10 BECKET ST - BUILDING INSPECTION (3) a
The Commonwealth of Massachusetts
`-� Department of Public Safety
\la,adunrtt,Stme 8uddmg Code(:80 CMR)Srrvnth Eduwn ♦r !
City of Salem
Building Permit AEplication for any Building other than a I- or 2-Family Dwel '
I rho`acrwn Fur Official Coe only)
[holding Permit .Number: Dale Applied: (7 Budding Inspector:
SECTION 1: LOCATION (Please indicate Black 0 and Lots for locations for which a street address is not iv it ble)
XNo-old street C It% /Town Zip Code Name or Building bl .1pp4.1111 )
SECTION 2:PROPOSED WORK
If New Construction check here O or check all thatapply in the two rows below
Existing Buildin ` Repair❑ 1 Alteratiun Addniun❑ Demolition O (Please fill out and submit Appendix 1)
Cha nge of Use O Change of Ocaipancy ❑ Other ❑ Specify:
Are building plans and/ur curutructiun documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Pruposed Work:
2 ' X O S
wary fed fsT �Loa�' vet f'T
X -
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Ccuup(s): - Proposed Use Croup(s): r
Existing Hazard Index 780CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
:N2.of Flours/ ies(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sStor
I
ft.)and Tutal Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r O A-2nc❑ A-3 A-0 O A-5❑ B: Business ❑ E: Educational 0
F: Facto F-I ❑ F2❑ H: HI Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-S❑
1: Institutional 1.1 ❑ 1-2 O 1.3❑ 1-4 0::[M: Mercantile O R: Residential R-10 R-2 ❑ R-3❑ R-40
S: Storage 5.1 ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use.
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 1118 ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
t -
Water Supply: Flood Ione Inlineation: Sewage Disposal: Trench Permit:
Debris Removal:
I'ubbc ❑ C'hd•d,it incl•iJc 19�r�d Znnc❑ Indllc.rte municipal C3 '\ Irrnch will not he I_iccmrd Unp—al?itr ❑
required ❑ur trench „r.i`vo i.'.
I'nc.uv❑ .rt uidd•n bl. Zonv,_ ..r..n ate warm ❑
)`roma i.d•nclo.rdl ❑
Railroad right-of-way: Ifuards to Air Navigation: i ...,i
\ I \ppld.ddr❑ L•InKltnv o ilhin.1oi`urt.ipivn.ich.1rra' L thc.rrc,.c,. ami• .IrJ'
•al- •,�.vnl h. Build ,,,1,-,J 11 I Nr•❑ ,.r \n❑ lr. ❑ ❑ _-4
SEC"rIO.N 8:CONTENTOFCFR"TIFICAfE OF U-CCPANCY
Lwld..ui•ni _. f,i•r .Il n�tru.u,m ___ tir[ui`.un l ....I icrlLrn __ _–__. __._
ee S r
1'
SECTION 9: PROPERTY OWNER AUTHORIZA:TION
me acrid r%JJrv,of 1'n'l+vrt% labs ner _
\.one lPnnt) Noand struet hitt ; rruen
I'n+1q•rh'lhv ner Contact Information
x
` t cL 4 t.�,11-si W7 `•f2 . 73E-'('
rode relrphone No. (busrnras) relephune Nu. (cell) e mail .iddro-"
I(al+p h.ablr, the proper" us,ner herrby aulhurizes
\'acne ?trcvt Address Cin'/Town State Zip
Ito act on the +nt vert% owner'. behalf. m.ill matters rielame to work .tut horized by this buildingernut.t + dtcutn nt.
SECTION 10:CONSTRUCTION CONTROL IPlease fill out Appendix 2)
111 t•uJ.Ln•u L>,,than 33,UUUcu.it.of cnduvJ s+acv and/or nol under Conamctton C.minrl then check here❑anal kip r•.Inui III 1)
10.1 Registered Professional-Responsible for Construction Control
Name(Registrant) rel Nu. 3 e-maul address Registration Number
Street .Address - - - City/Town " ''1 State Zip Discipline s Expiration Datr i
10.2 General Contractor
X Go—�s '</C(d" CG :i-'YIKr t /'o ll,jW�.
Co piny c ��3Lu c Y0s
Name of 'f�tw'}Re 77,ble fur Cun3trNctiu¢ �( License No. and Type if Applicable
Strent �d`fy� J !/��/✓u it �[-1s /'C/(� /aN C 4rY M//r1 a. /G-���
1 �Jo7 / 8t' 7ld'�o 66Ca town /c+ us 4c co'f ;l +ZjPC C4 r�N
Telephone No.(business) Telephone No.(cell) e-mail address -
SECTION 11:WORKERS'CONMENSATION 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? Ye No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =S
1. Building S Building Permit Fee=Total Construction Cost x (Insert herr
2. Electrical 5 appropriate mince al factor) =S .
3. Plumbing S
•i. Mechanical (HVAC) S - Vote:Minimum fee=.8 rj(contact municipality) -
S, Mechanical (Other) S Enclose checkX s tble to
(contact mun6. Total Cult S Ya
ici alit ).trick write check number herr
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
6v entering my name below. I hereby atrest under the pains and penalties of perjury that all of the mhtrmation rt int.nned in thu
.1pplic.1 and accurate to the be*t.rt my knowledgeand undersW ndmti.
I'ir.t
c-
11", l .tn.t -t •n name• 1 Title
�U+�•t ods ria, lift : r"t'n --
1/O�V I /a ` �f.lf .SFr
-/1I Int J �r Uly'r. y�/l pot
NIL,nisi al Ins ector to fill out this section upon a
I P P p application approval: _
- \uric I l,t tc
ryg � ���.
�v:' �FM.t ��f �. t, �re� iws e.� --n is
���'7 ,�_� 5�
w#��wg[.._..�-'.;•�=i ice.,r..':_: ��. ..
�i
I
r
"PV4m�� .a�wiw � W°° t p -�
(..W A � ,�
� I
J� i +a a„y. r�t��,q� � 4.
d � � ���
!� . i
�_
,�� �
..
a ,+ � ,. �'
w �.c _,.` �.��w,k '' � � .a
i � .. �# .. :, i�
u
K ;.:
.. �
4 y � _
.. ':. � ro5u: `. � 4
t-
' �.
y
�':
tL' zn'
v m
.. .«. T m
e� .% �� �.
muu T z
_• �v..
a�
� v i - o
m.
_ � �� .y � F. �,.
i i
�. .. �, _.� r .N � .���IL i "i
�. - _. u �� 'a b
Yk�
h ,�. '^si
�a
� � v '' �"� , r a��� 6
ti. - 3
;� c� �{ . 1 9fi
,,;,
, .
� � ��, ¢�� � � � i!
, r � i
_... � � d� � �� '" ���
a � �
� `� ... r. � �ac� Y �P�
I e
Massachusetts - Department of Public Safet,
�y Board of Ruildin- Reg-ulations and Standards
Construction Supervisor License
License: CS 87361
Restricted to: 00 �<`«.
LOUIS A FRATTAROLI JR
9 SULLIVAN CIR e
STONEHAM, MA 02180
�—G- ---o, Expiration: 1/1 21201 2
........�....,�..� Trf- 19254
y
CITY OF SMZM, Axs&XCHUSETTS
• BUILDING DEPARTMEINT
+ 130 WA.iHLNGTON STREET, 3"0 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJtBERI.EY DRISCOLL
MAYORT7-IO.'►fAS ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONItISSIONER
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:
-5,Tr/f q 44 s/C-
(name
C(name of hauler)
The debris will be disposed
^of in :
/(name o" f facility)
/41 4
(address of facility)
signature of permit applicant
� 'D of 5`'/ z p
,late
dcbrivlLJx:
CITY OF SM-ESM, AXSSACHUSETTS
BL'IIDLLNG DEPARTMENT
120 WASHLNrTON STREET, 3m FLOOR
T1Et (978) 735-9595
F.kx(978) 730-9836
��tgFAt EY DRISCOLL THORLUST.PMRM
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CONL]IISSIONER
Workers' Compensation Insurance j%Mdavit: Builders/Contractorsi Electricians/PIurnbers
A Iicant lnfnrmatioe Please Print Le ibl
LOyI s /f• ...a l,' R! (ri3,� s�. c (ter
NaITIC(Busitaess•Organiratlomindividual):
g n
Address:
City/State/Zip:
s /b�C �l9Mr , O.L(8 honelf: � 02 � 9� �7 �
Are you an employer?Check the appropriate box: Type of project(required):
I,V 1," a employer with �_
4. ❑ am a 6. ❑1 general contractor and 1 New construction
.
arliployees(full and/or part-time).' have hired the sub-contractors
2.❑ i a sole proprietor or partner-
listed on the attached sheet.; 7• El Remodeling
ship
rod have no employees 'These sub-contractors have V. E] Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its lo.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption r MGL 11.❑ Plumbing repairs or additions
3.El am a homeowner doing all wont b P per
myself. [No workers'comp. C. 1.52, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t :mployees. [No workers' 13.0 Other
comp. insurance requimd.]
-Any applic:un that chucks box el must also rill out the section below showing their workus'compensation policy infumation.
t I l.sneownen who,ubrnit this affidavit indicating they me doing oil work and then hire outride cantmaas mus,submit a new,afidavit indicating such
=Comracwrs shot Check this boa must anachod an additional shumt showing the nwne of the mb,ontncton and their wurkars'comp.policy information.
/um an employer that is providing workers'compensation iosumnee for my employees. Below Is the policy and fab site
iuformution.
Insurance Company Name: —..--
Policy q or Scif-ins. Lic. N: Expiration Date:
Job Site Address: City/State/Zip:
,%ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may W forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do herrby cnrij oder t e ns aJ as j er ry that the injwnrstdon provided above is rru and correct.
q'„ 1 Data: O 5 g 2.0/b
Phonc d l t — — 7
O/fieiai use only. Do rent write in tills street,to be completed by city or town afflelat
i
Cityor,ruwn: - . PermiV1.lccnse#__—_— . ..--
Issulag Authority(circle ane):
I. Board of Health 2.Building Department 3.Cityfrown Clerk J. Electrical Inspector 5. Plumbing inspector
6.Other .-- ------...
Contact Person: _ _ . __.- ... Phone N:
Information and Instructions
Massachuscus General Laws chapter 1 i2 requires all onployars to provide workers' compensation tier their employees.
Pursuant to this suture, an emplgree is defined as"...every person in the service of another under any contract of hire,
c%press or implied. oral or written."
\n einployer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more
q the Brewing engaged in a joint enterprise,and Including the legal representatives of a deceased employer,or the
I ecelver or truiice ul .tai individual,pnumcrship,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152. @25C(6) also states that"every state or local licensing agency shall withhold the Issuance or
renewal of it license fir permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally. NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
' enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
.applicants
Please fill out the workers' compensation affidavit completely,by checking die boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain it workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or"fawn Officials
Please he sure that the affidavit is complete ;rid printed legibly. 'rhe Department has provided to space at the bottom
of rhe affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'izase be sure to till in the pcimitllicense number which will be used as a reference number. In addition, an applicant
that in"submit multiple pennidlicense 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 locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by die city or town may be provided to the
applicant as proof that valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. whcre a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he 011 lice 111 Investigations would like to thank you in advance for your cooperation and Should you h:nv'c,riy quebtnons,
please do nut hesitate to give us a call. ,
the Dcparnnemt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investigations
600 Washington Street
Boston, MA 02111
'rel. 617-7274900 ext 406 or 1-877-MASSAFE
c:.tscd s-'t;-its Fax # 617-727-7749
www.mass.gov/dia