64 BOSTON ST - BUILDING INSPECTION R
=� The Commonwealth of Massachusetts 5
Department of Public Safety
NLtseaC 1111Yelte Slate Building Code(780 C%IR)
Building Permit Application for any Building other than aOne-or Two-Family Dwelling
`II (This Section For Official Use Onlv)
"I Building Permit Number: Date Applied: Building Official: _
SECTION 1:LOCATION(Please indicate Block k and Lot k for locations for which a street address is not available)
t3�sTD _f-wr uW. 16'�W410( J ---
No.and Street - City/Town Lip Code Name of Building(if,ipplicable)
SECTION 2:PROPOSED WORK
Edition of NIA Stale Code used If New Construction CheCk here❑or check all that apply in the two rows below
L'Xistinf; Building❑ Repair❑ Alteration x I Addition❑ 1 Demolition 0 (Please fill out and submit AppendiX 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:__
Are building plans and/or construelion documents being supplied as part of this permit application? Yes No ❑Is an Independent Structural Engineering eer Review rruir 'ed. Yes ❑ No0
Brief Description of Proposed N'urk:
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 encloectl (See 780 CNiR 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 a livable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑
R Facto F-I ❑ F2❑ H: Hi h Hazard H-1 0 H-2❑ 1I-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ 1-3❑ 14❑ 1 M: Mercantile❑ TRT Residential R-10 R-20 R-3❑ R4 0
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IAO IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CSIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate numitipal❑
:\ trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify 7_unc: or on site system ❑ permit is entlesed 0
Railroad right-of-way: Ilazards to Air Navigation: It lin�.a .,�: i,.• , i__.__. -
Not Applicable❑ Is Strut lure trithin airport appn,aih dreg? Is Ihcir review Completed.'
or Co n.rnt to Build -Ilk ❑ lrs❑ ur\'o❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I'. tition M Cnde:,._------._---_L'se Groupie): - ------ 1q,vof Construttioa: . _ -- _ 0,tupant I,kad per Moor' ---
Do"s the building Contain au Sl4inkler St>tam.': -_- _Spetial Stipulations. - .
. YA
SECTION 9: PROPERTY OWNER AU'HIORIZATION
nc and Address of Property Owner
Name(Print) No.and Street City/ own Zip
Property Owner Contact Information:
/-:f& sy 3W
'Title Telephone No. (business) Telephone No. (cell) a-mail address
I(rt pplii tble, the property owner hereby aulluxizes
�_xic ► GGt>AL�c� ��'�),��rx�� MJ�e/ or�a3
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)
If building is less than 35,00tl cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Con any elm/,�
Z/� Gt -
�raT3 e� S.
Name of Person Responsible for Construction License No. and Type if Applicable
yvMLOW
Street Address City/Town State Zip
%32ZA44 71?9 2J,3714id�—
TvIe hone No. business Telephone No. cell e-mail address
SECTION 11:}v)_)(aa'.ta;tU\II'I_NS, illp.NiV;UKANO .v[iiy\b'II: M.G.L.c.152. 25C6
A Workers'Compensation Insurance Affidavit From the MA Deparnnent of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit.
Is a signed Affidavit submitted with this application? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
Total Construction Cost(from Item 6)=$
and Materials)
_
1. Building 3 Building Permit Fee =Total Con truction Cost x_(Insert here
2. Electrical S �� .. D� appropriate municipt I factor)=S
3. Plumbing $
a. Mechanical (HVAC) $ o20LA&. — Note: Alinimum fee=S (contact municipality)
3. \lechanical Other S Endow check payable to
n.Total Cost 5 (contact mmnicipality)an rite c *ck number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPL 'A
By entering nry name below, 1 hereby attest under the pains and penalties of perjury hat.all of infonuatiun nnnt.nincJ in this
application is true and accurate to hj'. of nry knowledge and understanding.
r�1 0%eQC_ i� /�1 �1G mace—mil[ _ �7&- —' #K
---
I'Iease grin ,cod sil;n name Title -"clephone No D, to
>treet Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: _
LNamr. Date
CITY OF S,VL&Nf, NLASS.jCHUSETTS
9L•ILDLNG DEP.IRTIIENT
120 W-kJHLNGTON STREET J"
OOR
TIEL (978) 745-9595
KIMBERUY DRLSCOLL F.kx(978) 740.9846
MAYOR TNOM ST.Pmag
DIRECTOR OF PULIC P40PEATY/al'Qnam CosausSIONEA
Construction Debris Disposal Aftldavit
(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 MOL c 40, S 54;
Building Permit p is issued with the condition that the debris resulting from
this work shall be disposed of in a proper
111, S I SOA. ly licensed waste disposal facility as defined by NIOL c
The debris will be transported by:
(name oFhauler)
The debris will be disposed of in :
41 )4S
(name of facility)
(�ddre»of Fact6ty)
elynaNre orpermtt applicant
Q � /
nnvd by
L
,l CITY OF SALEM
PUBLIC PROPRERTY
'=S DEPARTMENT
Nu,W
1!: ,Vn„n.4:as ilnebr • inlrW, Mn�h.u.ln � I ,�JI•�/�
Workers' CuMP1113ation Insurance :"f)Ilav'it: Ilutld""Contracturs/k:le trlclansit'lumbers
► 1 )Ilan Infnnnutio
�r77 PI
NameIlluully.yl)rssnvninlvinJls�duull: ' q rin Le •hl
�llllrc.asr� Igi� CI �•
�l'huned:—
I .►ry y nu an vinplayer7 Check the apprnprluq box:
I.C 1 :tell a cmpluyur with 4. C I am a gunural comtraclor and I l'yper nfproject(requlrrd):
inpluyaclt(full und/ur purt•lime).r hove hired rove.ruh•uuntrauwn /i ❑New uunstructiun J I.ran a solo PrIlPrivr r Or pd erser•
:,hip and have no umP lu uc11 listed u the anachcd shout I I. ❑Remodeling
Y Thee aubcontrseton have,lurking thr me In any capacity, workers'comp, insurance. e' C nemoliriun
I No workure comp. insurance J. C We are a en,poretinn and its Q' ❑Duddind aJditiwt
ruyuiruJ.) Wyrcrre biro cliurciscd their 10•C Electrical repairs or additions
1.❑ 1 ,ran a hulrn u,vncr Joind all work right Ofeacn,ptilm par NICL 11.❑Plumbing rcpuirs or aJJitioru
myself.I fvo workers'cuurP• C. l52.110),and we have no insurance rcyuired.1 r workers' 11.0 Ruul-mpairs
:mptuyeus.IA'o
•by.q-1111c"A lhW rhdr Ass rite comp, ntsur+ncu myuin'd.J 1�•ir]Uthrr
'I tumunwnrn,. vi :llw IIII uW lhr wcl,un lister eww,ne IArir wweue'run,yrnurlum
hr ma,mil Ihir ameeWr imtluline IAut a auin yWiry ulh,rlrnlriun rMerk l"lhW LINWt the$Eat m,W anar11w1.W aaelll , r+ wort r,tt lll♦'r Alp uWWe currnc
nllrl,ArW alllwll, ItW IIa r01e mql.YIr11Y i nw JlnatYll InJl�ieing Plat.
x rw YrrAI Ia/rMlgrpp a W Ihfe Morita �I/.piney Inllwnyiva,
l ran un vrnployrr I/wf h prunlJlne IvrrArrs'rurnpeendoer Grrnrrrercr/w,ery eapluprra SAIV/a rM pu/lay and/u1 silk
„/ur„tors„a
Insurance Company Nnmr: ,�rr� y�i��/.wo
"'llicy a ur Suir•inx n. Lic. '�/1r�jl, 34(=�/ ""(f�^�(/ —
Eispirauun Darr: al Z
lab 5iW .lddresr, �or3.('/' %ON'cr�' . .
.Utach n en P — C'ny,5lalaZlp:.fi�(�L/,aB ffZ
YY of she wrrkon'cure unratlnn pulley Jeclarallun page(showing rho pollcy number,and esplratlua date).
Foliose w wcuro cweruge as required unJer Scaiun'J,►ul'.►IGL u. 152 eau lead to Ihr im
11nV ale rn 1'Llll0,rN1 y Idar umehyear 6npri.rIle 3,J r, u� ,roll ua civil pctlalllcs in Iho lurin ora 5TUP WORK ORDER snd a Rne
,,i up rn i?SQ!)n a Jay lgainst the nol•Itae Ile sdvr.cd Ihul a copy of Ihrs swlcmum may bupl`u)rw a�J tullha Ull�u urea of a
In,cshyauunf vi JW DIA ;br nnuru'ce:uKrr . ,
aV culit.dp,n.
/du/rorrovy r rrri/y unJer pains,ar✓prnn/tier u
/prrMly lover I/rr infiUrlse rmaisimpro rrJr�oboes/l vw un/corn eR
e / do /'D _ .
— G
11//Iriul,err only, qo liar�rrire in lAi.r urCu. ru err runrylelrr by city ur/Oliver„ I iu
l r i(v ur I'vlrn: _
1„uing .lulit.,t Pcnniul.lernral
y (rih10 ame):
I. II, urJ ,(Ilrulth 1. Ihulduy ny,.lrlll,rlll I. 1.it,. tun❑C'Icr It L l'lcclricdl lm)r'rlUr i,
G. Ulher
I Plumbing Imprclor
(',•�n.,cl IS awl: _
information and instructions
tot;)r their cntPleyees•
\LUi.IC haiell>:6,;neral LJws ehJpl1f I J2 trywrcs JII ear try
m n the 3a workers' other
' in r,n lulw is JetineJ As". .every person m the service el another un,ler.my cumnct of hire.
1•Uriu•ll, lu Inle s,;Iule, 0 '
:.press it unphcJ, oral or written." of lilytwo or mere
lu er or the
rn :,npluprr is Jelined ar"An individual, partnership, dills the le alrphrauen or other lobes entiry,
�J to a 1 tom vni loyeeo. However the
the I;,rcqumg ended' elm enterprise. And including the legal represeuratives of a eeceaseJ emp •
i f this
eCCly to of trustee a cal An II+JI4(Jual, Pslmershlp,Jasoelaaoe or other legal enaly,employ e ' P
merit t)a JeemeJ to be an employer.
employ.,' roman three mainrnents a,d who eihn or repair work en such in 911n{house
owner r t s truste U house having not more than three JpatQnenu arse who resides'ihermn,err Ih occupant h
dwelli
,Iwclling huuid of anarher whu d unenant thereto shall nor because of such employ
or on the Grounds or building Jpp shag withhold the issuance or
icensing
�IGL chapter 152, §15C(6) also Slates that"Ivory slato ar loons construct
bu agency
renewal of a license
of
permit
to operate s buslneu o to ens Ulnae wild Ih slnsuranee cal oroge in the lrequsrodlb for r
VD roduad;c�epl able evidsa her the onunonwcahh not anY ol•to political subdivisions ehsll
+ lieant who has not p
IS
l,Jdiuenally, %IGL chupter 151• 4
Cnmr inn any cunlract fo the Perfomtan e nteJbtateslu thwork e contracting authorityvieenca ufcumPliy+cawith the msuranc
requirements of this chrpler have been p'
�pypcuus checking the boxes that apply to Your situation and if
ansaaon alAdavil colnpl and
phone nul»bats)sloes{wish their cortilicatels)of
Pleam fill out the workers' comp n uneb),Jdlhess(as)Gad P LLP with no employees other than the
necessary,supply sub•contraclor(s)
hIvI
wired to carry workers' eomperuntiboensubmilled to the DePlettmem of Industrial
nswaneo, Limited Liability Companies(LLC)or Limited Liability pa Indlu rtnerships
menbdrs err partners,are not req
empbydes,a policy is requital. l3o advised that this Ivcraille. lso be s mayvIL davits of
►Ise be sure to sI{ruse Juno l e uested, not th1eMpdavit should
%ccidants for confirmation of inslsratleo c for the permit o license is being requested,
he rellln+eJ to the city or lowest that the application f o regarding the low err if you Art required to oblaill u workers'
ir
Industrial,%eciJents. Should: have Jt+Y 4
cernpansatiun policy, please Call the Depu mcnl st lh nulnbar listed below. Self ineuroJ companies should enter the
alf.insuronco license number ern the a ro lisle lino.
c-sty at.rows Omelets P provided u space at the bottom
YOU to fill out in the even) the O111ce of Investigations has to cunlact yuu regarding the applicant.
Ptra.c he sure that the afflduvit is complete ;mJ printed legibly. The Department w
of'the.aWaffidavit Wr y
wA
applications in any given year,need only submit once Affidavit indicating current
,If he ff wvi to till in the peout in
ithe even,
th tr which will h used as a reference number. In addition,an JPp re
And under"lob Jite AJJresi'the applicant should write"ell luealiuna in (' Y
has,oust submit n if necessary)
ssary)'Andue apD sd or marked by the city or town)nay be provided W the
policy inflomatioe lif necessary)'
town).' A copy'+f Iha utliduvit that has been officially sump
Applicant as proof that a valid JI'Aduvit is on file for ILturs pmmiu of Licenses. t now a urines nw:r m titled out each
A ear• ant as a home owner er citizen is obtaining A license or NOTPerini, not relate)to any business err commercial venture
t i c, a Jug license or permit to burn leaves ate)said person is NOT requited t dra complete alJhl)uulJis dy a have,ury 4udsuens,
Your
vw u+ Jev:uxe fury P
I he �)lticc „t lnvesrigatiuns would sue w d+Jnk)
please Ju out hesitate to glvc us A cJll.
fhc U.ptrunent's Address, telephone And fax number.
The Commonwrealth of Massachusetts
DepaiMcnt of Industrial Accidents
omee er f■vesdg,de ns
bop Washington Street
Seaton, MA 02111
fen. 4617.727E 617.
90072 a774917•MASSAFF
w WW.M3U.gov/dis
I
• ; aoaavmac ua- vcp,u uuon s , uoSt ndard
Board of Building Rcwlations anti SGtntlards
Construction Supervisor License
License: CS 21273 -
Restricted to: 00 j
RICHARD C WALLACE f`
4 BRAMAN ST
DANVERS, MA 01923
Ip
�--�-- Expiration: 10/31/2011
ncr Tr#. 6642
CITY OF Sq.
a 3 BUILDING .LICENSE
This is to certify That 3 k;
RICHARD C. WALI.ACE
4 BRAMAN ST. tt.,DANWRS Mass.,` t
Has been granted a license b fhe Buildin . Inspector. as a '{
GENERAL LrONTRAC
Attest:
ti. 5/12/43
I Issued), . Building Inspectot
y �fie i muiea o�./�amar/u ee!!a {
Office o of ConssumerurneAffairs&B siuess Regulation
HOME IMPROVEMENT CONTRACTOR
Registration:,,A04777 Type: ,
Expiration 7d1.5l2012 DBA
ICE CONSTRIi£TTIf ,
Richard Wallace
4 Braman Street
Danvers,MA 01923 '�( Undersecretary