5 FLORENCE ST - BUILDING INSPECTION i;
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• ' The Commonwealth of Massachusetts
Department of Public Safety
f (`„ \Ions,tchux•Ila State 9mldingCudeCSO CMR)SvicenthEdition
City of Salem
�( Building Permit Application for any Buildin other than a I- or 2-Family Dwelling
I` (Ihiv 5vctwn For Official Use 000
Building Permit Number: Date Applied: Building Inspectur:
SECTION 1: LOCATION (Please indicate Block a and Lot a for locations for which a street address is not available)
Nu. and Street 01v /Town Zip Ctde Name of Building(if applicably)
SECTION 2:PROPOSED WORK
If New Constructtun check here 0 or check ell that apply in the two rows below
Existing Building 0 Repair 0 1 Alteration O 1 Addition O 1 Demolition J8' (Please fill out and submit Appendix 1)
LChange of Use O Change of Occupancy O Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No B
Is an Inde�wndent Structural Engineering Pees Review rrquirad7 I Yes 0 No,O
Brief Description of Prmposvat Wurk: 1�-v 1%i•w` r'.v.� �, --F v"�d,,..-.,
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE/N USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O
Existing Use Group(s): Proposed Use Group(s): Y
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 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 St USE GROUP(Check as applicable)
A: AssemblyA-1 0 A-Zr 0 A-2nc❑ A-3 ElA4 O A-5'O B: Business O 1 E: Educational 0
F: Facto F-1 ❑ F2 0 H: Hijigh Hazard H-I 13 H-2 O H-3 0 H-4 O H-5 O
1: Institutional 1-1 ❑ 1-2 0 1.3 0 1-1 O M: Mercantile 0 FR. Residential R-10 R-2 O R-3 0 R4 O
S: Stora a SI ❑ S-2 ❑ U: Utility 0 Special Use O andd` lease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA O Ili O HA O fle O IIIA O file O IV 0 VA O VB O
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zane Information: Sewage Disposal: Trench Permit: Debris Removal:
I'ub11C❑ C buck tl uuhlde Phial Lune❑ Inaliarte municipal ❑ A trench will nttl be Licensed Dial tt.,d Site 0
1'r I%.ne❑ ur InJvnuh' Zone: ur on sue,%,tem 0 required Our trench ur ,pecdt':
permit to enclo. d ❑
Railroad right-cif-way: Hazards to Air..Navigation: \I\ I li•it•rlt ( %,mim wit Itrt itet I•n,•t—:
\nt \Iry•hc.d+la• I.�truclure we nhm.topnrt.irpruech.trea' I.iheo re%Iew aunplch•d.'
•a 11 ntwnl In IIu JJ vnduval ❑ \b.O or.\n❑ Yao❑ \tt ❑
SEC rION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I ,Idiom , l ( , Jc. _._ _ Lvl,ruuFq d. rw I•v ut Cun.uudwn: lktatpant Lnaal perlh, r
Iha•. Iha•builthnti to noam,ln tiFlnnAlcr�w Hem" �pa•C:al�hpul.unm.�
q7
SECTION 9: PROPERTY OWNER AUTHORIZATION
P N m\.uni_\t1.1r ..u1 noF.rrtll�J�6 n 1 �1 /- ,� jr
9679
Name(Print) .Nu,.and Street C jIY/rown Lip
Pn,pc•rty 0%vier Contact Information,
rifle Telephone Nu. lbusiness) relephonv No. (cell) a-mad addrt•>s
I(apphcabla, the property owner hereby authorize.+
.Name StrM Addrv.v City/Town State Lip
fo act on the +ru +rrtt owner's behalf, m all matters relative to work authorized by this building +ermil a + +hcation.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) '
(If N411jing is less thin 34.Uo0 cu. It.of vnaiuvsf. xe and/or not under Coro-fntctiun Control then cheek hen O and AugSccuun ILL 1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor �S
CD�S�n,c'�'u, �+• (o �SSo
Sumpan Name:
/-
�•M l �nn.•b\c o O17'^ �fe�ca-
Iyamq ttf Per. n Responsible rr Cunstroctiun License o. apd Type if App icable
L.1 +\L e ---, L< �6 ��1 u <-l') : 4 -�v-, �'0 L tom../ — _V 01
Address -- City/Town State Zip
4 �OJ
Telephone- No.(business) Telephone No. cell e-mail address
SECTION ll:WO V (M.G.L c. is2 2SC(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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(labor _
and Materials) Total Construction Cost(from Item 6) =f
1. Building f Building Permit Fee a Total Construction Cost x_(Insert here
2. Electrical f appropriate municipal factor)-f
3. Plumbingf
4. Mechanical (HVAC) f Note: Minimum fee.S c tact nicipalily)
5. Mechanical (Other) f Enclose check payable to
6. Total Cost (contact munici alit )and write check-nbilnber here
SECTION 13.SIGNATURE OF BUILDING PERMIT APPLICANT
l(v entering my name below, I her ebv attest under the pains and penalties of perjury that all of the ink,rmal,"n contained in this
applicalum is true and accurate fit the bed oh my knowletlge and understanding.
flea,e print and jgn name rifle rt•lephune No. Date
Street .\J.In•.. Of%/T,,tcn St.tte Gp
Municipal Inspector to fill out this section upon application approval:
\'ame I)air
CITY OFSALEM
PUBLIC PROPRERTY
T
DEPARMENT
12Z- A.Nif 11%1.:,INS I ii 1:1 T 0 "I.Al I M, M P)
I 11:1: # 1:%X:918.174-1 9846
Construction Debi-is Disposal Affidavit
(required I"or all demolition and renovation work)
In accordance %vith the sixth edition of the State Building Code, 780 CN1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit ft - is issued with the condition that the debris resultingfront
this work shall be disposed of in a properly licensed waste disposal I'acility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
(name ot'hauler)
I lie debris will be disposed of in
(nj=(5 iUi5ty)
o?16 Ro lit ad k) . Avint . KA
(address of facility)
S1611atuic of permit apt cant
/1.4
date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.1 V❑.K I lY DKISCut.r.
�lavOR 120 WAiHIN 7ION S'raet:T • SALEM,MASSMA It-spa ft s 01970
'rta.:978-745-9595 ♦ Pax:978.740.984E
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
i ilicant Information Please Print_Leeibiy
ValTte tliucincss/Or-,aniruioNlndiviclual):
Address: 4_7 eYSo✓n Aie
0197b Phone 7�1- 7411-a706
City,''Statc/%ip: SCE-Per'''1 m �L
Are you an employer:'Check the appropriate box: 'Type of project(required):
I. I am a employer with -3
4. Ela 6. ❑I am general contractor and 1 New construction
L�
employees fill undlur art-time).' have hired the sub-contractors
( P' 7. ❑ Remodeling
2.❑ 1 ant a sole pmprictor or partner- listed on the attached sheet. :
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
To workers' tom insurance 5. ❑ We are a corporation and its
i p. 10.❑ Electrical repairs or additions
required.] � officers have exa'ciszd their
right of exemption a MGL I LE3 Plumbing repairs or additions
3.❑ f nm a homeowner doing all work c�152, z 1(4),and w.have no
myself. [No workers' comp. `, 12.❑ Roof repairs
insurance required.] t employees. LNo workers' 13.0 Other
comp. insurance required.]
-Any applicant that checks box hl musl:dso lilt our the sectiml butuw showing(heir worked cumpemation put icy information.
' I lomeuwm:rs whu submit this alYdavit indicating they are doing ell work and Then him outside caumetors must submit anew affidavil indicating such.
-C,,nmac urs that check this box mucl aaachcd an additional sheet shusving IN name of the sub�contraoors and their workers'emnp.policy information.
l ant up, employer that is providing workers'c•ompensadoit insurance fur lily employees. Below is the policy and job.site
inforiuutian.
Insurance Company Vmne: (,G-f7Ca NQ-frQ»Lt- =rnccrCe-r'yC2�---
-- -
Policy#car Selr-ins. Lic.V: ......
. Expiration Date:
...........
Job Site Address: S if IOfetnee S� _ City/State!Lip: 1elGvs+ '�
Attach it copy of the workers' compensation policy declarnlion pi!ge (showing the policy mmnber and expiration date).
Failure to secure coverage as required under Section 25A of'vIGL c. 152 can lead to the imposition of criminal penalties of a
Fine up to S1.500.00 andlur 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 advised that a copy of this statement may be forwarded to the Office of
Investigations ul'the DIA for insurance coverage verification.
l do hereby certify under diet 'ns t id penolliez of perjury that the information pro videed ubave is true and correct.
St� tcaw I'll.wefi: F/y�/O /�7 q-1(�
2si01J
OfJiciul use only. Do not write in this area,to be completed by city or town ajJlcial.
CitvorTown.' - Permit/l.icensed__-._- _
Issuing:\ulhurily (circle one):
1. Ihtard of Health 2. Building Department 3.Cilyi fown Clerk 4. Electrical Inspector 5. Plumbing; Inspector
6.Other _-....._
Contact versun: Phone#:
Information and Instructions ,
Massachusetts General Laws chapter Lit requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be-deemed to be an employer."
N1GL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL'chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s),address(es)and phone nunnber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials .
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be Sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
towel."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Office of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised i-2ri-OS www.mass.gov/dia
�From: Rossman&Rossman 617 439 4434 08/11 /2010 15:40 #307 P . 001 /001
' co
n
Salem ist ricer Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT.311 FAX(978) 740-0404
WAIVER OF THE DEMOLITION DELAY ORDINANCE
It is hereby certified that the Salem Historical Commission has waived the Demolition Delay Ordinance for the
proposed demolition as described below, as per the requirements set forth in the Historic District's Act (M.G.L.
Ch. 40C) and the Salem Historic Districts Ordinance.
Address of Property: 5 Florence Street
Name of Record Owner: Benny J. Fisheries Ltd.
Description of Demolition Work Proposed:
Demolition of.single story, cinder block building.
Dated: 9/8/05 SALEM HISTORICAL COMMISSION
By.
L
THIS IS NOT A DEMOLITION PERMIT. Please be sure to obtain the appropriate permits from the Inspector
of Buildings (or any other necessary pen-nits or approvals) prior to commencing work.
o CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM. MASSACHUSETTS 01970
' TELEPHONE: 978-745.9595 EXT, 380
FAX: 978.740-9846
KIMBERLEY DRISCOLL
MAYOR
Section 116.0
DEMOLITION OF STRUCTURES
Structures over fifty 50 ears old must have
ftY( ) Y approval of the
Salem Historic Society,
UTILITY DISCONNECTIONS REQUIRED
Authorized Agent Date of Disconnection
Water
(see attached requirements) /L
Vf
Electrical
Fire
Health
Sewer
Salem Historic Commission S c e—
Dig Safe Number 2a o 32 0 i((.c
Pest Control:
***DOCUMENTATION OF ALL THE ABOVE MUST BE ATTACHED BEFORE
PERMIT CAN BE ISSUED***
Fee for Demolition $5.00 application fee plus $2.00 per 100 square ft gross area,
Minimum $25.00