7 FORRESTER - BUILDING INSPECTION 1
ga coo
The Commonwealth of Massachusetts
.jt
Department of Public Safety
i\Iassachuselts Slur Building Cudr(780CIll
..,.,.:�
Building Permit Application for any Building other than aOne-or TwrrFamily Dwelling
(phis Section For Official Use Cob)
Built ing permit Number: Date Applied: Building Official:
SECTION 1: LOCATION (Please indicate Block#and Lot#for locations for which a street address is not available)
-- or j Par^ _�i,�Phn /9 /ll
�i 7 d -No.and Street City/'town Lip Code Name of Building;(if applicable) —
SEC•1.ION 2:PROPOSED WORK
Edition of NIA State Code used If Nov, Construction check here❑or check all thal apply in the two rows below
Exisling; Iuilding❑ RepairrX Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Changeofoccup,lncy ❑ Other ❑ Specify:.__
Are building plans and/or cunslrucliun d+x'uments being supplied as part of this permit application? Yes ❑ No er
Is an Independent Structural Engineering P.. Review required?q/ j Yes ❑ No,07
Brrief Description of Proposed Work: /fJPPl1/✓2 hr
A4'l h ✓ �
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDYEION,OIL
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CNIR 34) O
Existing Use Group(s): Proposed Use Group(s):
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-2❑ Nightclub ❑ A-3 ❑ A-1 ❑ A-3❑ 1 B: Business ❑ Eo Educational ❑
F: Facto F-1 Cl F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ 1i-5❑
1: Institutional I-I ❑ 1-2❑ 1-3❑ hi❑ M: Mercantile❑ R: Residential R-10 R-2❑ 11-3❑ R4❑
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 ❑ HA ❑ IIB ❑ ILIA ❑ iiin o IV ❑ 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 19ood Lone❑ Ind kale municipal❑
A trench will not be Licensed Disposal Site❑ -
required ❑or trench or
Private❑ or indrntily Lonr: o or n site system ❑ permit is enclosed ❑ ____
Railroad right-of-way: Hazards to Air Navigation: \I , I�;�L;n, ' . ,;,,n, , I• •
Not Appli,ablr❑ Is Structure within.firpo ac rl approh area w? IS their rvvtv a niplood.'
or CIMS011t to Build rn,losed❑ 1 ins ❑ or No❑ Yvs❑ No ❑
SECT ION B:CONTENT OF CFRTII:ICATE OI'OCCUPANCY
Edition of Code:- CSo(Jroup(s). _ I\prof Construction: 01,up.mt Load per Ilooc
Loos the building,ontaiu,to Sprinkler system r.___---___Special titipulalions: - -. ._ -_-..
SECTION 9: PROPER IN OWNER AU I 11ORIZA77ON _
Name Jod ddiess ul I operte Ownrr
f ✓i��
Name(Print) No.and Street City/Town Zip
Propel t}'Otc tier ContaetInformation:
Title - ------- Telephone No.(business) Telephone No. (cell) a-mail address
II applicable, the property owner hereby authorizes
Name Street Address - -City/Town Slate Zip
to art on the property owner's behalf, in all matters relative to work authorized by this buildin• permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildin•is less tknp 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
�2 U-.fir o i 7
N� nc(Rc pep one No. e-mail address Registration NumlxZ9
Street Address City/Town State Zip Discipline 9xpirdion Date
10.2 General Contractor
CO
Coll] )all), Nape
Shvdie of Person Responsible for Construction License No. and Type if Applicable
� oa jWC�7 a qZ&
S reet Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11: Iei'I:F.17:91-i.ttpil'b_`E,:\tlt p� h�':=U i::\.V<'b::\r H 0,\pll_ M.G.L.e.152. 25C6
A Workers'Compensation Insurance Affidavit from the NIA 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 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
? Electrical S appropriate municipal factor)=$
3. Plumbing $
Note: N
+. Mechanical (HVAC) $ tinimum fee=$ (contact municipality)
3. Mechanical Other S Fnclose check payable to -
6.Tidal Cost S Sj Q Q (contact municipality) and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby atlest;Trpder the pains and penalties of perjure' that all of the infonnntiun asttaincd in this
application is true and acnlr,lt0 to the hcs of rep' napvlcdge and understanding.
Axvo-RQDL�_ �v�Pre —�- .3� 7D6S
Please print and sil;n name Title Telephone No. Dale
IVA
tilreet Address City/Town ----- Stale Zip
y�
Municipal Inspector to fill out this section upon application approval: 'T+/4. `'�"� /___,
Name Dale
�.• i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
�1111.n�Ir ,nlxr•u
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1!.IVAIta.%uw.v llxCYT • S.IUN. M,1».u.ut a I nine)'.
► orkers' Cumpenaatlon Insurunce "Iduvitr UullderyCuntracturVEle tricI nyPlig Wr
i tlicall farun...is
1 V;IInC t Iluahlvtl+baanr In 'hlrJlinrvinJrvlJuull:
li ddre.a.v: !C
Cily,Star %ip Phone
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.t ry 1 uu an vuly,loya"Cheek the I appropriale bur:I� I ins a vmpluyvr with f _ 4. Q I;,In u jenenl cuulrxlor and 1 IyM orproJvct(rvqulrrd);
'•❑ aniyluyceY(full und/ur pill-time).• huvv hire)the.vub•aimraetuy d' ❑New ctustrucliun
1 am a Sala pmprictor or panner- listed-in the inachetl.fhcct t vllip an,1 have no w" lu vas �• ❑Reinodelin�
cork As lilr inm in any cipaeily, workers'
Jubmnnptanytours have
a e
M. ❑1)tmolirion
(fle workers'vamp. insurance J. ❑ We are k caparstion and its 9. ❑ Dulwinr dddilitln
nyuircdJ og)leen havo vwrcint'd their J'❑ 1 um a hunncuwner Juing JII work right of seem vino 10•Q Eleerr(cal repairs or additions
myself. lx•o tcnrken'cunt p per Mcm 11.0 plumbing ropuip ar additions
p• C. 152. 41(4),ins)wit htivd no insurance rcyuired.J r cmpluyeen. h'o workers' 12.0 Ruufrepairs
''1" ' hcYe urW vhccYa Yes nl m en111tk IltburantY M4uiK9l.J 13.0 Uglier
r'•'n un Jlw xll tux IN wcuan mlor
'Ilan�lrrwrrte vkY awnh/this smalevit IIulkJrin 1 Jwrine lksir,aynYui vurlarert�Wkna indivy mriunrl;WL
'(•Mimh"rhsl ckc'vk rho hY roan YravArd•M aeJkitry us Jwne ill.fart Intl thus him"side euurnsh n n
ksyl.k*Jtuwine 1M nand side su►*o n "•'w%dri a trsw tlnaevil irrJiaseine vh'Y•
/run tool e/rtpleyer rhos It previd/nX nvurbrs'ru/nOrnmNon Juranurce/nr/thy e/r� Ind dw r,Ykas'cony.ryJKy mlbrnran,r
iu/YnnurAna p/ Yrq i9d0
1
1,
/i Mil pu/hy una//u1 xil�
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Inaurancc Company.Vmno: /G✓r_ .
1'ulicy M ur SYIf•ins, Lic,tt: — -
Expir4rlon D;Ite:�_
Jub Situ
.Yuach n cu City,Sidle/Zip: .
py of the werkan'eumpunsatloe pullvy Jvelurullun pugs(showing the policy nunlbur and utplrarius dare),
I+Jlluru to weure cuveruye Ja required uuJer Seaiun?JA ul'.►IOL e. I J2 coo lead to Ihd inn
'the it nl S1 w, J y Vur Idailune•yea impri.ranment• Js well J.acivil Iwndhivs in the lurm ul'a STOP 1VURK ORDER and a fine
Jfup rn ilJO nth d JJy.IYJIIUI Ilse viulalnr I)c advi.ti•d that J cu position oferiminal yeneltiy oI'a
Inv..fnl�Ju'us al'thu UI.► :br inf ur.u'cv a,vcrJ3v\ci iliv.tuutL pr°f IhlY.xutemcnt may 6e Iurw JcUcd to the Unice al'
/,/Y hereby t cnt/y amiss rl ins IrffJ/nth dHet v pr//ury/but the ill l urrnYr/on
p:1.. • reridet l agars is slue lull/ronecR
I
rJ%/leiY/,/rr ton/y. /)o nor Irrire in rhlr area, m de runty/caJ dy wiry ur/also a//IriuL
1
1 (ilv ur I'mriv: _
Lf sing .\ulhurtl 1'vT'nif/Llhmre s
y (circle nosh
I. Ilr'JrJ of IIe.Jth 1. Iludlhoy Ikpdrtmenl I, l'll1.'(unn C'(erk J. L•'IcevricJl ilia IcrNr i,
6. Oihrr
I Phunbiny Inayccror
t'•nl.tct I't nun:
I'haov 17
f I_y
information and Instructions
�Lte;.tehu,eus t.,icneral Laws chapter 132 wqutres all eugtloyers to provide workers' cmnpensder Her their c, of hires.
do tin foret is joined as _every pee+on in the service of mother uu,ler any.Jntnct of hire.
I`u r.u.utt to tilts,latutt, P
.press Jr unpljQJ, Jral Jt written." or lilytwo or more
the le 1 rOrtfenra gives of 1 dectasOJ entpluyO4 or the
�e e,rrplupar t+dclincJ as"an mJividual, purtnenhip..tssoclanoa.corporation ter other Icg,al cntiry,
wM enterprise. and itulJJing tW la to vm la)'ees. Hawcvcr the
t the t;xegwng engaged m a i tatioa Or other legal entity.a therein.
Y { ' P of the
ecerver or trustee of.in individual, pntmtershtp,Assoc
Owner of a dwelling{house having not snore than three apamnante and who resides dtereair or the oecu
Jwelhng house Jf another who employs pa non'to do tnainsnuncr,cunvuuctiun Jmeni be Jc cj cm ��btJ naetnployer
or on the grounds or building appurtenant thereto shall not became of wch emP ay shay withhold the Iswsaa or
-,IGL chapter 152. 425C(6) also states that"every slate or focal tlrucl b g dings i
renewal of r Ilccas@ at P Ilsaee wily the Insurance coverage required:
permit so operate a buslseu or to eosssruet buildings la the commasweultY or as
table evldoaco of comp of iu olitical subdivisions shall
nppllcsol who has not produced�SClvl,hulas"Neither the commenwcahb nor any D
Additionally, 1,IGL ahupter 1 S., S- ublic work until acceptable evidence ofcuntpliwwe with the insurance
enter into any cuntracs tut the perforotanct ul'p
1
raquirem.nls of this ahuphsc have been prt+enteJ to the contranin{authority."
Aypgcarra checking the boxes that apply to your situation and,if
ensation a111davit alga)completely.dphne number(s)along with then urtiticute(')th
Plcase riOf
ll out the workers' comp dd1.1111 P LLP)with no employc�re usher than the
necessary, supply rub eontroctor(s)nrrrtals), have
insurance- Limited Liability Companies(LLC)or Limited Liability partnerships( ant of industrial
insurance or Limited
Lers, are not required to carry workers'compensation insurance. If as LLC or LLP Boar
inembdcniplOYae',u policy is required. 90 advised that this alildavit may be g"slid d to the wflidam
eo coverage. AI'e be sure to sl{M slid Jute IhenI the t)'pastmanThe all1davit t ufw
%ccidens for confirmation of iNuran licatioa for the pantrit as license is being requestedto obtain a worker''
ha rclurtteJ to ills city or lown.th�uh+a an gmstions regarding the low or if you are-insured
co ies should enter their
Indusuiul Acuidans. Should y utarusis aIt ho auto ber listed below. Self insured companies
cutnpamstiun policy please call the Dap
.elf insurance license numbs'o t the a ro riate lira.
(:lty or'rows O(flelsls The Department has provided u space at the buttons
tined k ably. P the applieann,
a
r1casa he sort that the affidavit is n the 4%ta and p Beam
�uf dta aifidrvis Por you to till our in the avant the Olita of Investigations has to contact you regor rig
liconions in any given year,need only submit one atgatiu t ittdicmin{current
Of th a ig sari to r Y in the permiNicenxs lumbar which will be used as a reference lumbar. In addition.is applicant
Hutt moat submit multiple pennio1i id tinuld apP �J or marked by the city or town may ba provided to the
policy lufa tnwiun It necessary)and under"lob ;its Address'the applicant.should write"tell IJcuniuns in Y
tuwnl."A COPY of the u1ndaeach
vit that has been orflegslly ssmp'
applicant as proof that a valid at is on file for hrture Permits of licenses. Anew ttilJsvit must he Illled out venture
applicant
`'here a hums owner or citizen is obtaining a license or permit not related to any business or cortrnterei, vanrrw
t i.e.. dug licen.+s a permit to burn leaves cto.)said persot is VOT regYfraq riiatmpi aieJhl uulJdy a ha.O ,,ny yuesuons.
Ices¢do nut hasitatsto iun* would ll a to think)au in advance Fury P
nc� U,parnnent's dddrets, telephone it'd The Commonwealth
fan number wealth of Massaehusatu
Depuanent of Indlutsial Accidents
011f ce of Isvad4adons
600 Washington Street
Boston, MA 02111
rel. N 617.727-900 6CXt 17 702 o77d9"•MASSAFE
www.maw.gov/die
r .
CITY OF S.U&M , ASS.ICHL'SETTS
SULDLNG DEPARTNtENT
110 W-AsHLYGTON STREET, 3w FLOOR
TEL (978) 74S.9595
F.Vc(978) 740-9846
KIJ®F,UEY DRISCOLL
MAYOR T wmu ST.PtmRAit
DIRECTOR OF PLauc PROPERTY/HCIIMM;COMMISSIONER
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 l l 1.5
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 debts 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
Lhn. l(,Lc