9&11 FLYING CLOUD, 2&4 GRAND TURK WAY - BUILDING INSPECTION The Commonwealth of Massachusetts
1'•d Department of Public Safety
/� 1� �;,,'��„j \la..a,tchux•tl.State Bwldinh Cotle(780CNIR)Seventh Edition
e f!l OL City of Salem
BuildingPermit Application for an Buildingother than a 1-or 2-Family Dwellin
(This Section For Official Use Onlv)
Budding permit Number: Date Applied: Bulling Inspector:
SECTION 1:LOCATION(Please indicate Block N and Lot 0 for locations for which a street address is not available)
No.and Str t Cue /Town Zit C.xle Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here Oar check sell that apply in the two rows below
Existing Building Repair Altemtiun O Addition❑.. t7emolition ❑ (Please fill out and submit Appendix 1)
Changeof Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 0/
Is an Independent Structural Engineerin r Review required? r n Yes ❑ No Gl�
Brief Descri Lion of Proposed Wo k: - ''�
P514 c
Meat ad 0 i
aE.
CTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O
g Use Group(s): Proposed Use Group(s): r
g Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
rea(sq.ft.)and Total Height(ft.)SECTION 5:USE GROUP(Check as a licable)
sembly A-1❑ A-2r ❑ A-2nc❑ A-3 0 A-4❑ A-5❑ B: Business ❑ E: Educational ❑
to F-i ❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
itutional I-1 ❑ 1-2 ❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
rage S-1 ❑ S-2 ❑ U: Utility❑ - Special Use O and lease describe below:
l Use:
SECTION 6:CONSTRUCTION TYPE(Check m applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ 11100 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR I11.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
:\trench will not be Licensed Ui>fxisil Site❑
Pubhc❑ C heck ri outside FI...•d Zone❑ Indicate munta pa)❑ required O or trench ca f v:
1'neate❑ .+r mdenuA Zane:_ or nn site>%stem❑ permit r.enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \L\ ( .nn+.•......l<,. ... Pn•.o�.;
\,rt Applicable❑ Is Stnicnure+uthut auport appn,.ich area' Is the.r,C%1ew onnpdrtod'
•n tuns:nt to Budd end...vd❑ }es❑ ur\n❑ Yes❑ \o Cl
i
SECTION 8:CONTENT OF CERTIFICA FE OF OCCUPANCY
L,idnm d dude _. _l.c lavup�.r _ i�pc ui lun.t nr:cure tkarl+ant !�.ad per li.�.�r
IA•v.the buildu.�;:.main an Spnnklrr}ti.a•m': >tti•c ial Sbpulauuns _
SECTION* PROPERTY OWNER AUTHORIZATION
N e m+ \ddress of Pro •rn•(�avr2rr c '
Name(Print) No.and Street C itv/Ttmnp Lip
Pnokx±rh•lhVner Contact lnturmatlun 7 OD /f���/ �y� /9,7.� -r�A_,•,r,A ,d �f1"-^(/i/7f�J/r i Wes/
A / /J M
I n�s.+
Title Trirphonr Nu.(btts+naz.) Telrphamr No. (Cell) r-mall add
If a++licablr,the o
•n+ ly owner herebv authorizes
► E`e r O
�3&zriFz
Name _ Street Adds City/Town State Zip
to act on the +ro •rty.nvner behalf,m all mattes relative it,work authtmzed by this,buildin•permit a+ licatiam.
SECTION to:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(if build' is lava than 35,W1 cu.(t.of cnCl,vW: v snot/or not and v C,",uw'tion Comiml then check here O and skip Section IU.I)
10.1 Registered Professional gespomitile for Construction Control
e-mail ddrs Registration Number af�f�f4$F-t
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cum a Name: ��
itze �M////�.9� fLy
Name of Person Responsible for Construction ucense m rid Type if A 'table
d
y13 (jq� '3A 9-3Z1 ' Ap .LIFT
Telephone No.(business) Telephone No,(cell) e-mail address
SECTION 11.WORKERS' SAnON INSURANCE AFFIDAVii(M.G.L.c.M j 25C(6)1
A Worker'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application Failure to provide this affidavit will result in the denial of fhe' rice of the building permit
Is a signedAffidavit submitted with this a IicauonT Yea No O
SECTION 12.•CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(labor
Item and Materials) Total Construction Cost(from Item 6)=S 7
1.Building S Building Permit Fee=Total Construction Cost x_�(insert here
2.Electrical S appropriate municipal factor)=$
3.Plumbing E
NoteMinimum fee=E (contact municipality)
4.Mechanical (HVAC) E
5.Mechanical (Other) S Enclose check payable to
y Total Grit E 1,4K 4 (mntact munici li )and write check number here
SECTION 1 •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 cuntiuned in this
application is tnie and accurate to the best of my knowledge and understanding.
1'1 + pn and m nam fitly iadcphunr No. Uate
wvvt Ad lres, avn ate Zip
j >funicipal inspector to fill out this section upon application approval: I
V
a
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
U1V wwwanass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciaus/Plumbers
Applicant Information Please Print Legibly !`
Name (Business/Organization4ndividual): 6&z4z—
Address:
City/State/Zip: Phone#: a
A,r_,e_,y/oy,an employer? Check the appropriate box: Type of project(required):
L Ltd lam a employer with—_ 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).` have Lured the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner- These sub-contractors have
ship and have no employees 8. ❑ Demolition
employees and have workers'
working for me in any capacity. 9. ❑ Building addition
[No workers' comp. insurance comp. a corporal
required.]
S. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
_. comp. insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_
e
Policy#orSelf-ins. Lic. #: A/yaam/aU/D Expiration Da te:cyY�y/'G / a1z
JobSiteAddress: .27 &1 M/ 6ocity/State/Zip:Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations- of the DIA for insurance coverage verification.
I do hereby ce jy u der the ai6sanpenalties of perjury that the infor ation provided above is true and correct
Si ature: t e: —
r
Phone#:
Official use only. Do not write in this area, to be completed by city or town offtciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
f
Suggested Affidavit for Home ImprowmOuat^Contractor Permit Application
Fur omcc the otdy - J "�r/NAME OF CCCYfrOWN
revolt do
a.te
AFFIDAVIT
home Improvement Contractor Caw
Supplement to Permit Application
MGLa 14IAroquua that the teeo mclion &Iteration rce tion trnai asodcrmfvation eonvicesion.inprovcnxnl.rcnw.al;dcmoli
a eonutuction of sn additle to may rx ,cdstinc ouoa-oon VW build' ooatai;c&g st lost am but"mac than fourdwdhng units
. - to siruaurrs which sm adiaocnt to sans t idct= bmdiat be doac by Mmacd c (Maors.with=rtajn atacptionss..�sl�g with c
rcquircmcnts. I /y C— �I
t ` Est. Costr7 ((!('�� 3'
_ 7ype of WOric J /�
Address of Work 6 /lam/, fin/
Owner Name
Date of Permit Application
I hereby certify that:
Registration is not required for the following feasott(s):
Work excluded by law
_Job under$1.000
Building not owner-occoled
Owner pulling own permit
Other(spedfy)
Notice is hereby given that:
OWNERS PULLING THOR OWN PERMIT OR DEALING WrM UNREGISTERED
ECONTRACPORS FOR APPLICABLEHOME IMPROVEMENT WORK DO NOT HAVE
4 AOCESS TO'I'HEARBTIRATION PROGRAM OR GUARANW FUND UNDER MGL
4 c. 142AA
Signed under penalties of perjury:
I hereby apply for a_ i as the agent f th en
Date mractor Name Registration No_
0
C
OR.
Notwithstanding the above notioc; I hereby apply for a permit as the owner of the above property:
Date Own"Name
CrIY OF S1U ENI9 NLXSSACI- USE-rrS
° B1:u.1DL%G DEP j m%mia"T
41 4
4 120 WAsm%4GTOAi STREET, Yo FLOOR
TEL (978)745-9595
FAX(978) 740-9M
KIMBERLEY DRI.SCOLL
,I�fAYOA THo"ST.PIERRz
DIRECTOR OF PUBLIC PROPERTY/BvMM%JG COMSIISSIONER
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# 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:
�f3b4k/'0 011/z � 7
S ,�oSS egiE , 0,:;-78.0
(name of hauler)
The debris will%�os o of in
009b
(nadnc of Facility)
(address of facility)
kzI c
signature of permit applicant
o% �o
� date
•kbnaatr.kic