Loading...
179 BOSTON ST - BUILDING INSPECTION (2) ad The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) iii Building Permit Application for any Building other than a One or Two-Family we ing z(This Section Pot,,OffictalUse.Only)-„, -' r, Build ng Permit Number: 1,Date Applied Bwlding Official SECTION 1:LOCATION.(Please.indicate Block#-and Lot#fo'r locations for which aastred address i - o ovaMew � '7 5 ROS 14j)1612 (iMRaO f? No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ t\Iteration ❑ Addition❑ 1 Demoliti n ❑ (Please fill out and submit Appendix 1) Cha°ige of Use •❑ Change of Occupancy ❑ 1 Other pecify: C�l� 2SG .Tiyst/l/}/�d/✓ Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑� Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: SECTION 3:COMPLETE THIS SECTION.IF EXISTING BUILDINGUNDERGOING RENOVATION,ADDITION,OR CHANGE IN USEOR OCCUPANCY .., +.: . Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): �I SECTION 4:BUILDING HEIGHT AN D ,.. 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 applicable), A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ f: Institutional I-1 Cl I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 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 ❑ IB ❑ IIA ❑ I11113 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTIONS:SITE INFORMATION (refer to 780 CM_R 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 municipal❑ A trench will not be Licensed Disposal Site ❑ Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: AMA I-fisturic Conunis,inn Review Pra�rss: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes ❑ or No❑ 1 Yes❑ No ❑ 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: 7aoo,�aA 'SECTION 9: PROPERTY OWNER AUTHORIZATION _ Namle and Address of Property Owner h II tors Mel/vd ►2 7VvS Name(Print) No. and Street ,( City/Town �j Zip Pro erty Owner Contact Informatio ul 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)'v ; If buildin is less than 35,0Wcu ft:of enclosed s'aceanij��or not tinder.Coostruction Control then cheek here O`and ski' Section - 10f1Re 'stered Professional-Res Oonsible fdr Construction bon,tiols'. m1f1 w_v-- Name(Registrant�� �ephonreZN��l e-mail address G/ Registration Number /ljC� Street Address City/Town State Zip Discipline Exp' ati Da re 10.2 General Contractor' Company me Na f Person Responsible for Constr ictio�j License No. and Type if Applicable t�G✓��- + ` fly Street Address City/Town State Zip 1 Go-o nH u e- & S-9 cojr Telephone No. business Telephone No. cell e-mail address 1�• SECTION 11:FVORY.ERS'COMPENSATION 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? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS:AND PERMIT FEE; Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ a. Mechanical (HVAC) $ Note:Minimum fee-$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ (J' (contact municipality)and write check number here SECTION 13:S GNATURE OF BUILDING PERMIT 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 accurate to the best of my knowleke and understanding. mAic"l- Good r— - '4010evz_ JG7 Please print and sign name Title Telephone N C Date &C stiratllx.r .1 (Zt7. Ro�1 e y.- .�1/�' /�!g 7 Street Address City/WWn State Zip Municipal.Inspector to fill out this section upon application approval: Name Date CITY OF SALEM. N L1SSACHL'SET rS ' BUILDING DEPARTMENT IRO WASHLI)GTON STREET, 31a FLOOR : TEL (978) 745-9595 F.Aa(973) 140-9844 1<j.,,t1;FRt RY DRISCOLL T MAYOR HoatAsSr.PIERRfi DiRECrat OF PUBLIC PROPERTY/BUILDING CONMISSIONER Workers' Compensation insurance Affidavit: Duilders/Contractorv/Electricians/P(umbers Applicant Information _ Please Print Leeibiv Mitre(OuaitxsiUrstni:atianiIndividual):_ y91-e Af Address: �t(:t/ L, d- ' J OF City/State/Zip: cti Phone N: rl 7 ^� ^ Are you an employer?Check the a ropriate bast Type of project(required): I. am a employer with 4. 0 I am a general contractor and 1 employees(full and/or p -tima).a have hired the sub.contrdctoo B. ❑New construction 2.0 I am a sole proprietor or partner. listed on the attached.sheet t 7. ❑Remodeling ship and have no employees These sub-contractor have V. 0 Demolition working for me in any capacity. Workers,camp.Insurance. 9, 0 Building addition '(No workers'comp.insurance S. 0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers'camp, C. 152,i(1(4),and we have no 12.(] Roof repairs insuranca required.)t cmployees.(No workers' ().[]Other comp.insurance rcquircd.j •Any applleam tlut chsska bass)mwt alto 1111 out the%celiac below showing their waken'mmpenurlun poll informatiam 'I r,"eown«a who udindl this aflldavis indicating they an doing all work and then hip ougide c°ntnctat musi tuhrnli a maw alydavit indioling such. �C,mtracton that check this box mutt attached an additional their showing the name of the tutsa tendon and their workon'camp.policy infarmadan. lam un employer that Is provld/nR workers'ratnptntodon/usurrrnce jar my empluyeax Befew!s fhe po/fey uad Jab sif� inforrnudoa Insurance Company Name:— Policy 4 or Self-its. Lic. 4:`�_ _©/// eL� Expiration Date• Job SittsAdt)russ: IT L 2 �� / J City/statr:/Zip: r`/7-7 9 Attach a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). F'ailuru to sucure coverage as required under Suction 25A of NtGL a 152 can lead to the imposition of criminal penalties of a rinc up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a line of up to S330.00 a day against ilia violator. Ile advised that a copy of this statement may be forwarded to the Of lice of Invc,ligutiws ufthe DIA for insurance coveraya verification. /dd hdrrby certify raider Mt p ad penuhit erju /car r aratallan provided above 1 true rid carnet I'hn a t• /Ol7 S �� �6Z/� -_. O/jiciul use ads. Od oaf tvrirt in r/ds array to bt contpleled by city or rdwn n/Jlelat i City or .._ PurmtUi.lcenseq j ksuing AuihorRy(circle one): I. f)uurd of Ilcahh Z. Building Departumnt .1.City/town Clerk J. riectrl.11 Ltspector 5. Plumbing! in..+pecror B.Othur Contact Person:. .__ -._ Phone a: r. i f qh.r CITY OF St1.CZM1 1NL�SS Nc HL'SETTS 1 i _:•'t� ) ' 0U LLD L\G DEPARTNaNT 130ASHLYGTON STREE W T, 3AO FLOOR i T EL (978) 745-9595 R{x(978) 740-9346 I<IJ[BERLEY DItISCOLL i i�L�YOR T�lom B ST PiERRB DIRECTOR OF PUBLIC PROPERTY/SUaDNG COSQttSSIONER Construction Debris Disposal Affldavit (required for all demolition and renovation work) In accordance with the sixth edition Of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of btGL c 40, S 54; Building Permit k this work shall be is issued with the condition that the debris resulting from l 11, S 150A. disposed of in a properly licensed waste disposal facility as defined by NfGL c The debris will be transported by: (r ntc ut'haulur) The debris will be disposed of in (name of facility) JJ -- dress of ruitity) sign re of Pefalit applicant