20 FEDERAL ST - BUILDING INSPECTION (4)r
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The Commonwealth t31Vlassachusetts
De artment of Public9S �y1ry�.ppA %Massachusetts State Building Cp*504CbIRR� ~Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
1 Builduig Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
T No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix t)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No.❑
Is an Independent Structural Engineerin eer ev' w requi ed? es ❑ No ❑
Brief Des tion of Pro us� 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 CAIR 34) ❑
Existing Use Group(s): IProposed Use Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing' Proposed
No.of Floors/Stories(include basement levels)dr Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
1A1;
: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
Facto F-1❑ F2❑ If: Hi h Hazard H-t❑ H-2❑ H-3 ❑ H-4❑ H-5❑
Institutional I-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ R-4❑
Storage S-1❑ S-2❑ U: Utility❑ S ecial Us ❑and please describe below:
ipecial Use:
SECTION&CONSTRUCTION TYPE(Check as a licable) -
IA ❑ IB ❑ IIA ❑ IIB ❑ IHek ❑ IIfB ❑ IV ❑ VA ❑ VB ❑
I
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 Flood Zone❑ ❑Indicate municipal A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indenlify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \I\I l ,t i •nnn�i,ti n I , !,..
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ I Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s):_ Type of Construction:_ Occupant Load per Floor:
Does the building contain an Sprinkler System?: _ Special Stipulations:
ek0(> -Tb Z(, NCSZTIWEDOD 5 i Te7>g7a0b `t
SST -,7I G 1 rs
r
SECTION 9: PROPERTY OWNER AUTFIORIZA'riON
- t
Name and Address;of-Property'-Oivne,,'a
Nan (Prints No.and treet City/'Pot n Zip
Property Owner Contact fnforntiilion"Y4i ?;
/SWP'ff �T- �(Y —
Title Telephone No.(business) Telephone No. (cell) c-mail address
If applicable,the pr/operty owner hereby authorizes
Tire Jr1;V1i 11 o7�iUO L�e
Name Street Address City/Tot n State Zip,
to act on the property owners behalf,mail matters relative to work authc permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O antl skip Section 10.1
10.1 Re istered Pro essional Responsible for Construction Control ,�z
l e(Re istr f Te but d No a-mail addres ' Registration Number
Street Address City/Towd State Zip Discipline Expiration Date
10.2 General Contractor -
° r
Company Name ""v^'
Name of Person Res Bible fyr Cpns 'uctiun [icense No. and Type if Applicable
abl�
a��Isyl.��i� J el'
Street Address City/' wn State Z'p
woo
Telephone No. business Telephone No. cell a-mail address
SECTION 11:VYUI:F:L:RS'COAII'tN5,11'ION INSURAaNCO.,AFFIUAVI I 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
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Q4Q Building Permit Fee=Total Construction Cost x_(Insert here f?
2.Electrical $ .Q® appropriate municipal factor)-S f
3. Plumbing $ �
4. Medwnical (NVAC) $ Note:Niininuun fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTI N 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 iccurate tl •best of inknow dge and understanding.
Please pri&�° s ga n me„� Title Telephone No. Date
AAC&
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: °
Muriel/ Date
° CITY OF SiU E.NI, l�'Ws.ICHusETTS
s _ BL'1LDL�IG DEP.1RTJtIr�iT
3 '�r •i 120 WASHINGTON STREET, 3sn'FLOOR
TEL (978) 745-9595
F.'a(978) 740.9846
KIJtBERI F-Y DRISCOII
{NLAYOR - 7}ionLlSST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BU2LDi.%,G commtiSfONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anolicant Information — _ Please Print Legibly
Name InminessOrganiniiam•Imlividu.dl:
Address:
City/State/Zip: Phone U:
Arc yni an employer?Check the appropriate box: Eo
project(required):
I. 'am"employer with 4. E I am a general contractor and I
6loyees(full and/or pan-time).• have hired the subcontractorsew construction
2.12,1p
1 am a sole proprietor or partner- listed on the aitachod tihect: _. emodelingship and have no employees These sub-contractors have emolitionworking"fur me in any capacity. workers'comp. insurance• ilding addition[No workers'comp. insuance S. E We are a corporation and itsrequired.) officers have exercised their ectrical repairs or additions3.❑ 1 am a homeowner doing all work right of exemption per MGL mbing repairs or additionsmyself.[No workers'comp. c. 152,91(4),and we have no orrepairsinsurance required.) t employees.[No workers' er
comp.insurance required.)
•Any applicvrti out checks bus et must also rill uua file Icetiuu below showing their workers'mmpernea"Policy intummtion.
'Ihuncuwtwvs irAu whmit this Affidavit indicating they ars doing all work and then hire oubidoconimetot, at stihmil a now afOdavil indicating such.
4", mxtun that Omit this box mat atlachid an additiuml xhni showing the name of the sub contrutara and their workers'camp.pulley lntutmation.
!ran on empluyer that it pravfdinK ivorkers'ranrpensadon hisurarrce for my employees. Belay/s the po/Ivy and fob sine
iajarrnatian.
Insurance Company Name:-'GyLd2 [_-lamas=a[!-/_
Policy 4 or Self-ua. Lic.0: Expiration Date:
Job Site Address: L> P s �f 6L City/sfate/Zip:
Attach a copy ul the worlrers'compensation policy declaration page(showing the policy number and expiration date).
Fuiluru to secure coverage as required under Section 2SA of SIGL c. 152 an lead to the imposition of criminal penalties of a
line up to S 1,500.00 undiur one-year imprisnnmen4 as well as civil penalties in the form of a STOP WOR K ORDER and d line
tar up to 52So.00 a day against the violator. Ile advised that a copy of this statement may Ix: furwarded to the ODico or
Inrestigaaiuns of the DIA for insurance coverage verification.
I du hereby err ' er rhr puln.r u penoltl s ujprrfary that the injarniuNon provided above it trot anJ carrrae
Si••n a e" ..r, Date:
Phoned-
qIliviral"Seuldf. Ou our arise in r/rLr area,to be romyierrd by city fir rurun n/JiriuL
City tar Town: — ," . Permit/1.1cense M
Issulag Authurity(circle one): -- --- "_-- --- I
L lluurd of HMO 2. Building nepartnteia .i.('say/ruwn Clerk J. Electrical Lupcctur 5. Plumbing Inrpeetor
6. Oilier
� CunlaU I'rnonc .___--- Phone a: I
r
is< QTY OF SALEM, MASSAC'HUSEM
BUILDING DEPARTMENT
., 120 WASIWGTON STREET,310 FLOOR
'ILL.(978)745-9595
KIMBERLEYDRISODLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBuc PROPERTY/BUII.DING 00bA4ISSI0NER
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 c40, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit 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)
(ad ress of facility)
Signature of applicant
r'
Date