11 CHURCH ST - BUILDING INSPECTION 408 The Commonwealth of Massachusetts
I ;3 Department of Public Safety
4 ate Building Code 1."80 C\IR)Srvenlh Ednwn
\) City of Salem
Building Permit Application for any Building other than a I- or 2-Family Dwelling
I I Thu�acnun Fri Ufhcial Usr l)nlvl
Ifuddmg Prnnit Number: Date Applied: `" Building Inspector
_ SECTION 1: LOCATION (Please indicate Block s and Lot a for locations for which a street address is not available)
1 i C 4wrz k-\ Sf S> 0 1 U un If V-0-Zi
Xo.,ind Streel Cuv /Tolcn Zip Code Name of Budding (it applicable)
SECTION 1:PROPOSED WORK
If New Construction check here Our check all thal apply in the two rows below
Existing Building❑ 1 Repair Alteration ❑ 1 Addition❑ Demulitiun ❑ (Please fill out and submit Appendix 1)
Changeuf use ❑ lChangectfOccupancy ❑ Olhrr ❑ Specify:
Are building plans and/or cunstnrchun documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Descripliu of Prupusrd Work:
lw i
0_4)0 o-'
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):
Existing Hazard Index 780CMR 34: Proposed Hazard Index 780 CNIR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/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-2r ❑ A-2ne❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: HI Hazard H-1 O H-2 O H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ 1.2 ❑ 1.3❑ 1.4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 ❑
S-2 ❑ U:.,Utilit ❑ Special Use❑and lease describe below:
Storage SI ❑ P S g Y
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
CIA ❑ IB ❑ IIA ❑ 118 ❑ IIIA ❑ 1118 ❑ IV VA VB ❑
l
SECTION 7: SITE INFORMATION(refer to 780 C.VIR 111.0 for details on each itern)
Water Supply: Flood Lone Information: Sewage Disposal: Trench Permit: Debris Removal:'
I'ubllc Cl ChacA if,uibnta• Znnr❑ Indicate mumnl•al Cl
\ french will nni he Ul eri.rd Ul. ....al j,Ie ❑
rtvluirx•d Our trench �c.prcif c.
I'rn ete❑ g .rt Indc�llh Zone:_ or nit ate.c�trm ❑ permit t•encln•ed ❑
I Itailrmd ri ht-uf-wa Hazards to Air Navigation: x1-\ I b.e•n, t . in iu,� i.. R,, , „ I`,.,, .:
\,d \ipL.dblc❑ I.�I niilwc a Ilhm au)o rtl.i l•)v u.iih drra' I.Ihcu. n•.let. c. n+i dcirJ• i
SECTION 8:CONTENT OF CF.R"TIFICA fE OF OCCUPANCY
I ,ItluII 1 l- .,Ic - .___ l.`c l,i ru)v•I __ f.�cq 1.in.lrp.Il�n llCi Ul`.inl .U,I F'vl lrnn '
I)__ Ihr n l.tw n�rm Licr 'Ilpul.rinm•
J J
o� ��J
SECTION 9: PROPERTY OWNER AUTHORIZATION
\'.i se.nid \.Idra•s•ur i ro crty lha'ner
' efS�\-rtdac►���
\amrlPrusU N'o. ,tad?In•rl lliv; (own Gp I
1'n,per1y Uaa tier CorraR Iniurmation:
-
rltle reiephune No. (busme+s) relephune No. (cell) e-moil .ul.lrv—
If.t).rahi.tblr-• th5 propert\ gamer herebs-.tuthurites 1 E} 114
' Name }(n•rl .\Jdrr" Cih'i ioaen ti(atr Zip ,
w act on the proj,ert% ga,ne(.beholt, m Al matters reiattce tit work aothurieed by this buddin • prrmrt o p +hcahon.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(II budahn•is Isms thin?i•111)t1 u.tt of enduxJ v+ace and/or nor under Conatnichon Coutntl(ha•n check hrre❑and.kip t is. ;n IU 11
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mad address Registration Number
Street Address - City/Town State Lip Discipline Espiralwn Uatr
10.2 General Contractor
I• +✓1 Car..
Cump.iny Name:„ & 2:Z-1
Namp( u Persrm Rrsp m.iblr fur Cu s11ructiun License No. and Type if Applicable
S reet Address St /Town
-2j9 --�3 6 C'3 d � Q 6 y tc�t t Z� cam.
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERSCONIPENSAITON INSURANCE AFFIDAVIT(M.G.L.c. 1S2.& 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 sij4ned Affidavit submitted with this application? Yes Er-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(actor)_$
3. Plumbing $ ' 6
N. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
S, Iblecha n1caI (Other) $ Enclose check a Ible to
6. Total Cust $ payable
f S ,S o (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF EUILDINC PERMIT APPLICANT
Hs' entering my name below. I herebv attest under the pains and penalties of pequry that all of the infnrmaiinn n�nhuned In this
apphcatwn is true and accurate to the brat/ t my knoa•edge and undernlandtng.
3-r
I'II'.1Y')•nit acid .Igo inr file __— --
�I�a lo)hure \ii I).tic
Y VVl c aJ
�ti ra,l \J.Irv" lta:-(Haan �(.Itr
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Nluni.ipai Inspector to till out this section upon application approval:
- \amr 11,Itr I
CITY OF SALEM
' PUBLIC PROPRERTY
DEPARTMENT
..w::■:fr axox�.9 0
I1L WANa\610S$!MILT 1$At ILx,M.1.11d1.1 It V•1 a S197C,
08.745.93115 a F.tx. 97e•710•4846
Yorkers' Compensation Insurance Affidavit: Builders/Cuntracturs/Electricians/Plumbers
%onlicant Information lean leane P I t Le 'Al
V.IIT AlC l8uwr.dOraanvalimvinJrvuhwl)l: `0�` 14
Address: 'fc7O CkAAg
City.Starci%ip: (n . / yH 0 052 1 Phone#: ��/—S23
—6Q0
.t ro•)ou an employer!Check the appropriate bogy 'Type of project(reoluired):
1.0 1 am a employer with 4. Main a general coulrretor and 1 6• Q Now cull struetion
anploycus(full andtur part-tine)., have hired thu sub-contractors
2.Q 1 Am a tole proprietor or pointer- listed on the attached.chart : . 7. mnodeling
ship toed have no ampluycas These subcontractors have V. Q Demolition
working for one in any capacity. workent'comp.insurance. 9.-0.pui ding addition-
-- 1 No workaft cuing.Tusuralrce —.`5. Ws era ii corporation and its
required.) otYlcers have cu-m6 al their I0.❑Electrical repairs or additions
D.Q 1 um a htuncaowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.LKo workers'comp. c. 152,41(4).and We have no 12.Q Ronormpoigs
insurance required.j I employees.LKo workers' 13.❑()that,comp. iituuranLV requined.j
•Aar.pphrats dtd cN%ft km dl must also till ud the usual below showing.heir watkwi cumpmuaiod juicy inhdmutwL
'I flonvowneit who submit INS afAdevil indlemiee they Ile duine dl wurlt and Ilia him outside L'ammtmm mWl.utwln a row afndavit irWiauine wwh.
•f.wtrawwc that think this Iles mew alacked m additiaul,hoes Jutwing the lime of the ruk4mtraHoir and tied wwkvn'Comp.pulxy inraanatius -
1 tad tin employer,thug h providing ovorkers'compenmtioe i'Lrgrogcefor)my employers. Below is the polity and job site
lnfurmgthus.
Insurance Company Vmne•.
Policy 11 tit Stir ins.Lie.it: ._ , __ Expiration Date:
Job Site Address: Cuylslia zip:
Attach a cupy or the workers'cumpeniation policy declaration poke(showing the policy number and expiration date).
Failure to+scum cowruge as required under Section 23A ul'\IGL a. 152 can lead to the imposition oreriminal penalties airs
rind up Ill 51.500.00 and/or one-year imprisonment,a9 well as civil penalties in the font of a STOP WORK ORDER and a fine
of up In$250.00 it day.lguinst The violator. Ile adviacd thug a copy urthis stutclnen,may be Iurwardedl to the 011icc of
Invrang,iuwns ul'thv DIA ibr mmicirce covcraga,erilit:rtlun.
l do hereby certify!#order the pains and penaBiev dfperjury that tie inIturmtrllen pruvided dbovot it true said correct
t,�:rtltad� 2 I
u te• Z6 c
r)/Jkiul use ally. Do not write,in this dreg,to be cdorpleted by city up rotvn ajjieial
('itvurTalrn: _ Pcrmitll.ieeouetl, _ -,
Issuing.tulhurily(circle one):
I. Ilnard or Ilralth 2. lluilding Departulem .1.t:illr fort Clerk 4. Electrical Inspector N. Plumbing lnspector I
6. other
t'oalael Tenon: _ .- Phone•Y• .
1
CITY OF SM.&M. NLisSACHUSETI'S
• BCILDLNG DEPAR-nt&NT
' 120 WASHNGTON STREET, )iO FLOOR
TEL (978) 745-9595
PAX(978) 740-9846
W.jtBEjt RY DRISCOLL
NMAYOR THomu ST.PmRRB
DIRECTOR OP PUBLIC PROPERTY/Bt:MDNG CONNISSIONER
Construction Debris Disposal Affidavit
(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 MGL c 40, S 54;
Building Permit At 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
111, S 150A.
The debris will be transported by:
Lc���1rcl k S S�
(name of hauler) T—
The debris will be disposed of in :
(name of facility)
SSLG7�d�• S�Cw
(address of facility)
signature of permit applic
date
I.Ana�d J•w