281 ESSEX ST - BUILDING INSPECTION (3) I ;► The Commonwealth of Massachusetts
` ` + Department of Public Safety
�'I/ •.-,.,•Z �J I-�� ur"ei'¢q .\1as,tchusrlh St,ur Buildinti Cudr(780 C�1R)Seem th Edition
111 779 OL-ZS�� City of Salem
I Liclin Permit Application for an Buildingother than a 1- or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
111 S5Sex; Wr �Qr4y� 219 110 1-A.tt, +aaL
:Nu. and Street Co. eL, City /To%,,n Zip Code Name of Building (it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ 1 Change of Occupancy ❑ Other Specify: A oa GN✓';n LJ
Are building plans and/or construction documents being Supplied as part of this permit application? Yes ❑ No ❑/
Is an Independent Structural Engineering Peer Review required? n Yes ❑ No E3
Brief Description of Proposed Work: AdA OnI vo Wig
G" r= D!'Gv ,
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): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/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-2nc❑ A13 ❑ A-4❑ A-5❑ F B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H:_High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-111 R-2 ❑ R-3 ❑ R-4 ❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ - Special Use❑and please-describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ 1 IV ❑ I 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 if outside hood Zone❑ Indicate municipal ❑ A trench will not be Li Lensed Disposal Site❑
Fri ca le❑ or utdent0% Zoncc_ or on site n%<tem ❑ required ❑or trench or�Pecif%:
permit is enclosed ❑ _
Railroad right-of-way: Hazards to Air Navigation: ..\I:\ I se min l mmi*�im Itrvir . I'n -r.,;
.N#1•.\.P'F'Iii,ihle ❑ tl tiu:uctury Lcithin airport irpo"Ich area' Is their recie�c rnmplcled'.
I' Contsenl l+`11 Build ench1.ed ❑ t f`-�. Yes❑ or No❑ 1'es ❑ No ❑
' SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
lid tint .H C odo: LSr Grouplsf. fcpe of Construction: Occupant Load per Moor:
I)ocs the•building antlain an Sprinkler Ststrm.': Special Stipulations: .
SECTION 9: PROPERTY OWNER AUTHORIZATION a
Name and Address of Property Owner r/
'L` 1 �55CXSi, LL n @- �,t sv �f `�I �F, rf✓iVy// S I y
> No. an Street City/Tnwn Zip
:Name(I rint) -
�Plruperty lTv ner Contact Information: 6,�i L�
JLS'� 7�t9f a.'+ y%'tk h6 ti'Zr Ltt33'��
il
Title Telephone No. (business) Telephone No (cell) e-mail address
If applicable, the property owner hereby authorizes
�. 'ame Street Address City/Town State Zip
to act on t e property o+y ner's behalf, in all matters relative to work authorized by this buildin + termit a t tlication.
SECTION 10:CONSTRUCTION CONTROL (Please4ill{put:Apyeirdix 2)
(If buildin•is less than 35,000 cu u.of enclo d s pace and/or not under Construction Control then check here❑and skit Section 10 1)
10.1 Registered Professional Responsible for Construction Control
1 f ame(Registrant) Telephone No.
City/Town e-mail address Registration Number
NI State Zip Discipline Expiration Date
Street Address
10.2 General Contractor
Company Name: + • :'r "'!;� 7 tf6
Name of Person Respun+ible f Construction a Lice e.No;;and Type if Alicable
fjf` S ovZ s1 /Jre� A v 1qs
Street Address�$ZZ City/Town State Zip
+v 1 -1W-
Telephone No. (business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152.§ 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6)_$ l boo
1. Building $ /noo Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ 300 appropriate municipal factor)=$
3. Plumbing $ 47, Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $ Ar
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ ! wOO, (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 information contained in this
application is true and accurate to the best of my knowledge andunderstanding. ,(� I
S e_ i f G✓1 7A 7.6 I Kex S+. y)A a I U _�07 . �� I 8141 / 2 Im
I'leasa print and >il;n Want • v--' lit Telephone No. Date /"
01970
�lievt Address Cite/Tm%n St to Zip
municipal Inspector to fill out this section upon application approval:
ame Date
f
CITY OF SALEM
PUBLIC: PROPRERTY
DEPARTMENT
I ,. . . I.: q . I:•. . . ..all � �lu �l. \I�..� .Lr
Construction Debris Disposal Alllda% it
(re(luircd hir all demolition and renu\anon \vurk)
In accurdancc \%ifh the sixth edition of the State Building Code, 7SU CAIR section 1 1 1.5
Dcbris, and the provisions of 1•IGL c 44), S 54;
Building Permit At is issued with life condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I1I. S 150A.
The debris will be transported by:
Inamc of hauler)
I he Dcbris will be disposed of'in
(name ul Ixl6fy)
1•rdJrei. ullaw hlvl
a�ila !c dpanut .ygrh�ant
IJIi
CITY OF S.1LEM, AxSSACHi:SETTS
BC QDLNG DEPART\LENT
7. 1_O WASIiINGTON STREET; ) -FLOOR � ,.•�� , � F-»„•:
TEL (978) 74S-9595
FA.X(978) 740-9846
KI\BERLEY DRISCOLL
MAYOR THo&L%s ST.FmRRR
DIRECTOR OF PL BLIC PROPERTY/8UMMVG CO\QOSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electric(anslPlumbers
>nollcant Informatlon _-- Please Print Leeiblr
Name IBucirwv.Ortysoatiotvindavidtnq: 9-/ CSC ST lt:
/"4ddresr. �/l-FgiPfoto?� 'Yf. iz, Cs, ok/ ar cSf ynY L70
City/State/Zip,. J R�/ail /IR . 007 '�9 Phone 0: `?X - gO 2� - 231
Are you a employer!Cheek tits appropriate box: Type of project(required):
I.❑ I am a employer with d. 0 I am a general contractor and 1 6. ❑New construction
employees(full and/or pan bnt
-time).• have hired the subcontractors
2.
I ain a sole proprietor or partner- listed on the attached shc%L: 7. �emakling
ship and have no employees These subconttsctors have g. ❑ ► emolition
workingfor mein an capacity. workers'comp.insurance
Y Pac tY• 9. 0 Building addition
I No worker'comp. insurance S. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
).❑ 1 am a homeowner doing all wont right of exemption per MGL 11.0 Plumbing repairs or additions
myself. (No workers'comp. c. 152.f 1M.and we have no 12.0 Roof repairs
insurance required.)t employers.LNG workers' 13.0 Other
comp. insurance tequimd-1
•My applicant that chocks boa el must am rill out the corcin•below showing their wonket•craripwit>do policy insovmarla►
'I I.tttwawttat who cabinet the aflltkwie indicting they ran doing all work and thus hit mitide eantrecbn~athmk a now andtvir inditying wet
:f.nam,ura that check this ban mud anoctod an ad nons1 chwea'hawing tiff noire'err Ntl•Conlltnart and their woman ramp.gooey iararmouaa.
I ant an employer that ir providlnir workers'rompentedoa lnrrronee for my empoloytas. edow/i rby polla7t awd JaI r!!e
In.urrnce Company Name: ��Z/t4 G Y � �Cq `a ._L�tS• � ,�
Policy M or Self-ins. Lie. H: U/C Zo z o a I6 F$ 00 Expiration Date: X0V
Jab Site Address: 281 ♦;SSA cS T ( L; Z, u�)F City/State/Zip: 6�c(cy 'e, , P/,997d
,%ttack a copy of the workers'compensation policy declaration page(showing the policy number and expirsNoa data).
Failure to secure 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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. lie advisixl that a copy of this statement may be forwarded to the Office of
Inveangmiuna ul'die DIA for insurance coverage vcriticatiun.
of da hereby certify under pains and penalties of perjury that the informadow provided above is true and cartes.
�ry f i r q .cY Uut : v <6Z!�2
Offscial use mdy. Du not write in this area,to be curnpierd by city or taws offiriaL
City orTwvn: ecrmit/LlcenseM
lisuing.hwhurily (circle oney — - --- I
I. Itwrd of Ileallh 2. nuilding Department 3. City(rown Clerk !. Electrical Inspector S. Plumbing Inspector
6. Other
_
C"Tract Person:__
9
LO••.
•••'''•♦•'•''° •J�
.;LLr?.h"-���:�•:♦:.:Q�::••n:•S.Qw•n� 'w•r:•:a:.:.:Q�••✓�:•:•:Q�:�S:•:d•3:QJw'•:w•�:•:�:gY,�:q�:�:�:�E4�:cJ.E�A:rS:•:�4
:ii"�'i�•L's'
:hLL':L''•• •. COL i
i•:ti•:0 ii J:i•i�;�;;i� y..
'��'•r:•:L:•.}•'•:•••ram I';.:;a.};•;s:',�,
• .gip.:
L;r;�;�•♦.•s,.,•Ld•;J ;. •.LO.O",L•�1••-:...-.-.•so•.•:o.-s emu.
•,:•:J,♦;,L�:r'J�ii':•�LLO:•''•'�i+i i�::•.Si.i�;':.�iL�:•�}';. .tier}•OY�;.LO•J4'•:i•::•:•:•'}: }i•O:'•:i44:��;}}}}'•:•:•�L•�✓•L:•}i:0i}LL:;:JJAL L•:WJJJ.''Q LLO.Oh.S••J
------------
>}:A:••.COL;.:+'• .}:•::•:v.
::ti•'•'• L .D•'•},P,>'•;rY •}✓O:•FLLL•JO.LLti':✓J• --
:•:ii'P,✓�h•A:LLLY✓J✓L••hLhOrJ:JJ.::O L•S•L•J•
h; �:;:•' :i0 y�;i•;•}•',LhLOLLiLLL•
`�'D:i.}N'JOJJ✓O✓�L%LL L%hLLLOVO
L'•"'iL ..
:LO•✓.' 6 O:L
I ,I I�•• , is}
iiti•:
1• .♦•1h♦
.'.GrJIM.G•JJ:V
��J.�.• JO♦�E: r. � �OJ:
,11�•1♦h?I♦•J♦'� � k•J�
f�1♦Q�:Nr�.pOJV �O.N
rS •°h�6,J:•fi�ie4'n:♦:•:�:�a♦4 S_ie 'r_Q�:a_`.LQd�_Ar_G_gQQ1S:Qe�nSA•...•iaA:•:♦ar :cP♦A ceh:Q��y_14 CQA•�:i y:Sl
•✓i•OO:S••gM:•:S i❖:i
f,•,•i•i•J••OPJ.R •J.1
.•••i4h JJ M Mi ` � �h J•
f•�JJ❖MOJJY >�SS
h,J♦h44•••.• h.J.
•S••OJ••JJJJ A i:4 i
.(JJO♦•SS40•:SS•J:Q•i I♦S
f'y1.6� �kOMi S♦h Mi:tiv ir�i
J>1'O.In6hS.nnh•J.ir°ih°•y:•y:♦J�r i
•:�:44hey�::G•J•nn... W .e
•�ai.•ii••�04W„Mr. •PO ♦.•J♦i♦�r..
•:.k�:kSS.S:�r!:❖:•:4:•i�...OO$.h0•.!:4E
•,ra♦• ': JJ..•d'.,. acne♦.n.^,�f�
✓• •• ♦i�i•1005•dr^i�d4i i�ii'iM-•i�i? /
SSIPN:+i♦O M�y•J�ktiN M,•:•••;n<'r.S' 'i
M?M.SSiS,M:'O.'i4y;S O�rJ��•,ci.4,�
'�CiiyS•,Si�O .•♦. ••�r•i.♦.ww....ew.,w�.• !•y:riS•rM ♦•S.MJf�:h'r!.S4'd M.••SEi' .•�.�
i444•.MJ°.•�Sih�:•J:•h•••;•.i r!•.n•.wpr.
.. •.•h♦••4i is f.Ml♦.J�•iiS' ♦ S•S♦i•LrJ♦.•..• si.♦.•..♦..u1, � i4♦yi
:•: ••h0�i'O bri'�:iiMiiiS i��E;l:�
•i •f•:•i�,Siy JJJ.y S:•i°i•♦•:GSi♦•:jr•:ern••z'.•. .w.
♦I I JA JPJ♦4•A•OJJ♦4Sy.••. 1•�h��:�.•_•:�-: :•i
•�I•4SM y O•M♦M♦SShM♦Sy:AE'i :�a`A°I r�y�Q,�":•y:•JJ�♦,•�S♦1
r•�i•�M�•P:❖A••a• •S.♦�•S'i JC 4 i•:•O'•.IO:S•1'-••-•=-0..f. /
♦4°• 4QJJ••i•OOi•���.•O�afa4.�0♦bSS44°'d.S�••♦•M•S
Of�;Q♦:4J.y i°i'♦:9❖iiii SNi:•i❖:•ibli•JJi•ii°•ii40♦ •:1•J:.
�:•,•J,!,;• •E.GMiSAiILMI•i�P� !i�+S�•,O:f�:O.::
64•�$S:Jgj n4nS::L•:•::!::4 �5:1.•�•:�+,:•s♦P:•�:�OJa 1'ii
:•Ji'TI aGSGM,J,♦M�'4�SSSS4G4.44•TNGM.O•.�A'ehOS'
d:b°' Jy4�i:',:4• • �:��i!f7 J� y:iSM :•Si h:!y:J�f
•J♦':•J��JJO•`••°♦:•:S4♦O�:p i•.J♦ :•:Sl♦.♦•.°.••S•Mi Jy. ••1'O�
.y •..♦.... •.♦M:`♦.••:Ohl❖:4°•JO,SS.J}W♦
i hy.••�•:SO•OO.SMJ••Jy♦hh4•Oy.♦i•O.S•POJ♦MJJ•h:•
•4♦• dOJ♦h•4 4hOOMO�M001SWd•J♦•i0•iMJ.MJJOR4•
♦•• •h•.♦,S••.JJ:•J•y♦•h•J1•••iiOM.S44•J
•p hh�MJi4•h4M:JJJ••4�OM••Mi i•:hhS•J•Oh•O
J AMii•OJyi 0•S•P♦M J• M♦�MOOJJJJ•S:•O
�•�♦o.o.•.•'..•JSJC;J.•..v a oSSM.oSho♦.oS 4•
YD 04S.SOSi♦.•MiSS••disSS•OJ•SMJOi•Oa1.•O
S♦� .t4•iMiShJ♦,•♦♦.•J•J♦.• •dJiS•i•O♦M:O S���S♦�♦�♦�S S•O�SSO4b�:♦•••A�M.4•JiSS♦i•O
/riw ♦4b^iW+4WSO4•,�}S 4 f S M•.J
ii4`•♦♦f::.7�:•�1�'••'i:ii0 ySS i❖:•:d:�i:�:
i.�♦�1f.0_.•.MSe•••iTEw.•.:S•:•.!.nA•.•A••J:n 1M♦.
I„I •y:i•
I � I♦.i
r:♦:hS
I♦O�iQ
Wi P.`OJv.•��1 4•♦•
���iS.nuc♦.nn♦y