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11 FRANKLIN ST - BUILDING INSPECTION y • The Commonwealth of Massachusetts 7 1, Department of Public Safety •r \la"0chu set is State Building Cade(.'So C\IR)Seven lh Edition City of Salem - - Building Permit Application for any Building other than a 1- or 2-Family Dwellin i (This Section For Official Use Only) Building Permit Number. Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block M and Lot M for locations for which a street address is not available) 11 6'l�r}� KI �%� S+ SRbew. MIA 01170 No. and Street Cite /Toyvn Zip Code Name of Building(it applicable) SECTION 2:PROPOSED WORK If New Construction check here O or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other Specify: PA-R�to vx la�A-(,l.S 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? f Yes ❑ No�, Brief Description of Proposed Work: t3wka pq-R.-� o- Le I+LL / i✓ I�e.t,rtcw,� 1�..3 Otis it SuJ r S ¢ n�w 'e 7 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): t• Existing HadInd r ex 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-I ❑ A-2r ❑ A-2nc O A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑ F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2 ❑ H-3 El H-4 ❑ H-5❑ 1: Institutional 1-1 ❑ I-2 ❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 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 ❑ JIB 7 IIIA ❑ [JIB ❑ 1 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 Flood Zone❑ Indicate municipalX A trench will not be Lia•med Disposal Site ❑ Private ❑ or mdentily Zone:_ or on site.% tem O required ❑or trench nr �peCifv: permit is endu cd ❑ - Railroad right-of-way: ` Hazards to Air Navigation: xl.\ I Ii. I,air 1 , nnni ii ni It,oi,:+ Pr, n Slru Clore icrthin.urpurt apF+i oath area' I. their iiviuv completvd' ur l n.cnt to Build enclosed ❑ Yes ❑ ,,r.No )en❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Gdilinn „I Code L,v Gnni L'I>l: frpc of(.unntrn1Ct1,in: Occupant I lead per Floor: 1)oe, the building contain an Sprinkler Sv.tem': Nff=5 SF+ecial Stipidatiuns SECTION 9: PROPERTY OWNER AUTHORIZATION N one and \ddress of Pro le wn tPAN�o2iC DLt1]/�7 i//1y > No.and Street - City/Town Zip Name (Print) // Property Uwnrr Conlac Into Ili ® ✓L laalciLel j �0/ By I�IAR176dGDf�f��7 1/- � ( ( �"`" �G f/eS Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property uw ner herebv authorizes Name Street Address City/Town Stale Zip to act on the pro pedv owner's behalf, in all matters relative hi work authorized by this building permit apill ica tion. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If buildin•is less than 35,000 Co. it.of enclosed s pace and/or not under Construction Con trot then check here 0 and skip Section III.11 10.1 Registered Professional Responsible for Construction Control w, ►\ ,P" P 9'936S- N: ke pis rant ` �Jt Te�F onee N�.�o� e-mail address Registration Number' /Q "T O r U Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name: Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. (business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.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 si ned Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item and Materials) Total Construction Cost(from Item 6) _$ 6�0Q 1. Building $ q O©C') e0 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ 3 00 o eo appropriate municipal factor)_$ 3. Plumbing $ Note: Minimum fee=$ (contact municipality) 4. Mechanical (HVAC) $ 5. Mechanical (Other) $ Enclose check payable to 6. Total Cost $ 6 ODa p0 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I herebv attest Linder the pains and penalties of perjury that all of the information contained in this application is truue annd0 apcc�u rate to the best of my knowledge and understanding. Please print and>ign name Title Telephone.No. Date 7trre•t \ddresa C it_%/Tutcn_ `;late Lip 7 �a e J� 5c-o�.b of qo Municipal Inspector to fill out this section upon application approval: \ame D- %lassachusetfs - Dcp:trtmcnt of Puhlic Saf, _— - Board of Buildin; Regulations and St:md (Itls Construction Supervisor License License: Cs ✓19385 Restricted �—�—_ WILLIAM R BOTTE' I 378 FOREST AVE SWAMPSCOTT, MA 01907 t ^mmiw'„ Expiration: 1122 10 nrr Tr#: 10714 i _ CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT - \I 11 I< 120 A'AiIIINGIONSTI<EFT ♦SAI f\I, ` ASI'At I IIII.I-IS jI'I%l. TrI:'178-74iA3Y5 • FAX:978.7401984t, 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 N -- 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: Alntt S(wtee_ iJcs�osfrL- (name of hauler) - The debris will be disposed of in (name of rani (address of facility) -0 signature of lxrntit applicant a 1 slog _ (late T CITY OF S.U-&N[g 2%L-ksSACHUSE- TS BL'IIDLNG DEPART%LF.NT 120 WASHINGTON STREET, 3w FLOOR TEL (971) 745-9595 FAX(978) 740-9846 IV,BERL EY DRISCO[l VSAYOA 1� omsST.Pmm - DIRECTOR OF PL BLIC PROPERTY/BLRDLNG CO%L%USSI0%ER Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers >nollcant Information t Q Please Print Letiblr Natne (dusimc Organization,InLbvtd"): W 1 \�cq t"t f, Imo Address: 319 ryr ,e_r, I City/State/Zip: 5,-0t,R sc-o++ On& Phone s: 9 79 S18 s8'o 0 ,%re you to employer?Cheek the appropriate boa: Type or project(required).• 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).• have hired the subcontractors 0 am a sale proprietor it partner- listed on the attached sheet : ?• ❑ Remodeling .hip and have no employees These subcontractors have g. ❑ Demolilion working for me in any capacity. workers'camp.insurance- 9. ❑ Building addition I No workers' comp. insurance 5. ❑ We are a corporation and its required.) officers have cKercised their 10.❑ Electrical repairs or additions 3.ElI am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.[\o workers'comp. c. 152, 41(4),and we have no 12. Roof repairs insurance required.) t employees. [No workers' 1, o❑G�a s dos �[ comp. insurance required.) � 'Any applicaad that cheeps Dos 01 must also rill wr the scoriae below showing their'vorhes'campensatfun pulicy information. 'I I,vneuwrtas who suttrnit this affidavit indicating they am doing all work and then him o saide o rmcsem~submit a now amdsvit indicating sut3 T,wimcmn that cheek this Den mud attached an sdditi,ad.hens showing den nine of rhs sub-eontnsebe and tbek wuhrm'comr.pwicy infomuuat. l am an cosp/oyer that/s providing workers'rompetassdan Inturenee for my employees Below/s the policy and fob lisp information. Insurance Company Name: Policy 4 or Self-ins. Lic.N: Expiration Date: Job Site Address: City/Statc/Zip: Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration slate). 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 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$230.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the OtYtce of Investigations of the DIA for insurance coverage vcritication I do hereby c and r t r pat' s and penalties of perfsay that the infarmmloar provided above is true and earrr6 4_n ttur0: r Date: � f ••��,,frr���„ffr������ Ph one A: 1 7 8' T 06 iD)T1clal use only. Oo not write in this area, to bat completed 6y ratty or/own oJflefrL I City or ruwn: _ Permit/1.1cense0 hsuing Aulhurily (circle one): j I. Iluard of Ilrallh t. Building Department 3. City/rown Clerk 4. Ftectrical Inspector 5. Plumbing Inspector 6. Other Gnuacl Person: _ _—. _. Phone N' IVlalll LCVCI 0'B" 70' 6 5[oram Wall height 7'6" 1d'r 55'10' T 310' m 15' « Hall 3 e' Y 3'6' Basml 6'8" F>B v d'8' � Bn¢a13 9Ra (11 r U—L fxs not Fxl+t nn3 13' l� Moln Level SERVPRO9692-OP4 8/31/2009 Page: 2