0008 CEDARCREST ROAD - BPA 12-249r
The Commonwealth of Massachusetts
Department of Public Safety
Alassach use[Is State Building Cute(780C�'1R)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(-Phis Section For Official Use Only)
Building Permit Number: Date Applied: _ Building Official: _
VVV SECTION 1:LOCATION(Please indicate Block#and Lot#for locations fur which a street address is not available)
No.and Street City/ own Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of NA Stale Code used_ If New Construction check here❑or check all that apply in[he two rows below
Existing Building Cl Repair Alteration ❑ :\ddition❑ Dcntolilion ❑ (Please fill out and submit'Appendix 1)
Change of Use ❑ Change of OCCupancy ❑ Other ❑ Specify:._ _
Are building plans and/or construction dtx'untents being supplied as part of Ihis permit application? Yes ❑ No Nan Independent Structural Engineering Peer Review required? Yes ❑ No„!2_"
Brief Description of Proposed Work:._
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 enclosed (See 780 CKIR 3.4) ❑
Existing Use Group(s): Proposed Use Group(s):
i
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)At Area Per Fluor(sq.ft.)
Total Area(sq. ft)and Total Height(ft.)
SECTION 5:USE GROUP(Check as ap cable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E. Educational ❑ Y.
F: Facto F-I ❑ F2❑ H: Fli h Hazard H-1 ❑ H-2❑ H-3 ❑ 1-1--4❑ H-5❑ '
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ �I: Mercantile❑ R: Residential R-Ind—R-2❑ R-1❑ R-4❑
S: Storage Sl ❑ S2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION I YPE(Check as applicable)
IA ❑ IBO IIA ❑ 11B ❑ HIA ❑ Hill ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CAIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ htdicate municipal❑ it trench will not be Licensed Disposal Site❑
required ❑or trench or specify:
Private❑ or indenlifV Zone: or on site system❑ permit is enCIOsed❑
Railroad right•of-way: hazards to Air Navigation: \i � i � .. : . ..
Not Applicable❑ Is Structure within airport approach area? Is their review comploc,11
Of Coiurnt to Build CnclOSCd ❑ 1 1 es❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CEI(-I'II9C.\'TE OF OCCUPANCY
Fdi[iau of Code: L'se Cruup(s): IN pe of Cunslrurtinn: Occupant Load per 19 oar
Does the building contain an Spriuklor Systrm : SpeCi,d Stipulations:
(
SECTION 9: 1'ROPI;R'TY OWNER AU'1'11O12IZA'IION _
Nome and Address ut Property Owner
ss�3rs�e��' -G��97o _
Name(Prix tf) No and Street City/Town Zip
PropertV Owner Contact Information: -
f itle Telephone No.(business) Telephone No. (cell) e-mail address
If ap tlieable, the roperty owner hereby authorizes
�19c e
Name Street dress City/Town State Zip
to act on the property owner's behalf, in all matters re alive to work authorized by this buildin omit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if buildin is less than 35,00t1 cu.ft.of enclosed s pace and or not under Construction Control then check here 0 and ski Section 10.1
10.1 Re istered Professional Responsible for Construction Control
N tnueReeg�ist an Telephone No. e•n ail addres� o��iq), c istruion I`1wnb- t
o ��r bail �/`YL�v-
Street Address City/Town State Zip Discipline xpr tionDate
10.2 Ceneral Contractor I
L' �Gtl C()/u5t/ L✓C
Cunt Mny Name
_- fd C- �dr �-7J0
Name of Persor`�1R-e_sponsiblle for Cur- //�� bl
License No. and Type if Applicable
z�{�
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:act t t.A111 ,NSA ru t\_1V;1J1:n.vc' Al+u',tVl r 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
ind Materials) - Total Construction Cost(from Item 6)_ j(7 �. BS)
1. Building $ Building Permit Fee=Total Construction Cost x_(htsert here
2. Electrical $ appropriate municipal factor)=$
3, plumbing $
4. Mechanical (HVAC) $ Nish: M1lininuun fee=5 (contact numicipality)
5. Mlcchanic l Other 5
Enclose check payable W
6.Total Cost 5 (contact municipality)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 into nation ontained t this
application is true and accurate tothe best of utv knnwledge and unders6unling.
�f �_C � /cIS---- C�P��I Co. � 7 L�- 9ro�i
I'Icasr pnn and sif;n name - - - l"ills Trlep It e N Date
�treel Address City/Town A-.�t,tc lip
Municipal Inspector to fill out this section upon application approval;
' Name Date
CITY OF S.u&m, 1�L�Ss.1CHL'SETI"S
BLUZLNG DEP.IRT\tENT
120 WAiNLNGTON STREET, )re EZOOR
TM (978) 74S.9595
)(MCBERLEY DRMOLL R X(978) 740.9844
'Nayolt Mo"ST.PMUA
Diucrox OP pL13LIC pRopERTY/StMONG CONSUSSIONER
Construction Debris Disposal Affidavit
T (required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H 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
l 11, S 150A.
The debris will be transported by:
l--ql,v f
(nam0 of hhauler)
The debris will be disposed or in
(name of racaity)
(add ssnrracllny)
eiynamre y pecmit applicant
4tc
k \ CITY OF SALEM
PUBLIC PRUPRERTY
DEPAR
TMENT
,un,MI I Y'r MIN, 11
I''. tVn,tusv;ws i+arut• • ieu•ss, M.tu.u.nl u i IsJI',l�
Workers' Cumpensatlon Insuruncc %lildaviC 1lullderf/Contractor3 Eleetrlcians/Ylumbers
� , )Ilcant In unnrllo
Plc• Int Le •bl
V;rinoalllHnk.Ya)rlan+NllnNlnJrYnlaailf �/� ` �
City,.5tarc.%ip Ur K/
—
I .lry y na an vaq,Ioyer7 Check the appropriate boy:
1,Q I ant a empluyvr w ilk 4, Cl I am a general cmnraelor and 1 I yPe of pro)uct(required);
nipluyvus(tell undlur pitminte).•
a solo pmpncntr or Partner. hew hired Iha.�uh•cunvaclurs (� ❑New cunsuucliun
?• I am listed un the anachcd sheet t
ship wid have no uln lu cow �• Relnl)dtling
P Y Tltwe sudeontrscton have
working Air Ina in any capaclty, workers'comp• insurance. Ljnemolirion
I No workers'cutup, insurance J. ❑ We ars a eruporalion and Its q' ❑Budding udditiun
nyuircd.J ol?lcen have eevreinvd rheir 10•Q Electrical repairs or additions
).Q I ant l homcuwner doling all work riyhr of eaentption per hICL I I.❑Plumbing rcpuirs or additions
mlutan (No ui r d.) t aattP• C. 132,010).and we have no inruranca rcyuired.).r cmpluyves.(No workers' Ig•Q RuufrePuirs
vrnnp• insuranvurcyuired•) IJ•QOther
.any.ppAcu/gw:ArcY•(his�I muq:Jw till w1 rM.uruao 41uw awwul r
Il�mw,Vnrn vhv ararmil lAir all'Wvirindg1d +in r eAvukv um,1eumyrneft nrylicy,nlur+lY,li,u�l,Mlrworn rhN vkra+ke Du TIW nwchwl as aue�urwi amine dl,rub ana Ikrr AW wnih eu+rrne
Avwt,Au win IIw"A- dflr ruaeaur +Ore rr,Wl.YI�rIM i 11I.1 Jlnueril IIIrI(.nllrlle Ylv'll.
aeuwe and IAra avA,ln'mny.pdary rnaurnirj+y,
/our un ONO for thus lr prurlJlgr NorAwi'rurnpatrnNaa ln.rurnnrejor my enplopaa.>4 Br/oar/s rhePu/ley and/u1 silk
iejurnrurlur4
Insurance L'umpaily Nmnc�_
Policy 4 ur Svlr•ins• Lie.rr:
�— Eapirat+un Data:
lob Silo: �klJresr: —�
\Inch a vuyy of the workers' vumpenwtlun pulley Juelarall
u,,eves cuverage,u required u un page(showing Iherpolicy numbur and evp1ruNua duty,
fu+luru nder Svcliun:Jr\ul'.11GL v. 152 eau lead to dte im
tiny up m.i LJIIOJM und/ur unt•year irnpri.v,Imnunt, as well J,,civil pcfralhu in this Ionn of a STOP WORK ORDER snJ A rtne
of up it) i'JO.ran Jilt Jay.rguirul Ilse violator. Ile advr4c•J rhut a v+Ipy of As..lalcmvin may bePl'vu'srw,lr�J u ilion l Ilia nal pen hies of s
hu,snyulnrm ul';Iw DIA ;or msar.mvv c„vcru3c a tlli.alwn.
/dudw lrerrhy t vrrijY nnr/vv tha nri
! rid pnro/ 'Friar r rb iujunaurlow provlllall ubab v%r true urr.l{'orraeri
r 7
rl//leial rna m+ly, /)u nn! rrirr in rhi.r urru. ru Aa runrylrrrJ by cir
yurrorva.q/$iut
(7ryur I'nwn: _
!„uinu .lulhnrily (circle � Armit/Llcvma l
noel;
I. 1livJ If lleahh 1. Ilwldul'� Ihp,rrnncr+I 1. 1.il).'fwan C'Wit 4. llccrric,rl lea tcctur i,
4. Ihher
I I Plumbing Imycctor
l•"nLlcl I'anmc
I'hunv r
Information and Instructions
s JetineJ as" .every pelsan 1n the aervi:e of another umtet.lily cunIrl of hire,
�Lusa:llusctts licneral L+1emv'Y1 a it 52 ,eywres all enyiluyen ioprovlJe workers canpensap„a tot their Cc ofhir es.
I'ursu.urt to tills slatule, an Y
;.press ur ,npllcj. Oral or wrmen." oranon or Other legal entity,or my two or inure
urutenhip. dillig atwo,eery to t.r or the
\n ernpluyer 1+JelineJ]f"on individual. p Io m MOO)
However the
d the I;,reguulg engaged in +Joint erircrpnse, and including the I�gal rcpreseuutives ut a deceased entp Y
ecerver ur Oust.-.-ul.tit inJindual, pasmership, ssoeiatiuo of other legal.-nary,cmp Y g ' P
to be an unployer."
the
Cher who employs persons to Jo maintenance,cunawctiun ur repair work un such dwelling hutw
owner ul'a dwelling house having not snore thaw three apartments and who resides theratn,or the occupant of
,1wclhng huuid of ono loy'.4thereto shall not because of such employment be deemed
or On the.-rounds or building Appurtenant
sItd chapter 152, t)1SC(6) also states that''svory state or local licensing difillugoae its the y shag withhold the issuanceor 22o►
renewal of a license or perrult to operate a business or to coa stria with Ilia
h bullsinsuranee coverage Irequr ed.
Pp rode cod cC+IP;,brte�YlNeince Of iher the onunonwealth nut any of ill politicos subdivisions shall
+ llcum "ha has mat p
\ddiuunully,NIGL:hupter 15p for
enter into any contract Pa the parfom+un evenroJbo that convect i aluthore+tyviJarce ufompliwrce with the insurance
requirements of this ohupler haMMOMMMMOMMMINNO w been p'
�Ppgcanta to utusituationm+d if
ensation affidavit eompletaly,by emending she Doses that apply Yof
aJdressle4 and Phone numbers)along with then cartPloy tsl other
Plea.a till out the workers' comp LLP with no employees Other than the
necessary,supply sutsaontructor(s)n uneUL' have
required to carry workers' eempetntseio subInsu mUted to the Deparotmm t odoes
I�ustriol
insurance. Limited Liability Companies(LLC)or Limited Liability Partnership t
metnbers ur paMars, are not
employees,a policy is required Be advisaJ that this affidavit s surf
t artme at of
accidents for confirmation of insurance coversge. Ass° po sure to ilea end being the ue'steavinot the f. 11te otllJavit should
he rctttmeJ to the city or town that the upplication for the permit or license is being requested.
obtaill a`'workers'
Industrial Accidents. Should ynu have any questiooa regarding the law ur i'you ate ur
calliper satian policy,ple0�call the Depatananl line.
nutnbar listed below. Salt insured eompanie,should enter smelt
r° riate
self•inaurea license number on the a
faty,of'rowe omelal,
the Applicant,
Ptc:+sc he suro that the afllJuvu a cumpleu :md Primed legibly. The Department has provided u spuca at the item
Of the uffiJavit for you to till out in the event the 0111ce of Investigations has to contact you regarding PP
applications c any given year, need only submit Ono affidovit indicating wrtera
,if 110 ba%Ore to f Y in the fill
out i the a nwnlwr which will be used,ts a reference nunlbar. In addition,an Opp team
that must submit multiple pen y)and Ae tin s" h matkad by hf ho city or town tiny be provided to the
and under"lab Yite Address'the applicant shnulJ write"all luuatiuns in Y
or
policy intormution Iif necessary)'
town).,.A copy of the uffldavit that has boon officially sump'
or lieonsos. A new atllJavit nwst be tilled out each
ennit not related loamy business or commercial venture
applicant u proof that a valid affidavit is on file tot Mute permits
your. NVhcre a hu+ne owner or citizen is obtaining a license or p
iesnsa or permit ro burn leaves ere.)sail person is NOT required tocampleta this affidavit.
uesumu,
dog I P you have Y 4
I IIC )Ili:.-ul hlYevtlgatluns would IIAo W ihink you ill aJv{IIIea tut yuUt:OU eratiun and ehuulJ
plea+.- Jo nut hesitate to give us a call.
fhc U.p30111011'4 addroas, telcphune and Au number
The CofnrnonweaUL of Ma,s ichusefa
Depa went of Industrial Accidents
Offlee of lavestl4sdons
600 Washington Street
Boston, MA 02111
Tel. p617.127E 617.
00ext 06Of1-877MASSAFE
www.rnass.jov/die