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14 CANAL ST - BUILDING PERMIT APP The Commonwealth of Massachusetts Department of Public Safety \la..,tahu.a•Il.SI.ue llurlding(.'ode(,SO C\IR) ,-%vnlh EdrtSon ! City of Salem Building Permit A lication for any Building other than a 1• or 2-Family Owellin (rhis`aa'tion For Official Use Only) Ow Ltinl;Prrmrt Number: Date Applied: Budding Inspector SECTION 1: LOCATION (Please indicate B ock a and Lot s for locations for which a street address is not available) �Yh ..No. Ind Sir City(-F..a.ii Zip Cade .Name of Building (a•ipphoible) /-/ i/ SECTION 2:PROPOSED WORK It New Construction check here O or check all that apply in the two rows below - --- - ----Eor ting-Budding 13— -Repsrr-❑ -Alteratiu Cl-- tidal iliam-❑--Drmoliliert-0-(-1-'leasrlill+wt-and-submit-1pprn.lix-y— ChangeofUse ❑ Change of Occupancy ❑ Other ❑ Specify: Are building pl.ins.ind/orcur trtiction documents being supplied as part of this permit application? Yes ❑ NuAf- Is an Independent Structural Engineering P r Review required? / a rNar4jr Brief Description of Propovd Work: CY Aiia+•�C-Pi lA i /V SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDER DING 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): 1' Existing Hazard Index 780 CMR 34: 1 Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Fl6ory(sq.ft.) T� 0 V Total Area(xl.ft.)and Total Height(ft.) \ CiC r SECTION 5:USE GROUP(Check as a licable) A: Assembly A-1 ❑ A-2r ❑ A-2nc O A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 O H-5❑ I: Institutional 1-1 ❑ 1-2❑ 1-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4 ❑ 1 ❑ S-2 ❑ 1 U: Utility❑ Special Use ❑and • lease describe below: FS.—St—age I Special U.W. �. SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB Cl IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA O V80 SEC ION 7: SITE INFORMATION (refer to 780 CNIR 111.0 for details on each item) french Pennif: ' Debris R val: Water Supply:-, .. Flood Zone Infortnation: Sewage Disposal: \ trench will not be Lrcrmed Di�L,...il�rlr ❑ 1%&hi: Check rl,rubrde I L.,al Znne❑ Indic.ite rnunial,all� s. rcyuired O or trench ,r n .ilEcdc. 1' cy❑ iv indcn bls Zone:_ nnm.rtr•c.lrm Cl❑ )•rrml i.cndo.rd ❑ ) Railroad right-of-way: Hazards to Air Navigation: ............ I6 , ., t \, 1 \)•Idi..itllc❑ 1-'4ru.lurc o l d' . r l •n•cni nlluJd vnJ: .c.l❑ ❑ ❑ SECTION 8:CON TENT OF CERTIFICA fE OF OCCUPANCY I .lilnm.dl .ic L-c l....ulv.i — (i i'c q l-. n�lnr.li,nl lhiup.inl l , .i.11cr lLui, _ - I6 ,. rhr l•mhfuq..nn.nn.m �I•nnklrr?a.ivm` >I`rri.J �nfuldliun. __ _�.--_ __--__-_- I 11G.l `�© IOh/Ri�h SECTION 9: PROPERTY OWNER AUTHORIZA FION , \'.one.lnd AJdre,Tit Vr,j1%•rt% Oee'nrr I \e +r ,, .N,r..Ind Street llh r Gncn Vr.,lj 0 t nvr('ont.lct Inlurmeuun: Tulr l relephone No. IbusmrsJ relephone No. (call) -mad .nl.lrc.. -_ J 1(C,,,1 r)+heal+Ir, the rrl_c .`a.nerherrb(-a ihlrr Name ?trey Address Cily/Town State Llp ❑+act on Ihr I,n+re•rI% m%ner'.behalf, m.dl matters n•lativr lu work authunta•d by this buddln •lletrillt.1 + nc,atlon. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (II lrud.hn•IV Icss Than li,(Vucu.it.of endo.J>race•and/or not under C,,n,lru,tum Cunlrul Ihvn check here❑and.kl +5voion IU 1) 10.1 Registered Professional Responsible for Construction Control rgi3tGl - , rep one No. e-mal).ar.. ress Registration Number Street Address - City/Town State Lip Discipline Expiration Date 10.2 General Contractor - - u C�tmpany N mW^ �� 3 2 8 0 1 J4 C6h�f uG� 7J Nam Rierstj Respu vi a for Construction W tense No. and Type i pplicable _ Street Address 1z p ,Lity/Town n — — - �—37f��63 dTCrrvsP cat�c cappeant Telephone No.(business) Telephone No.(cell) - e-mail address SECTION 11: WORKERS'CONVENSATION INSURANCE AFFIDAVIT IM.G.L.C.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must becompleted and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a si ned 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) =S 1. Building S Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical f appropriate municipal factor)=S 3. Plumbing S 4. Mechanical (HVAC) S Note:Minimum fee=-f (contact municipality) 5. Mechanical (Other) S Enclose check payable to 6. Total Cost S . �j (contact munici alit )and write check number here SECT( N I7:SIGNATURE OF BUILDING PERMITAPPLICANT 8y vnlrnng my name below, Ihr by attest fe/,yhe pams and penalise,of perjury that ell of the mfurmaniw cnntalned in th1.. .Ipplic.uum I]true anal accurate r hr r� uevledFeand tlndvr.tan,ling, -- 37 I'Ic-l�.•c'p1ant a I •ign ,.'Inc.r Fl tlj') -rJ Rar �� ( /✓1 phrne \•� rtrrel Wdrv— ca%.'Lavl Ste tr GF, - I 11Un1e1pJl IIISPKfIIr 10(III out this section UPnn JpphCJhan approval: - _ _ I ;t Crrx of 5:�N1, ,tiLS,ss.�cxt.sr;z rs BLICDL\G DEP.\R'f1tE.r\iT • 120 WASHL�IGTON STREET, 3'a FLOOR TEL (978) 745-9595 F.*.x(978) 740-9846 Kl%iBERLF-Y DRISCOLL THOMAS ST.PIERRE MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electricians/Plumbers A a Iicant Informatloo Plcase Print Le ibl Name(Business Urganira orvindi ' ual): C, nr/vJ Atldress: ! A City/Statc/Zip: Phone hl: 978_ 37•-TCC7 Are you an employer?Check the appropriaI. Type of project(required): 4• am a general contractor and 1 6. New construction I.❑ I am a employe with ❑ employees(full and/or part-time).• Kays hired the sub-contractors 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet: ship and have no employees These subcontractors have ii.demolition working for me in any capacity. workers'comp.insurance. 9_ ❑ Building addition No workers*con insurance 5. ❑ We are a corporation and its ( p• lo.❑ Electrical repairs or additions required.) officers have exorcised their right of exemption r MGL I I.❑ Plumbing repairs or additions J.❑ I a homeowner doing all work c g15 , .and we have no myself(\o workers' comp. 24 1(4) 12.0 Roof repairs insurance required.)t employees. (No workers' 13.0 Other comp. insurance rcquircd.J -Any upplleaun tea chucks boa 11 most alvo fill out the section Wow showing than vorkni eompmsmiun policy manmation. I hvnauwtwa who submit this affidavit indicating they am doing all work and than hire outside contractors most submit a new alydavil indiotina such :Cuntmcton thal,heck this box must atimbad an addieiurul shut showing the name of the mb•cantncton and their workan'comp.policy information. /am an employer that ll prev/d/nR Ivorkers'compenrar/en h uronce for n y empluyeez Below is rho policy and Jab s1 e injarmurion. Insurance Company Name:- o� —.-j'///`t/ L- wr✓u/ Policy g or Self-ins. Lie.N: � ,,�1 Expiration Date: Job Site Address: N v�/ l ld �� P/ / City/State/Zip: ,%nach a copy of the workers'compensation Polley 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and.a line of up to 5250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Ol lice of Investigulions of the DIA for insurance vera w venficatiun. 1 da hereby certify an the ul a d is 111e1 of periusy char the infurmatlos provide)tab rig ue mid conic t 9o, 3 7r 611 O/Jicial use aaly. Du not write in this errs,to be completed by city ur Iowa n/flrl A City or Town: .-- Issulail Authorily(circle one): I. Board of health 2. Building Deportment 3.City/f own Clerk J. Electrinl Inspector 5. Phmtbing Inspector 6.Other i Contact Pursun: _ -__ . . Phone it: gonDlr,�� CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 1e 120 WASHINGTON STREET. 3RD FLOOR SALEM, MASSACHUSETTS O1970 2 TELEPHONE: 978-745-9595 �. rygD� - FAX: 978-740-9846 KIMBERLEY DRISCOLL MAYOR Section 116.0 DEMOLITION OF STRUCTURES Structures over fifty (50) years old must have approval of the Salem Historic Society UTILITY DISCONNECTIONS REQUIRED Authorized Agent Date of Disconnection Water (see attached requirements) Electrical Fire Health Sewer Salem Historic Commission ry Dig Safe Number 2 0 1 b s (j 9 Pest Control: ***DOCUMENTATION OF ALL THE ABOVE MUST BE ATTACHED BEFORE PERMIT CAN BE ISSUED*** Fee for Demolition $5.00 application fee plus $2.00 per 100 square ft gross area, Minimum $25.00