval to re-use any lines, the lines shall be inspected for condition and capacity. Sewer
and drain lines proposed for re-use shall be inspected by a Licensed Drainlayer with closed
circuit television equipment and a copy of the resulting DVD shall be submitted to the City
Engineer for review. Water lines proposed for re-use shall be inspected by a Licensed
Plumber and a written report shall be submitted to the City Engineer for review, Any other
lines identified shall be abandoned as described herein.
6. A demolition permit shall not be issued until the items above have been completed and the
Department of Public Services has conducted an inspection and signed off on the water and
sewer portion of the Building Department prerequisite Utility Disconnections Required
Form.
roved bgo
D H. , P.E.
City Engineer
\\Salemdc0l\WaterAdmin\dknowlton\My Documents\miseellaneous\demo regulations water;sewer and drainage 1-30-09.doc
CITY OF SALEM,
MASSACHUSETTS
BOARD OF HEALTH PubliCHealth
120 WASHINGTON STREET,4"'FLOOR prevent.Promote.Protect.
KIMBERLEY DRISCOLL TEL. (978) 741-1800 FAX(978)745-0343
MAYOR lramdlnnsalem.com LARRY RAMDIN,RS/REHS,CHO,CP-FS
HEALTH AGENT
DEMOLITION OF STRUCTURES
Prior to demolition of any building the following information shall be provided to the Board of
Health:
• Asbestos testing report.
o If asbestos is found, provide an Asbestos Notification form ( ANF) 001 and an
asbestos clearance certificate with application
• A pest control report from a licensed Pest Control Company.
o If pests are found provide a treatment plan and certification from the pest control
company that pests have been effectively controlled has to be submitted
• A Dust mitigation plan indicating what measures will be instituted to ensure dust from
the demolition project does not migrate,over the property line.
• If the structure was built before 1978; The Demolition contractor has to be licensed
Lead Safe Renovation Contractor by the Department of Labor Standards and their
employees trained in the use of Lead-safe work practices.
Additional information may be required based on the nature, location and length of the project
City of Salem, Massachusetts
"ire Department
48 Lafayette Street
David'3N Cody Salem, Massachusetts 01970-3695
Chief Tel.978-744-1235 Fire Prevention
97 '44 6990 FaX 978-745-4646 m e
dcody@asalem.com 978-745-7777
Demolition
• Before a structure can be demolished, the Salem Fire Department shall conduct a
preliminary demolition inspection, to ascertain any conditions which may require
a fire watch* or other preventative measures to be taken before, during, or after
the demolition process. Minimum of two weeks notice required to schedule
appointment
• A permit to demolish or remove a structure shall not be is
sued,until the
preliminary inspection has been conducted and a report of requirements necessary
to prevent life safety hazards has been obtained by the applicant.
• The inspection report shall include but not limited to: cutting and welding permit,
fire watch, on site storage of materials, underground storage tank compliance....
• Proof of utility disconnects.
• The requirements outlined in the report shall become a part of the restrictions of
the demolition permit issued by the Building Inspector.
*Fire watch patrol Salem Code of Ordinances Sec. 20-124
October 5, 2010