0010 BLANEY ST - FERRY TERMINAL =` The Commonwealth of Massachusetts
Department of Public Safety
•j.`i�. i\Ltssd:h ISO t t.S'It.nr Building Cudc(7811 CNI1?)
�•"'' Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Phis Section For Offi(ial Use Only)
�/ Building; Permit Nund)er: _ Date Applied: _ Building Official:
/ SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
'\ Nu.dud Street City/'I'utcn Zip Code Name of Building;(if applicdblr)
SECTION 2: PIiOPOSFD WORK
Edition ul AI:\State Curie used _ If Nrlr Construction(heck henrxOr check all that apply in Iln• two nnrs bclme
Exi.clinl; Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Pledse fill Out and submit Appendix 1)
Change of Use ❑ Change of Or(upanc}' ❑ Other-❑ Specify:--
Art,building plans and/or Construction documents being supplied as part of this perm r . . J Yes ❑ .-❑ --
Is an Independent Structural Engineering Peer Review required? ❑ N, l
Brief Description of Proposed Work '
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGO" 'ION,ADDI" -N,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (.See 7tio C�\IR 3-4) ❑
Existing Use Group(s): proposed Use Grou p(s):_..—_
SECTION 4:BUILDING HEIGHT AND AREA
Nn.uF Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area sq.ft.)and Total Height(ft.)
SECTION 5: SE GROUP(Check asapplicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-"t A4❑ A-5❑ B: Business ❑ E: Educati el ❑
F: Pacto F-I ❑ F2❑ H: i h Hazard H-1 ❑ H-2❑ H-1 ❑ LI--4❑ 5❑
1: Institutional I-1 Cl 1-2❑ I-�❑ I-1❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-7"'- t?-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describ,., '-- w:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ 1 IIIA ❑ Hill ❑ I IV ❑ 1 VAX VB:C3:::::]
' SECTION 7:SITE INFORMATION(refer to 780 CN1R 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit•. Debris Remuval:
PnbhC❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench%%ill nut be Licensed Disposal Site❑
h :
Private❑ or indrntify Zeno:__ or on site syshm n•qu fired ❑or trenc or specify
❑ permit is enclosed ❑ _.___._._—
Railroad right-of-rvay: Hazards to Air Navigation: "I'' , � ,,uu...
Not Appli(ahlc❑ Is Structure within airport approach area? Is their rev ic,v completed'
or Consent to Bolden,losed❑ Fes ❑ or No❑ - Yes❑ No ❑
SECTION B:CONTENT'OF C1 RTI1 ICA'I'F.OF OCCUPANCY
Edition of Code: Use Group(s). I:vpoat Construdiun. OIL uPanl Lund per l lour
I foes the huild ing(onl tin an Sprinkler Svstent''.___.____Spacial Stipulations:
4l �
SECTION 9: IIROI'ER IN OWNER AU I'11011 IZATION
• Nauuc.md :lddrrss of I'ruprrty Chvnrr .
Name(Print)
—_ — No and Street City/Town __— -- -- zip
Property Ole ner Contact Information:
itle _ _—— elephone No. (business) Telephone No. (cell) c-mail address
T T
If applicable, the property owner hereby authorizes
_. Name Street Address City/Town S6te Zip
to act on the property owner's behalf, in all matters relative to work authorized by this buildin ennit a>>lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
It building is less tlwn 35,0011 cu.ft.of endorsed spice and or not under Couutmction Control then check here❑and ski Section II1.I
10.1 Registered Professional Responsible for Construction Control
crrHGrz- Very
Telephone No. e-mail address Registration Number
Nome(Registrant) P —
1� Street Address City/Town State Zip Discipline Expiration Dale
10.2 General Contractor
\L.
Company Name
Nome of Person Responsible for Construction License No. and Type if Applicable
s : f��.��\�t�s
r s37
Street Address City/Town State Zip
Tele phone No. business Telephone No. cell e-mail address
SECTION 11:��u Wr J-I,�, c u mu l_\5_�I n,\ IVFI n. NCI l I I_.1-':;3
.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Indidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the e issuance of the building permit.
Is a si reed Affidavit submitted with this a lication? No ❑SECTION 12:CONSTRUCTION COSTS AND PE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)_$
1. Building Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)_$
3, Plumbing $ contact numici ililY
Note Nlinimum fee=$ ( W )
1. Mechanical (HVAC) $ 9,� )t/ '
3. Nicchanical Other `� 4� 4vIQ'�V
Enclose chunk payable h/ t���
xh.Total Cost $ C7 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
under the wins anJ nnahics a(perjor, that all of the infunmotion omained in this
By entering nit' name br low, 1 hereby attest u I I
application is true alid accurate to the best of�nuy knowledge and understanding.
.___ __----_---- ——_ Title ---- lelel lone i o. Dale
Noose print and sign n.mm
Street Address Cily/Touvn ate ip -
hunicipal Inspector to fill uul this section upon application approval: ___ -/D rue
`—
u�
CITY OF SALEM
-; ,;1' [PUBLIC PROPRERTY
DEPARTMENT
.RUC. ntl Y:rnlN all
\I111 y1'
I!:\Pn N11AG IU.\jlalL•7• � $,111•N, M.U1.\a.I II V 11��1'17,^,
Ihl. '77411i9i'I5 a 1'tx 9711•74C•'Is46
Workers' Cumpenaatlon Insurance :Illlldavit: Iiull,ders/CuntrecturslElectrlclane/Plumbers
s sltcrnt In nrinaflo
PI rtnt a •AI
Vit IT1C I Ihurle,yr7raanrratinNlnJlvuluull: � S CppJ�
1Lldrusv: �\c �oQ �
City,State,Zip- �wJQo t �� Phone moo\ - cs.�1--1zS4
1 uu an euryiloyer:'CArrk the appropriate but:
I I:ml a employer with 4. I,y o/prn)ect(r*qulred):I ❑ I :un a gcncral couuaclor and 1
Lrc
uyees(lull infiYur part•tintd).• hove hired the sub-gmlraclurs �' new cunslruetiun
a tole proprietor or p rtner- listed on the anachcd shcet : 7. Remodeling
nd have no empluycos These sub-contractors have
ng Air Inv in any capacity, workers'comp, insurance. d• 0 Mmolirion
orkers'cutup. insuranceJ. W*an s enl q• ❑ Oudding addition
J. porstion and its) otylears have meenirud their 10.0 Electrical repairs or additions
horrlcowner doing all work right of e`19111 ionper hIGL 11.0 Plumbing repairs uraddition.[N'o wnrkers'comp• C. 132.41(4),and we have no
ce required.) r employees. (No workers' 12.0 Ruufmpuirs
�� crnnp. insurancvrequired.) 17.0Other
• p.gtpycua film cAeb bra AI moat alau till on she vrcnun trlYle oww.,re their roh or'Cu l
'Irvrn.ntwnen wAir naxlul Ihis Amdav(r ineivaria I renalY{wl lrulivr rnrurnraiw�
Y biro+re Juno all work and that Aye:71i roxrrirlpe n+wl wleny a new+IRderil;nd(�ytin u
f,mrn,hn.rhM aM•vk IAie A•i Illrirl atr;Aed ell aJdil(oyl,h,wl.louring the name a/Ille rtak.eWe
rwkm and their ruAxe' Y �k'
/tun un errlpioyrr Ides If pravi✓/nx lvorAers'cumpenenllnn bararanes w illy
n em rat .pJler rnlbnnanuw
Lr/urrnusisps y p/J dre Bdury/i Or pu/ifty un✓il b.airs
Insuruncu C'umpany.Vlane:��__
I'olicy d ur Sulf•ins. Lie.rf
Expiration Dave:
Job Srod ,\ddreaa:
.\nach a ell
py of Ill#workers'eumpunvation pnllcy duelaraliun pule• Clty,Statei'Llp: ��a._v"� H A \a10
(showing the policy number and e.tplratlue Jute).
I allow to.veeurY cu%craye as required under Sccliun:!A ul•NGL c. 152 Can lead to Ill*imposition oferiminal penalties of a
ITrti u11 n Sa Ma
y Idailuue•ynr imprismmncnl, u' wull as eivll ptnallrus in the 1•unn of a STOP WORK ORDER and a fine
of up nl i1S0.00 a Jay Ileainsl Ills violator. Ile advLrcd thut a copy of this.delcntent may be lurwarded to the UnTlee ul•
fill'migalrmia ul Iha MA for m'twirce m',ver.hu %cif ilic+I:un.
/ (a/ier'.4 a rrli/y mrJer IG*prri u
Wjj_)ePfiIfzjA1 the in/urrnirllon yrvri✓a•✓ubuvy is vur an✓eoneta
�PC'rb�re
y \
I17/)trio/rnr unty. no,rnr rvrire in this urtu, to Ae runny/rife✓dy city ur tolvn u//Iriot
(ilv or fmrn:
" Pcrmittl.lerme I •
hvuinle .\W busily (circle noe):
t I. Ilt,.ard of IIe+Iti, 1, IlurLlim�j Uy,.lrnnerlt i G. )Iher I I:iI 'fnClerk J. Llectric.d l ,cctur i, lumbingory P luytetor
t•."atact Ill nun:
I'hune 7•
i
information and Instructions
rton n the service OI anoher uoJer.ury cuntnct of hire.
�Ll,;achuutts General LJWa shaperrcywres all entplo)ers to provide ,wrkers wmp 'll ler i tic their cusp hire.
es.
I'ursu.un to uus ,latute. in reePferre is JctineJ as".-every pa
,+pre,s or Implied. oral or written." two or more
�n crnpfuper n Jc'incJ as"an individual, partnership,.Issoeiatnta.corporation Or Other Icgal cntiry,or any
utM emerprise, and including the Icgal npresenalives of I era slo)ees IHowcvcr'the
t the I ,reguing engaged m a 1 armer,htp,assoewooe or other legal cntiry,cmp Y a ' P
icceaver Or Iruslee Of.trl individual, p
ON
♦ r+han th three
tnaintenunca, cun,ruction or repuit work On ilach dwelling house
Owner of a dwelling house lout^a not more than three apartments and who resides therein, or the occupant O
o do
,twcllmg huuie of another who employ. pe
Or,m the erountLtt Or building appurtenant thercro shall not because of such employment be deemed w be an employer.
ctn'll
mGL chapter 152, tj3SC(6) also s'ate.rafe•bar Bess or to const that"IyOrY State at local ruct buildings in the ro 311 Agency shall mmoleweultb for any r
renewaI of a license at permit to up Rance with the Insurance coverage required:'
,SC 7)states"Neither the conunonwcalth not any of its political subtlivisians shall
:lypllcant who has not produced acceptable evidence of comp
\JJitiunally, %IGL cllupter 1 S_. S- ( ublic work until acceptable evidence OfcunlDli ulce with the insurance
enter into any contract for the parfomwnce of p
requiremun's of this chaplet have been presented tO the contracting authority."
Applicants 1 to our situation cold,if
compensation at'nJavit coin letely,by checking the boxes than aDP Y Y
P with'heu cartiBcute(s)of
plea sir rill out the workers' comps adthealas)and phone number(s)aloe{ with no employees Other than the
necaraary, supply su�contractor(s)name($).
workers' conlpensuion insurance. if an LLC or LLP does have
insurance'
rice, Limited Liability Campanian(LLC)or Limited Liability Partnership$(LLP)
memb In or partners. an not required to carry
enlDlnyeas,a policy i$required. Be advised that this Affidavit may be submitted to the Department of 11 Industrial
requested,
not the Department of
\ccidents for confirmation of insurance coverage Also be sure to iconsills end Jute the u seed, It Tlu stntlavit shoal
quest" regarding the low ur if you are required to obtain u workershould
enter
he tatttn,ed to the city or town that the upplie Q i stohe nur the mber listedcbe license is
Self�n ured coin is should enter then
Industrial Accidents. Should you have any q p�
compensation policy.Please call the DepuAm
self-insurance license number on the a0prowilite line.
City or Town Officials
the applicant.
please he sure that the affidavit is wmpleta and primed legibly. The Department has provided o apace at the bottom
Of ill*affidavit for you to f1I1 out in the event the Office Of Investigations has to contact you regarding
applications c an given year,
need only submit one al)ldavit indicating current
I'I_usa be sun to tilt in the panniVlicense nwnbOr which will be usyd as i reference number. In addition,an app
that tnu►t,ubinit multiple pennio'licmisa appthe locations
rovideJ to the
policy iuf'ormation l if necessary) and under"Job Site Addres`d or marktadtby+the city or towntray iunp in Y
townl•" \copy°f the unlJuvit that has been officially sump'
applicant as proof that a valid at is On file for fL'un Permits or lot related
t now alusines must m tilled out sae
y ear. Where a hume Owner or citizen is obtaining a licenser or Penult not related to any business Or commercial venters
t i a dug licen.+e or permit to burn leaves etc.)said person is NOT required to complete this affidavi
I he )ili.c , i Inveitiyaliuns twuld Idte to thank you in advculce tbf your"Operation anJ shuulJ you halo.t°y yuesuons,
I,Ica,e dO nut hesinfe to give us a call.
fhc U.paruncnt's adJte+s, It: and fax number'
The Commonwealth of Mamchusetts
Department of Industrial Accidents
OMCS of favesdgadons
600 Washington Street
Boston, MA 02111
'f ei. M 617-727 4900 ext 406 of 1-877-MASSAFE
Fax 0 617-727.7749
4.20.115 www.mass.gov/dia
CITY OF S.u.E.`I, NLksSACHUSETTS
SUILDIING DEPARTMENT
' 120 WASHINGTON STRM, 3'"Rocit
TML (978) 745-959S
FAX(978) 740-9846
KISBERIEY DRMOLL
.MAYOR THci.�usST.Pmnz
DIRECTOR OF Pusuc PROPEATY/ElLaMNG 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 I 11.5
Debris,and the provisions of MGL a 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
I 11, S 150A.
The debris will be transported by:
`(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
vgnatu eFpe'rmit applicant
date
I.M1n vif,Lw