57 BEAVER STREET-2 WATSON STREET - BPA-11-756 The Commonwealth of Massachusetts
Department of Public Safety F-
State Budding Code 1,80 C\IR)*,-%en I EdI❑un ! X
City of Salem IL
Building Permit Application for any Building other than a I-or 2-Family Dwelling i
(Chn Sec nun Fur Uffict.11 U+e Only)
Building Perim.Number' Dale Appbed: Building ln.prctor:
SECTION I: LO ATION IPleme indicate Block s and Lat a for loc+tiom for which+ street address ,s not+va,la blei
...-'- � 1- o" 5Tyam,
Xo. and Street Clta r in+vn Zip Code Name of Budding tit.t ppfrc.t Life) tat F
SECTION 2:PROPOSED WORK V
i New Cun,truclion check here Out check all that apply in the two rows below
- —- -- --Exrtin�Burluing- --Repair --Allrrotion-0 a9diHon-O--Demolition-0�T-'Jea�-r�.- .,.•• t •-�,.v' bm+t-Appendix-J-)
Change of Use Cl Change of Occupancy ❑ -- Other ❑ Specify:
Are budding plans and/ur cunstrucuun documents being supplied as part of this permit applicatiun? Yes ❑ No ❑
Is an Independent Structural Enginrrri�nf'` Peer Review required? Yes ❑ No ❑
Brief C).crlption of Prupu.-d Work- �er MI se rl-L-- grjaS �iJ e� �'✓'�-- '7'
ih exrS � a .t r v
t0T � t- 50 is .F r nraf.i,• G•� ' .iaf�r'. ear_: 1S
ce,. Yh•3S•r deoC's '.✓1 . .in r �C.. err•✓ /oa.t_ !'o✓-a "`VVVV
v_.(' L'p n✓\ '3N- o-.i� �o Co-.••, s <, r9r�-r �Ra `r
(j, t' S r p opon .4�N,LS Or- {r.•t a fa.a r/c 15 O/9,2 ne
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING VNDERGOING RENOVATION,ADDITION,OR �•
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
alunpd
ng Use Gruup(s): Proposed Use Group(s): r
ng Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
rea(-,q.ft.)and Total Height(ft.)
SECTION 5-.USE GROUP(Check as applicable)
embly A-1 ❑ A-2r ❑ A-2ne❑ A-3 ❑ A-4❑ A-5❑ 8: Business ❑ E: Educational ❑o F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑tutional 1-1 ❑ 1-2 ❑ I.3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-4 ❑.
age SI ❑ S-2 U U: Utility C7 Special Use❑and lease desmbe below:
U'..r: SECTION 6:CONSTRUCTION TYPE(Check a a licable)
IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA Cl V8 ❑
1 SECTION 7: SITE INFORMATION(refer to 7W CMR I11.0 for details on each item)
I ' Debris Itemov+l:
Witte Supply: Flood Zone Information: Sewage Disposal: French Permil:
Pohl,, ❑ I Check il.nd.tda•I�L,•.I Lnnc❑ Indicate mumc,f,al❑ \ Irench wdl nut he Li:crned D,,p,....11,1, ❑
I'ncale❑ , r indcnble Zuna•: , r n.dr.c,lrm❑ requlrid ❑or tra•nch ,r,f•c:,t�.
j Railroad right-of-way: flatards to Air Navigalion: \ra IL.b n, t ..,,, , ,..,,R,. •.. --
-\ol \Fpn.,ddo❑ I.�Iru♦I,nvt•ohut.nrp„rl eppin.,dt.vo,t' I, dteo n•t rot, n.ml•I.n.l•
.., 1 ..,,..•nl u• Ittul.i 11❑ le. ❑ \•, ❑
1
SECTION q:CON TENT OF CERTIFICA CE OF OCCUPANCY �
I .l it li nl •d l ,.•tc .__ L cl.n.mp,.I — Ct f•a •11. n,I ni:n. n .___ l4'iuf`.urt l ••d.t f or l L •n __. __._._. ._...
tl. r. iho Dui ,hnq.nnl,,m.tn�pnnkcr?t,tom'' `Faaal�npulanun, �
SECTION 9: PROPERTY OWNER AUTHORIZATION
of Properly Otv ner
\.arts•(Print \o nd 5trcef it% r Lnvn
Uri Informlin N / a 07,JreO &1
0 o�
ri dr relephone No.lbu..ina:>) relephune No. (cell) r-mail .i.ldrcss
If.Ipphi.lble. the property .•sr ner herebv auchomes i
Name -Nreel Addre s Ci1v1 Totvn State Zip
to act un the ro•ert% owner's behalf, m.dl matters roans v to work aut honn•.1 by thi,butQhC3
hun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out App(11 t•ud.hn•u to+Ilan 15Mxx)ru. ft of endosaJ.•are anJ/ar nut uudar C.nptrudwnControl Ihenr10.1 Re istered Professioonal Res onsible for Construction Control
e t I one r-mat a rrss ber
Street Address - Cily/Town State Zip Discipline Expirattun Date
10.2 General Contractor -
�
Company Name:
GS 0 � 2
Name of Person RR �p//tmible f Cupstru ion / License No. and Type if Applicable
�b`�GC fI�1
Street rrss State Zip
-1 ( _.f ✓��. ?Sl _�15s Yo3�j City/Town "74- & / 3-7
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSA ION 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 issiaaiaee of the building permit.
Is a signed Affidavit submitted with this application? - Yes No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building S L1.1 Ofl0J
in Permit Fee=Total Construction Cost x
2. Electrical § g —(Insert here
appropriate municipal(actor) _$
3. Plumbing §. Mechanical (HVAC) SNote:Minimum fee-$ (contact municipality)
S, Mechanical (Other) S check s tble to
6. T.dal Cost - S p•y�[7 r�0 munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMITAPPLICANT
Ry entering my name below, I herebv attest under the pains and penalties of perjury thm ell of the in/ormamin o.nt.imrd in chi.
.Ippfic non �.trt and ac era to to the best.4 my knuwdedgeartJ understanding.
- &A-- ---- J�1 `fa 5�9
V iv..,r pnnl and -ign name (.Ile
Z-'t rrl �)�h.mr Mace
Y r I f.11r l
i
/CV r
� l
%futmipal Inspector to fill out this section upon application approval:
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CITY OF SALEM
xi'.' ' J' PUBLIC 13ROPRERTY
r- DEPARTMENT
TSo
I!C WAx11.\6 I\1\Sts ELT s SA h.M.M.\D.\t.11l t47 IsJp)7C
lilt:97j.71S9595 s 1'\.r. 9711•71C-I846
Workers' Compensation insurance :%fftdsvit: Builders/Contractors/Electricians/Plumbers
\ 1 llicunt information / Pleme Print Legibly
�IiIsi1C Illuanwavl)rganva�tli—nNlndnviJu��ul��1: `
Address:
City,Stare;%ip: S j ` Phone if: �� l �Ila 9
IAre) Ian employer:'Check appropriate box: 'Type ufproject(required):
I. I am a empluycr with rf 4. 0 1 ;fill a general contractor and
cnJployees(lull unJ/ur part-time).• have hire)the soil-contractors /'' new cunstrtutiun
2.0 1 am a sole proprietor or partner- listed on the anachcd,hest. : 7• ❑Remodeling
ship and have no anployees These tub-contractors have M. 0 Demolition
working for me in any capacity. workers'comp. insurance. _ g.___ _OuiWi
--
--— -- - - --)N�wttrkcrs`cump. iusurantt:_T.S.-.O--We arc a corporation and its -- - --- 0 n6-aJJitiurt -
rcquircJ.J oRiccn have exdnisdd the
-is' 10•O Electrical repairs or additions
3.0 1 ant a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp, c. 152, ¢1(4),and we have no 12.❑Roof repairs
insurance required.) t cmployces. (No workers'
camp, insurance rcquired.l 13.0 Other
Any.iiplicam film checka boa sl musl alas Jill we file'iechoo Wow dluwine'hair wwkua•cw'psnwiun pulicy iof lrnwliun
'I lumarownen who aubmil this sfllalarif indiurine'hcy fie duine In wuk and lives him outside emtorwers must.films an"Aridavil indiulinx•f.nnmcbas that check this bolo mum altxhnd an addirioua oilcan atmwine tha llama Of ill@ mbKentractars and ken wukun'tomy.pdk:y inlbm'adw.
/one all elnplrtyer thus It providing ovorhers'eornpenrndon inrurnnce jot sty etnp/uyrrs. Be%ov is the pu/!cy rand/ob site
lnjorolulifuL �a��
-Insurance C'ompaoy Name:
2 00 — L -2o1
Policy 4 or Sraf•ins. Lic.d: z-
3 b� `� _ g _ EApiral'on Data
Job Site Address:_ 5� t/�� y .t C S�4-H-
uylStatd"Lip:_
.mach it copy of list workers'compensation policy declaration poke(showing the policy number and expiration date).
Failure to sccuro coseruge a required under Section 25A ol'JIGL c, 152 can lead to the imposition of criminal penalties of a
find up to SI.500.00 undlur one-yea imprismmnunt,as well as civil penulhcs in the torm of a STOP WORK ORDER and a fine
of up to S250.00 is Jay against the violator. Ile advoted shut a copy of this muicmunl may be forwarded to the Office of
III\'�.1Ihan to uI Ulu UTA lbr soNurar a Cj vY rj' \ Ut)n,
/du hereby rrnijy under tat p ri 'r ptn tJer lr/•per/rtry that the irljurinuNon provided
/above is true raid correct.
Official rut way. Do ant writt in Ihir area, lu he coerp/rttd by city fir lawn o/Jfi ioL
i
City or'fown: _- . Pcnnitil.Icvnso N-
Issuing Aulhurily(circle foe): ,-..
1. hoard of llealth 2. IAlildifi; Ilcp;trtu'cnt 3.Cily/Turin Clerk a. Electrical Ifilpcctor i, Plumbing Inlpeetor
6. Other
l'nUaCl l'cnunt - . _ I'Aunc Y:
I
Information and Instructions
.Iass.rchusetts Ucncrai Laws chapter 1 i2 requires all employers to provide workers' compensation for their cntployces.
rursuant to cilia+mute,an implorer is defined as ..every person in the service of another under any contmct of hire,
eapress Jr implied.oral or written."
�n ernplofwr 1%dclincd as"in individual,purtnenhip,associrtioa. corporation or other a del entity,or any two r t more
.It the 1J(egoing engaged Ina Joint enterprise,and Including the legal re preYClllativea Jf]deceased employer.Jr I t
I eeetvef of f(aalCC Uf.N IIIdlvldual,pattncrship,assoetalioa or other legal entity,employing employees. However the
owner t.a dwelling house having not more than three apartments and who resides therein,or the occupant of the
.Iweiling house of another who a urtenantttheretorsonstshag ndo n u
ys otbecause of such employment be deemed to be an employection or repair work on such dwelling rs
or on the grounds or building;I
SIGL chapter 152, Q25C(6)also states that"every state or local licensing agency shag withhold the Issuance or
renewal of n license or permlt to operate a business or to construct buildings in the commonwealth for any
applicant wire has not produced acceptable evidence of compliance with the Insurance coverage required:'
Additiunully, hasGI.chapter 152, §25C(71 states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ufpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
-- -- please fil4out-the-workcra' compensation affidavit complerelYhona number(a)along with rheicking the boxes that lcertificas o-Yof y to your nand,if
necessary, supply sub-contractors)name(O.addreLimit d Liability
p with employees - —
insurance. Limited Liability Companies(LLCworken'tcompensationainsurance.rtnerships(If an)LLC oroLLP does have
et than the
members or partners,are not required to carry
employees.a policy is required. Be advised that this affidavit may be submitted to the Deportment of Industrial
Accidents for confirmation of insurance eovenge. Also be sure to$ign and Jule the afl7Javn The -part it should
he retllnmcd to file city or town that the application for the permit or license is being requested, not the [h partmcnt of
law or if you are required to
a workers'
Industrial Accidents. Should call the De you have nny questia nt at theenu number ligarding st d below. Self-routed companieatshould enter their
coinpensation policy.p P
sclf•insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided u space ut the bottom
Of the affidavit for you to till out in the event the office of Investigations has to contact you regarding the applicant.
1'I:use be.sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that mrut submit multiple penmitllicem"applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locutions in (city or
town). ,A copy of the affidavit that has been officially stamped or marked by the city or town Inay t7iduvit nws t provided to the
applicant as proof that a valid affidavit is on file for future permits of licenses. A new a be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business Jr commercial venture
I i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
I It,; I)I Iiic III investigations would like t0 thank you in advance fur your cooperation and should you hake:1ny questions,
please du not hesitate to give us a call.
The D:parunent's address. telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdigadons
600 Washington Street
Boston, MA 02111
Tel. N 617-727.4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
c:•. . d c tls www.mess.gov/dia
'b CITY OF S.UENl, NLkSSACHUSETTS
Bt:tLDLNG DEPARTNMNT
120 W.UHLNGTON STREET, 3'FLOOR
TEL (978) 74S.9595
FAX(978) 740.9846
KlJ(BERLEY DRISCOLL
,MAYOR Tkows ST.PrERRs
DIRECTOR OF PCBLtC PROPERTY/BUILZING COMMISSIONER
Construction Debris Disposal 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:
l/
(name of hauler)
The debris willl_be disposed of in
(name of facility)
(address of facility)
Lgre ermit applicant
date
my �z