52 BROAD STREET - BUILDING JACKET UPC 10333
No. 153L-3
HASTINGS. MH
CITY OF SALEM
DEPARTMENT OF PUBLIC SERVICES
REQUEST FOR CURB CUT
DATE OF REQUEST: 3 /Z 9 lel
REQUESTED BY: C DugrD T rxzZ Af l PHONE: 92 9 -75-9
LOCATION (as specific as possible): 5-2 /�wFry sT
t OofTa�a %i c'r✓✓� Y sio� .r �iTav��7Y �i�✓� e-Zi7i./
LENGTH OF CUT: 20
COST PER FOOT: SS.00
INVOICE TO:
----------------------------—----------------—---------------------------------------------------------
FOR OFFICE USE ONLY
��PROVED BY: �� 12., BLDG. INSPECTOR
S. 2i Liv DEPT. OF PUBLIC SERVIC
NOT APPROVED: DEPT.
EX?L.k-NATION:
DATE OF MOICE:
P AYN ENT RECEIVED:
Tr I
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts Stale Budding Code(780 CXIR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Data Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block M and Lot 0 for locations for which a street address is not available)--77
No.and Street City /Town Zip Ctnfe Name of Building (if applicable)
SECTION 2:PROPOSED WORK '
If New Cu struction check here❑or check all that apply in the two rows below
Existing Building Repair Alteration ❑ Addition O Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use O Change of Occupancy ❑ Other ❑ Specify:.
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No /
Is an Independent Structural Engineering P r Review required? / � _ Yes ❑ No Q/
Brief Description of Proposed Work: {��i % lz'W r -5 • Pea & e AXOEg- i 0 1 S
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 Group(s): Proposed Use Group(s): C
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
jAssembly
lours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a Iicable)
mbly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F-I ❑ - F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
tional 1-1 ❑ 1-2 ❑ 1-3❑ 1 4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4 O
ge S 1 ❑ S-2 ❑ U: Utility❑ Special Use❑and lease describe below:
.se: SECT ION 6:CONSTRUCTION TYPE (Check as a Iicable)tB ❑ IIA O IIB O IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public.❑ Check it outside Flood Zone❑ Indicate municipal Cl A trench will not be Licensed Disposal Site❑
requiredOortrench or.peciti:
I'nvalr❑ or mdvntily Zune: ur un sue systrm ❑ permit is enclurd ❑
Railroad right-of-way: Hazards to Air Navigation: "A I bq,-rnr C ,,nm h....n ltc,1,,. Vw,t-:
\ut \pphcable❑ 1,Struclure,c rihul eupurt approach,vra.' Is their rev ietc comploed',
,a l nt.cnt to Iiu JJ cndo.cd ❑ 1'cs❑ or.\'o❑ 1'es ❑ \n ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I[,hhon of C"dc: _ L'c Npe st Con%trucuun: Occupant Load per I loon
I Toe.the buildutg contam.tn Sprinkler Scstem': Special Shpulahons:
\0 A 0 e I-. �rc'e-jl'�
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of proper v Owner
Win . (14,/ 2 5Aw Sf Re ve e/j lk)e 4/9is'
Name(Print) No.and Street City/Rrwn Lip
Properly Ow r(- r tart 1 for atiun:
i � �fa � 9 -Ze3 G Z y7
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Torun State Zip
to act on the rnr perry owner's behalf, in all matter% relative to work authorized by this buildin g permit a p plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is Iesc thin 15,0LX)cu. tt.of enclowd> acc and/or not under Coretructiun Conlrul then check here O and skip Sectiun I0.1)
10.1 Registered Professional Responsible for Construction Control
JAA P MOOUt, t_^2k-q-2, -0,?VW -- CS
Name a•istra t) Telephone No. e-mail address O/ / Re gt r un Number
2� tiSG�f�o J/ RIVIO 6e 41&
Street Address City/Tu n StateZip Discipline - Expiration Date
10.2 General Contractor
Ja11 J, M0Ob..� 1 Q �
CompanxAme, c.S �� !'G/ H �C
Name. o --on R lx)nsiblebo nstruction License No. and Type if Applicable
�/s�r�p�ry h I //�t �I Fb aeoegeI!, 44&
Street�Addr 01 (OZ �9 3� city/Town State Zip
C/kTTellle ,hoone No.(business) ��nTele hone No. (cell) e-mail address
SECTION 11:WORKERS'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 R/ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor Total Construction Cost(from Item 6)=S
and Materials)
1. Building $ 6 d d — Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing S
4. Mechanical (HVAC) S Note:Minimum fee=$ n ct m nicipali/tyj')�/�
5. Mechanical (Other) S Enclose check payable to � -
6. Total Cost S (contact munici alit )and write check number here
SECTION 13:SIGNATURE 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.uatrate to the best of my knowledge and understanding.
J041 d 10 /700 2 l raw N ei- _ o Z(06 5//, /
19ra.c F+tint and satin name fitly R•Icphunr No. Date
drG / � C21 Town Statme Zip 6/
Mu
nicipal Inspector to fill out this section upon application approval: '�2
\'ame Date
Ci- Y OF S.U.E.`19 AxSSACHUSEM
ScoxILNG DEnantENT
120 W.%_;M0IGTON STRM. r FLOOR
TIEL (978) 745-9599
F.%x(978) 740695"
KINMEALEY DRISCOLL THOMASST.PMRU
MAYOR
DIRECTOR OF ft et.tt:PROPERTY/et:ogee co.%L%nsslo'.%En
Workers' Compensatlon Insurance AMdavit•. guilders/ContraeterWElectrielanslPlumbers
knpllcant Information Please Print Leolbh
Valnt ItluarresrOrgrntruion IttJrvtdual): JC. u to Ynco l)Z
Address: 2 SGIRGO� oL
City/Statdzip. dtoo lief {ryl p Phone N e 7,66
,ere Yoe so employer!Cluck the appropriate box: Type of project(required)
1.Cl 1 am a employer With a. Cl I ant a PROW contractor and I & Q New constnrcties
2.4utrployecs(full and/or part-time)•• have hired the nob cornraccore
1 am a sole propricu r m partner- listed on the anached all rtt : 7. Q Remodeling
:hip wool have no amployees Them sub-contrecters have L Q Demolition
working for ma in any capacity. workers'comp insurxoct 9. Q Building addition
1 No workers'comp insurance S. Q We are a corporation and its
rtyuird.l
oRieent have exercised their IO.Q Elscrriwl repairs or additions
J.Q I am a homeowner doing all wort right of coma ption per MGL 11.Q Plumbing repairs or additions
myself.(No workers'comp c. I5Z 11(4),and we haw no 12.0 Raof repairs
insurance required.)► .mpbytma iNe workma' 13.0 Odor
comp insurance n quireLl
-Any wppliC"ore dome boa et wtr alw tea wA ibr mie bdow,kowidg tbdr warts'conowa d s peliey idanrWea,
'16wwawiwea who sullied dkb aAdwis idferins nay an Joins all work and this blow whir osaaarawa Woad Addeo a now arrlrvid inol{aong AWL
{{,wim,,wv due climb ibis ban ataa MINIBOOM addintt W dtnd"Wine de-tarty 0941 aktW MOM ad thtdr warbws'comp.policy iaPornasaa
I am an#arprysr chat b providing,weriers'com/ensatlro/naarsnavfo►aq*NP/eyees Qe%w b flmPm'A7 awdM slat
infortwatbia
In%urance Company Name:
Policy M or Self•ins. Lie. I►: Expiration Date
Job Site Address: City/Slawzip:
.snack a copy of the workers'compensation policy declaration pap(skswing the policy seaber and atpiretlon date)6
Failure to sesure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to S 1,500.00 and/or one-year imprisonmem,ar well as civil penalties is the farm of a STOP WORK ORDER and a Ran
Of up to S250.00 a day against the violator. lie advi.*M that a copy of this statement maybe furwurded to the Olyice of
Invc,etgatiana ul'ilia MA for insurance covcrags v%aAcatima
/Js hereby crrlify t Oder the pw/as and peas/Iles of per/u7 the#the in/ornatlow provided above is true end a a/rrd
,=iitire: I /0 Uuu: .S/�aka
Phone a: J 0 4 of - 0 /►1 voo
O/flc%d We aII/y Do/I N W///I rn/hrf Y/[I� /e 6e CYIap/r/d by city or rown olvorial
I
City orruwn: Permit/1.Icrnsel__. _
I.suing.%whurily (circle unc):
I. ❑uard u(Ilrwllb 2. Husldlny Department J. Cicytrorn Clerk t. Electrical 6dspector 5. Plumbing Inspector
6.1)Iher _
4- "114 t Pcnon: _ ._ _.. Phone e•
�e CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I'.I.: MIH '•Mlr.'ll IIC� 1J11.\1..��V)I MkIT 11.\,�\I III J 1 ••I'1
\t .n lot rrl:v7 t•NS7i'/i I'fit:N7/•NS'I:,M
Construction Debris Disposal A111davit
reyw
'reJ lurrll de
molition
olition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 I I.S
Debris, and the provisions of MGL c 4U, S s4;p is issued with the condition that the debris resulting from
Building I ermit rl licensed waste disposal facility as defined by MGL c
,his work shall he disposed of in a grope Y
1 11. S 1 SIIA.
The debris will be transported by:
S l
t nome of hauler)
•1'he debris will be disposed of in
kii
m oil Ity
%33 t,l�tres,lrlxdllyr
14L2
learn
"µ
dale
Islassachuselts- Department of Public Safety
Board of Building Regulations and Standards
Construction.Supervisor License
License: CS 76129
Restricted to:,,00 ,
JOHN P MOODY
22 SCHOOL St
BEVERLY, MA 01915 xs
Expiration: 9/25/2011
t'unm�io4�arr.' Tr#: 7096 _>
tis
JOHN P.
' HOMEIMPROVEMENT TRACTOR
4 Registrat�.oe 131858 I.
Expirattonc_.. 612010 Tro 275332
y„ jvt :�_I idual i
JOHN MOODY\ �;k. �� {
. ". 22 SCHOOL ST. � -. ;' CO1
r BEVERLY,MA 01915"
Administrator
I
s III