11 FRANKLIN STREET- BPA B-10-210 "Building
The Commonwealth of MassachusettsDepartment of Public SafetyMassachusetts State Building Code(780 C\IR)Seventh EditionCity of Salem
Permit Application for an Building other than a I- or 2-Family Dwellin
(This Section For Official Use Only) ,(
Z Building Permit Number: Date Applied: Building Inspector:
f i
SECTION 1: LOCATION (Please indicate Block M and Lot M for locations for which a street address is not available)
;�-•' No. and Street ! / tr C'il�• /To%,,n s-•A6 PI Zip Cud" 0/9'7o Name of Building (if applicable)
Tom/ SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that appl y in the two rows below
Existing Building Repair❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out a"AppendixChange of Use ❑ Change of Occupancy O Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permitapplication?Is an Independent Structural Engineering Peer Review required?
Brief Descri lion of Proposed Work:
1
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): p
Existing Hazard Index 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-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-i❑ R-2 ❑ R-3 ❑ R-4 ❑
S: Storage S-I ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ JIB IIIA ❑ IIIB ❑ 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 municipal ❑ A trench will not be LicenseLID,, osal Site ❑
PI vah•❑ or indenlik Zone: nr on site s%stern ❑ required ❑or trench "I'pecity:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air.Navigation: \1:\ Ili1,,tt( ,nnini*�ii n Rroi,,� I'n•,
- \•d :\I•pliiat,le ❑ I.SlniCture rnlhinairportapproach• t,j, I+ their rev iew aanplek•d,
111 ( .m1111t lu Build cndo.ud ❑ Yes❑ nr.No❑ Sr> ❑ \n ❑
SECTION 8:CONTENT OF CERTIFICA FE OF OCCUPANCY
IGdiwm of "dv: C,r(�ruuplsg rape of Con.trniCtn0n: occupaot Load per hour:
I)ov. the building Cnnla um un Sprinkler Sm-.0.vn': Special Stipulations- .
�� Gold
SECTION 9: PROPERTY OWNER AUTHORIZATION
-Ny�me.in I Address of Property Owner
Name (Print) No.and Street City/Town Zip
Properly l %%ner Contact Information:
%lac% 090c ——
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner herebv authorizes
Name Street Address City/Town State Zip
to act on the property ore ner's behalf, in all matters relative to work authorized by this building permit a ppIica lion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) �t
(It building is less than 35,(k)O cu. it of enclosed s pace and/or not under Construction Control then check here O and skip Section 10.1)
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
Cu. anytNa e:"�D� d 3. S Z
y L.cX. s—
'c T A
Name�f Peon Re�msib)e for unstru ion �'y L� ense No. and Type if Applicable
,Sir eYtt ldclress City/Town 1, State Zip
Telephone No. (business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE Al-NDAyii,(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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item Total Construction Cost(from Item 6)_$
and Materials)
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $ Note:Minimum fee= (crmract municipality)
4. Mechanical (HVAC) $
b. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ S. (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name bej1Pw,, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true�Anaccur, e to the b n of y k uwledge and understanding. —
Title Telephone No. Dale
Ple.tsc print and sign name —
street Address ( ity;'T'm'n Site Lip
Municipal Inspector to till out this section upon application approval:
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The Official Website of the Executive Office of Public Safety and Security(EOPS)
Mam.Gov Home -
Public Safety
Department of Public Safety Licensee Complaints
Liceaee Type construction supervisor
Liceme 0 35169
11"trictioo 00
Name Richard B Goldberg
City,Smte.Zip Beverly,MA,01915
E.piratioo Date 3/3/2010
Stann current
N.cumpininu round for This Licensee,
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CITY OF S.ULE.`I, NLkss.AcHusETTS
BI:ILDING DEPAR'f1tEINT
I?O WASHINGTON STREET, Ye FLOOR
TEL (978) 745-959S
F.ax(978) 740.9&M
KI,IBERIBY DRISCOLL
MAYOR T� o&L%sST.PIEltlts
DIRECTOR OF PLBLIC PROPERTY/gl'QDLNG COMMISSIONER
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers
Anplicant Information Please Print Letiblr
Nalne (Busin orpnitaiiontlnddvedual):
Address: —7 Xa-�-1 LL
City/StatdZip: �� "j Phone M:
Are you an employer'Cheek the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and I
employees(full and/or pan-time).• have hired the su&connacmrs 6. Q New cdmatructiao
2.❑ 1 am a sole proprietor err partner- listed on the attached sheet : 7. ❑ Remodeling
ship and have mt employees These sub-contractors have I. ❑Ikmolititm
working for me in any capacity. workers'comp.insurances 9. 0 Building addition
(No workers'comp. insurance S. 0 We are a corporation and its
requited.]
ofAcm have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workeri comp. C. 152,41(4),and we have no 12.0 Roof repairs
insurance required.)t employees. LNo workers' 13.0 Other
comp. insurance required.)
•Any applicant this dtecis Dot el meat alws fin stet the atria below showing their workm'comprnsadwd policy information.
'I Isestcarrea who submit this anldsvfrindicating[hey ant doing all work and then him ovoids comracton oast suhmir a new,aflTdsvil indicating such.
:C,,nim"n that cheek this has mug attached an asldidiwd shed showing dta invor of do Ntfcaatraetwa and that#workeu'corny.policy inrormatim.
/um ox employer that/s providing workers'Tompeatadaa lnsaroaer for my swrpley"A Bill I the po!!cy awd Jos Siminformadon
Insurance Company Name:
Policy N or Self•ins. Lie.p: Expiration Date:
Job Sire Address: City/Staw/Zip: _
\ttach a copy of the workers'compensation policy declaration page(Showing the policy number and expirsNon date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of■
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 m S250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
I it vcnn gations ol'Ihe DIA for insurance coverage vcri citation. -
/do hereby Terrify under rha peixs surd penaldes of perjury that the informarlow provided above is true wad correct
�i_riat a rc: Dare:
Phone A:
iOfficial use an/y. Do nor write in this area, to be curnpleted by city or rows a/JkirtL
City or ru%vn: Permit/Llceme
suing.\ hority (circle _-
I ut
I. Board of Ileallh Z. Ruildlnu Department 3. City/rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
b.Olher
'Lunlact Person: _ _ _ __, ___ Phone p: