B-19-875 - 0129 BRIDGE STREET - Building Permit ' 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 Seefton Fof Ofi :Use Only)
�, (� Bu�ldmg Penaut'Number• Date Apphecl: Building Official
SECTION,1:LOCATION'(Pleaseindicate:Block'#:and Lot#for locationsfor which a street address is not available)
No.and Street City/Town Zip Code ame of Building(if applicable)
SECTION 2 PROPOSED WORK
0 Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building go' Repair lr Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No a
Is an Independent Structural Engineenn Peer Review required? ✓ Yes ❑ No br
Brief Description of Proposed Work � & P L A-L1r.r LA-1 /Alit O t,Qie tit.,t f H
Al 6--LA:i
—�
SECTION 3;COMPLETE THIS SECTION<IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CIiANGE`IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Usi�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 GRQUP(Check as apphcable)
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E. Educational ❑
F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ 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:
;; SECTION 6_CONSTRUCTION TYPE(Check as applicable)_::
IA Cl IB ❑ HA ❑ ITB ❑ ILIA ❑ IIIB ❑ IV\❑ VA ❑ VB ❑
SECTIOIV_7 SITE INFORMATION(refer to 780 CMR 1110 for details on each item)
Water Suppl : Flood Zone Information / Sewage Disposal: Trench Permit: Debris Removal:
Public[7 Check if outside Flood Zone Cd Indicate municipal ' A trench wfl not be Licensed Dis sal Site
or s 62 P
Private❑ or indentify Zone: or on site system❑ required ' or trench permit is enclosed❑ .V
t((/
Raikoad right-of-w�`' Hazards to Air Navigation: MA Historic Commission Revie Process:
Not Applicable Is Structure within airport ap roach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No 1 Yes❑ No l"
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:
�IIS M )�.j L- QO MINet4F
6
SECTION 9 PROPERTY OWNER AUTHORIZATION::
Name and Address of Property Owner Q G--%& C_-017 9 . PO, P t- $ l �$�lL c G✓l� + ® C Z
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information KC AI,4 er14- J9<4 Ll.A M 0 Q
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10 CONSTRUCTION:CONTROL(Please fill;out Appendix 2)
tnuldui �s tess:than 35,000 cti.ft,of enclosed s ace aiid or not urider'Construehon Control then check here 13.
anil ski ;Section 10.1
101;Re tered Piofessional'Res onsible for Construction Control;
Name(Registrant.) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
.
10 2.General:':COntraetor
Company Name
'dc-i y v9�a� jq C oa /(f
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address -I I City/Town State Zip
-feleiphone No. usiness Telephone No. cell e-mail address
. _.
SECTION 11:WORM9 COMPENSATION 4SURANCE AFFIDAVIT GtL c 152§25C
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION12 CONSTRUCTION,COSTS AND PERMITFEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6, _$
1.Building $ gZC0 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ b appropriate municipal factor)=$
3.Plumbing $ O
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ 0 Enclose check payable to
6.Total Cost $ 00 (contact municipality)and write check number here
SECTION 13SIGNATURE OF BUILDING'PERMTT 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 ae at to the best ofm'�y knowledge and understanding. .�
lease t and signname Title Telephone No. Date
Street Address — - City/Town State Zip
Municipal InspRctor.to fill out this section upon application approval v
Name Date
r w
CITY OF SALEM MASSAC HLIS� E u � TI'S
BUILDING DEPARTMENT
120 WASHINGTON STREET,3'®FLOOR
'AL.(978)745-9595
KMERLEYDRISOpLL FAX(978)740-9846
MAYOR THOMM ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING Opt WSSIONER
Construction Debris Disposal Affidavit
p ffidavit
(required for all demolition & renovation work
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris,
and tie 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:
aL—KB C)4/8 UK
(name of hauler)
The debris will be disposed of in:
Rb
�� c l� ►cVC��
(name of facility)
/39
(address of facility
gnature of applic nt
(today's date)
i CITY OF S �i.E��i, N XSSACHUSETTS
• BUHMING DEPARTNIE.NT
`Jv 120 W 1SHINGTON STREET,3so FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KIMBE t? FY DRISCOLL
NMAYOX THOMAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CON.MaSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4nnlic,ant Information Please Print Legibly
Name(Busim-WOrganizatiorVlndividual):�,
Address:_7 Ok—(ZRV Ce Lj —NL
City/St;ate/Zip:_ AN-C I honeV.
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑1jew construction
employees(full and/or part-tithe).' have hired the sub-contractors
2.ElI am a sole proprietor or partner- listed on the attached sheet.-# 7. Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. q []Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3. 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,41(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. [No workers' 13.❑Other
comp.insurance required.)
•Any applicant that chwAs box#1 must also fill out the section below showing their workers'compensation policy information.
t I It meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new atrdavit 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 an tr nplayer that is providing workers'compensation insurance for my employees. Below Is the policy and Job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a(Mpy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 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 S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Idoherel7unier,th uins air pena! s o r* that the information provided above t rue and orrect.
. i en;t t Date. 1� �Z/ ,2
Phone 1O Jfcia,l use only. Do not write in this area,to be completed by city or town oJfc'iaL
City or Town: _- Permit/I.1cense#
Issuing Authority(circle one):
I. Boaud of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Oth(�r
Contact Person: Phone#'