11 CHURCH ST - BUILDING INSPECTION (27) t
The Commonwealth of Massachusetts
I ' Department of Public Safety
��'A I:• � klasn,trhturlls Stab Building Qulc(780 CkIR)
tiCo3'
Building Permit Application for any Building other than aOne-or Two-Family Dwelling
(This Section For Official Use Ooly)
Building; permit Number: Dale Applied: _ Building Offici.
SECTION 1: LOCATI (Plea •indicate Block N and Lot p for locations for which street address is not available)
and Street City'/ilm 11 Zip Code K ame of Buildinl;(if applicablo)
SECTION 2: PROPOSED WORK
Edilion of NIA Stale Code used If New Construction check here❑or check all tha 1 apply in the two rows below
FNisting; Building❑ Repair Alteration ❑ Aaldition❑ Demolition 0 (please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:-
Are building plans and/or construction doctintents being supplied as part of this permit application? Yes ❑ No ❑--
Is an Independent Structural Engineering Peer Revie mt red? Yes ❑ - No
Brief Description of proposed Work: �, ��///
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here Ban Existing Building Investigation and Evaluation is enclosed (See 780 ChIR 34) ❑
Existing Use Group(s): Proposed Use Gruup(s): _
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)& Area Per Fluor(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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ VI-3 ❑ H-4 ❑ H-S❑
1: Institutional 1-1 Cl 1-2❑ 1-3❑ 1-3❑ M: Mercantile❑ R: Residential R-'10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Ill IIA ❑ IIB ❑ ILIA ❑ 11180 1 IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 760 CMR 111.0 for details on each item)
Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
public v Check if outside A trench'w ill not be I.il el 6ed 1)IS POsnl Si lc
FIooJ zone❑ Indicate numiiipal
required ❑or trench or
Private❑ Or indenlifv Zunc:_ or On Site system ❑
. - prnnit is enclosed❑
Railroad right-of-way: Ilazards to Air Navigation: ' "I.no,. .] '.1 I'
` Not Applicable❑ Is Structure within airport appn+ach area? Is their rev iet% ront.pllvtotl'
or Consent to Build on,laud❑ 1 es❑ or:No❑ Yes❑ No ys
SEC'I'ION B:CON'TEN'r OF CE7('I'IFICA'rE OI'OCCUPANCY
I:ditiollut(,Ode: (Se(.rUn p(5): Ivpeof Contill'lKllnl❑ l)i Cllp.lnl l_U.hI per I'I DU r:
I)OCS the building c attain an Sprinkler Scnlent?. __—_ .-_Special Stipulations'.
SECTION9: PROPER'"OWN Fit AU H IOR IZATION
Ndmc.utd :ddress A Pioporh Ow nor
19
Name(Print) No..knd Stmcl Cih'/I'ot' �j�/�/l'/ LI("
Proprrty Otcncr Qntlael In unnalion.
'fide Idephone No.(business) Telephone No. (cell) c-mail address
It appI icablo, the proper J'owner hereby 1111hofizes
Name Street Address City/Town Slate Zip
to act on the property km ner's behalf, in all matters relative to work authorized by Ihis building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less 0um 35,IHX1 cu. ft.of enclosed s pace and or not under Constn:ction Control then check here O and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
I ;
Name apt' tot 1 T• o tc e-mail address- Regbistration Nuntbu.�_ ,7
J�c��./
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Co npan ' More� I
Name Person Responsible fur t tstruction icons•Nu. and Type if Applicable
02
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e- ail address
SECTION 11: tvt n:t`r7L`;"t i.lmnll_V,A Hn.v I.Al I'WAVI I M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be cant leted 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 O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ Building Permit For-Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)-5
.1. Plumbing 5
J. :Mechanical (HVAC) 5 Note: Minimum fee=S (contact mm- ti_cipalily
5. Mechanical Other $ Enclose check payable to
h.Total Cost $ z '� (contact mm�icip, itv)and write check number here
SECT[OK 13:SIGNATURE OF BUILDING PERMIT APPLICANT
BY entering nta name below, I he«by altVSt,under the pains and penalties of perjury that all of the inforniatio cot .tined in this
application is true and acccur.uc to the best otpoty knowledge dnd undurSlanding. 5
PleasC print dnd Sign name Il TcicphonL,No. Dale -
15119
Stn•ot Address Cit\'/town Slate Zip
Municipal Inspector to fill out this section upon application approval:
Name Dale
f•�
CITY OF SALEM
; :l' PUBLIC PROPRERTY
DEPARTMENT
.1 W:l xf1 Y',nl,t,1II
t1,,,-it
51 atL•1'• S.1thvs. IV(.111da.l li V 1 nvl Y)�
Workers' Cumpenaatlon Insurunce 1tOdavit: Bullders/Contrac torsi Electrlclynsiplumbers
\ i )Meant In urinatio
plc• � tin Le 'hl
V;imC Illuu,n;,tr'1)rganlralinNlndlruluxll:
Address:
Ciry,.5rarc•7ip• I'hone it:
I .try)1'u an vngtloyorl Check the Appropriate boss:
1.Q 1 ,un J empluyer with 4. Q I:url a gencnl annraclor and I9MW 1)M'rf prn)oct(rwlulrtlJ):
Ll !jini
ycex(full JnJ/ur purt•iinte).• have hired lM;suh•cuntracwrs f'' ,❑�New cunxlructiun
sole prnpricfor or partner• listed on theanached,hect r y ICI Remodeling
d lava no cmpluycuti These subcontrseron haveg lily ma in any capacity, workers' comp,mslrrsnct. g' QDemolition
rkers'comp, insurance J. Q We are s an 9. ❑ OuiWind udditiun
J.J Wee on and itsotylccm have escicixcyl their 10.QElecrrical repairs or additions
homeowner JuingJII work right of afempolls per M1I(IL ILQ.IalumbinY repairs ar aJJitinry
INo unrkcrs'comp• c. 152,§I(4),and wa how noe rcyuired.l t cmployces. (No workers' 12.Q Ruul'rrpairs
comp. insunnom re4uircd.J I J Q Uglier
n).�,pAcaln IAW cAecYa sax AI mop:d.1.11 viva aln wanvin Wow avis i,,,Anal IAis amdxvA i11JIcJ1in , Y Ave wwlwti cunf�f wivn rout ultnrur,tm
Y Avg Jw JuinY dl,wrY a1W IAex Ain?uwfldn eunrnxrarx mome.vAnil a ne,11 alndtvil it1,1t1an;n r .
'r Mlraally,Ihp tAvice Ihlx Eox Inux1 a1liAxd„n aadll6yvd,Avila,An it's;this nanM o/n11 IVe etllYfapaye and Thew UurYerY'
Y ►Y.
I urn all emspfayer that Ir prat/d/ng IYa/�erl'farnpe/IfA//0/1 IILWryIOetl Or/n NO A, castle I'llfty Wismanm
hr/unnutGna /n y p/J eeh Bdmv/s Mtl pu/Ity and/ab sf/or
In,unncu C'umpany Vame:JG/� /!
Policy a it Sclf•ins. Lie.to:
Expirution Dare:
Job Site Addresf: `
City,SlateZip: O D touch a copy s%the workers'eumpenwHm puUcy declaration page(showing the policy number and eaplratlua date).
PJllure to,aura coverJge,u required unticr Scuiun 2JA ut'.NGL v. 152 eau lead 10 the imposition of jnd%:al penalties t a
et'uit m SI rA14M Jnd/ur one-year imprisn nncnr, j, well Jx civil facnall,cs in the larin orb STOP WORK ORDER anJ a fine
o/up to i!JO.tN1 A JJy.Igmnst the violafor. lie advmcd?hut a copy of this,mvincm may be t'urwarded lu the Oilice of
Ia P�p1,�Jlu,na ul Jiv DIA for cov040%cnlicJLun.
/Ju/r.•rrhy,:rti/yrun/errJrerui .mIJpenuMetujper/ury that she surmull,1100 prvriJed Abuse is trae and comet.
1)��frlY/,vie Ullly. /)J,IAt write in thif urea, Its he cump/ried by city ur tatrn a///4it12
f IfsVr 1'glYn; _
f„uing \. W hni?r Pcrinit/l.lcenfe 0
I y (circle nw);
I. IL,AtJ of Ila•JI?h 1. Iluddin•;A. thhvr Ucp.lrtmcul I. Cit).'I'olvm Clerk a. L•'lectriall Iug m
accrur ;. Plumbing Infycctar
' I
I
information and Instructionsn 1 IheirenlPlayees.
on in the service of another under.IIIY contrset of hire.
�Lusaclwsens lieneral Laws chapter 1 i2 rcywres all euyiloyen to provide workeq wmpensa t
1"asu.utt to ties .ututd,an eenpfaraa is detiteJ as"_.every pe .r:
,.press or unphcd, oral Or written." or;nt two or more
urtnarship,assdxiauun,corporation or other legal nary, lit t.r Or the
�n,•tnpfopdf I+JctineJ>f*'an individual.p to in ce l d crib Nets Of
tilt
e
u tho I:uequ rig engaged m a iwnt enurprise, and ituluting the legal representativeslo a deceased emp Y
ccmvcr or uusleo ul'.ut iudivtdusi. p
+erpr'"lp, ,ssoclatloa to other legal cnnty,emp Y g ' P occupant Of the
owner of a dwelling{house having not more than three aF311cr nu and who resides thenm,or the
appurtenant thereto shrll not lxcattsa of such employment be deemed to be an employer."
dwelling Iwusa of another who employs persons w do maintenance,cunslructin r repair work On such dwelling owe
or on the grounds ar building upp
�lGl chapter 152. ¢25C(6) also slats+that"every state at
total licrosla{agency I shall withhold the issuance or
gesee with the Insurance coverage required.'
renewal of a license or port to operate a business or to construct Wings In the commonwealth or say
applicant ribs has not prndueed Accept able ovldence of a co
�dJnwnully, �lGt-chapter !5_', S-'SCt7)stale$"Neither the commonwealth not any of its political subdivisions shag
aster into any contract for the perfomwnw ufpublic work until acceptable evidence ofculupliwtce with the insurance
reyuiramcnis of this chuptar have been Presented to the convactin{authority."
�pplicauts P to our situation and, if
es and hone number($)along with their canilicate(s)of
Please rill out the worker' compensation affidavit completely,by checking the boats that apply Y Y dx+ogler Than the
I sub-contractors)name($), •addles+( )' P with no ens log
necus+ary,supply
LLP)
workers' eornpeosanon insurance. if an LLC or LLP does have
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships
netnbars at paMers, an sat required to carry be submitted to the DePartment of Industrial
ampbyeaa,a policy is required. Be advised that this affidavit tray t nt of
Also be sure le alp and dull
theuascaJ ring the Dapsstmt should
.\ecidents for confirmation oP insurance col won rot the permit oc license is being req a workers'
ha returned to the city or town that the upD uestions regarding the low ur if you are required to obtainshould enter their
Industrial Aculddnt2. Should you have Any 4
compensation policy,please call the Departtrlenl at flu nuunber listed below. Self•in+uraJ companies
salt-insurance license number on the o ro rialto line.
(-try or'rown Officials
the applicant.
ptcasc he sure that the affidavit is complete ;tnJ printed legibly. The Department has provided u sputa at the bottom
Of Clio aifidavit for you to fill nut in the ovens the 011ice of Investigations had to contact you regarding
I'laasa be sure to till in the permitllicmtse number which will ba used as a reference number. In addition,is aFP _ dot ur
that must submit multiple pannitllicettsa applications in any given yea,need only submit one ut71 un uroviJeJ ("It nt
policy ittt'olmation lie ectiaviryhat has been officially d tinder"Job Site ddress'*or marrkedthe tbyi'I'd city or tow write n tnay iunp o l' Y
the
town)." \COPY edmit+or licenses. A now allidaviI must be tilled out each
applicant as proof that a valid affidavit is on file for tbturo pto any
t tile.
JugR a hoiseme oowner
lOr it bairn Ieaves��)wIJ person is NOTirequired toJomPlatc this t not iC Ifidav imtttercial venture
cooperation altd sltuulJ you huts.trig yuesuons,
I he I)I lice III IIIveitlgations would ilk@ to dwok you it, advance fur your
l,lcuse du nut hesitate to give us a call.
the Ucp:uuncnl's adhere, telephone and fax number:
The Commonwealth of Massachusetts
Departrnent of Industrial Accidents
011ka of Investigations
600 Washington Street
Boston, MA 02111
fall. M 617-727-1900 ext 406 or 1-977-MASSAFE
Fax 0 617-727.7749
www.maw.gov/dia
CITY OE S.u.E.Avi, NLUSACHUSETTS
BLLMLNG DEP.%M.LENT
��,r
120 ASHLNGTON STRM' 330 FLOOR
TPL (978) 743-959S
FAX(978) 740,9846
K15t8ERLBY DRISCOLL THOAAS ST.PEEN AB
MAYOR
DfRELTOR OF PI:HL[C PROPERTY/Hl'IIDLNG CO\LMI55[OVER
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 r0 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:
(name of hauler)
The debris will be disposed of in
(name of facility)
address of facility)
signature of permit applicant
date
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