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13 FRANKLIN ST. BPA B-11-793 The Commonwealth of Massachusetts Department of Public Safety \V � NIaSSOChnSCttSStatcBuilding Code(780CNIR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 13 PA4 et/ti A p 01,40o s(T r-O©D No. and Street City /Town Zip Code Nance of Building(if applicable) SECTION 2:PROPOSED WORK Edition of NIA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building Repair❑ 1 Alteration Addition❑ TDernolition ❑ (Please fill out anal submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:Are building plans and/or construction documents being supplied as part of this permit application? Yes H - No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No U-i" Brief Description of Proposed Work: r /AICL -, SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 31) ❑ Existing Use Group(s): I 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-i❑ B: Business f3' E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-1❑ H-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-1❑ S: Storage Sl ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use. SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ 111) ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑ 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: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ require ❑or trench or specify: Private❑ or indenlifv Zone: or on site system ❑ permit d 0 or t e ❑ Railroad right-of-way: Hazards to Air Navigation:. \L\ I Lqn 1,-,u i lo-Ii ......,,: Not. ❑ Is quo, um within airport approach area? Is their review completed? or Consent to Build unclosed ❑ . . Ycs❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Iiditiun of Cudc: Use Group(s): 'IN PC of Construction: Occupant Load per Floor:_ Does the buildinf;contain an Sprinkler S\'stun?: _Special Slipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address Of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑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 Company Name �t Zee C ,4P-L 1,-11 %'d CS - 70bV3 0o Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 7d J1 —Telephone No. business Telephone No. cell e-mail address SECTION II:w'OIa:hIS'CiIkIPG.NS;\I10\ INSURANCJ.AFIIpAVI I M.G.L.c.152.§ 25C6 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 13 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ �a d 1. Budding $ ) 0 0© Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ a appropriate municipal factor)=5 - 3. Plumbing $ 4. Mechanical (HVAC) 5 Note: Nlininmm fee=$-(contact municipality) 5. 1.Icchanical Other $ 2� p Enclose chc'<k payable hp 6. Total Cost $ % 60 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my mane below, I hereby attest under the pains and penalties of perjury that all of the information contained in this nppl' on is tru°and accurate to the best of any knOwledge and understanding. Please print and sign name Title Telephone No. Date Street di� City/Town ate Zip Municipal Inspector to fill out this section upon application approval: t ame Date CITY OF SALEM "*' ' `r PUBLIC PROPRERTY DEPARTMENT N%Itm 12C.WASHM;It^$I a EL•I*a $.\llt.\I, Ihi.:'/)14713-9395 to 1:%x. 97MJcC•'+sM Workers' Compensation Insurunce Builders/Cuntracturs/Electric(ans/Plumben %yol(cant Inronnrt(onPrent LeelAly Vi1111�Ilhnutetir)rgantrarintyloJlv�duull: ( �/� `. G��.->,dZ7 City,Slam Zip !Vj � T�/!� _, I hone il:.ore)lau an employer'!Cthe approprldle box: 'Type o/pnlject(nyulnd): 0 1 ;ml a umpluyur wit4. ❑ lain a general coutraclor andemployees(full and -time).• have hired the.sub-cunlracturs /'. ❑ New Construction 2.0 I am a sole proprietortner- listed an the anaehcd sheet. : 7• emodeling shipand h ale no e+ns These sub-contractors have d. 0 Demolitionworking filr me in aacity. workero'camp, insursnce.I No workers'comp. c6 5. 0 Wa arti a cotporstinn and its �' ❑ OuiWing udJitiunrequired.) orttcers have exercised their I0.0 Electrical repairs or additions 3.0 1 ion a horneuwncr do work right ofexemption per bIGL 11.0 Plumbing rcpuirx or aJditinna+nyself. (No workers' e. 152.§1(4),and we have noinsurance required.j t .anpluyccs. (No workers' 12.0 Rout'nprincomp. insuranw nquin-1 13.0 OtllerIGaI chucks boa el m Jill out the vrdlJn twluw dwwlnx ttr w _ 'I rotnunwnan who sullmir this aflWavit indluliaa Italy ate doing ill work and aim wisida cal moon mug.u'hatir a am al'RJavil imlic ding wuh• •r,mtnvuwr tha ehvxk this bar mitt anxhed an addiii, wl..hwr.Mrwillv the nanleornle tua.emrxlen and thew workm'comp,ptlhcy moameadua. /floor un elnpleyer flout h providing lalerkera'ru/npenoallon 11Ltalrimreefor my erop/gyeer. Bdnry is the pal/icy mild/alb.cih in`mtYnutinlL Insurance C'ontpaay Name: 1'nlicy a or Self-ins. Lic.it: - _ --- .-- . .. _ Expiration Date: Job Situ -Address: clipslale/Zip: Attach it copy of the workers'cumpumatiun pulley dectarutlun puke(showlnp the policy number and csplratlun dote). Padur:to wcure coverage as required under Suction 23A ul'JIGL e. 152 can lead to the imposition of criminal penalties of a tine up ran S LS110.r>n and/or wIa-year imprismmncnt, Js well Js civil penalties in the form of a STOP WORK ORDER and a rate* of up to S250.00 a Jay.Iguinat the violattle. lie advised that a copy orthn slialcinent may be lur\vardcd to the 011ice uC LI\'�-NIIVnrllis ul Ihu DIA ler to,isciliec poverJ.L' %%:I it0.Allon. /Ju h.•rehy crti�y nor!�cr the nrlin r mad prnu/ries u/per/nry thuf the in/urosul on provided mbuve is trat and correr4 �nr ff pp I)at••�-/� c�0// U//Icial rose ugly. Do tint writs,in this areal, to he cuuip/rfed by city alr regal"u//lcialL I C'ily or 'rotrn: _- . Permit/Lln•me 0 I hsuintl Aulhurily (circlo lane): I. IluarJ nrllrJlth 2. Iblil(lim, 1),,I ,cat I. Cit)i fund Clerk J. Electrical t :, h. Olher _ ut IIccfur Pluulbiny hlypecror I l l,ntaet 1'cnegJ: . . Phoae.1: Information and Instructions Nlassachusetu Ucnenl Laws chapter I i2 l,led s all very person in he ss to crvi:e of anothereu i lertnny contract f hire. Pursuant to thug%latute,an rmplusra ix Jctinea ag"...every Qe'. vpress or unplieJ, oral or written." �n erepluper is Jefinca as"an individual,partnership,assoeianoo,corporation or ether legal entity,or any two r t more a the I:regohtg engaged n a joint enterprise•and including the legal reQrexcntativesof adceased employer.u the owner of a dwelling house having not Wmare than three apartments and whotren�c therein ortity,employ irg nho occupant of dither the dwelling buuse of another who employs persons to do tnaintenunea,cunstruction 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." �IGL chapter 152, �25C(6)also states that"every state or local licensing agency shag withhold the Issuance or renewal of a license or per to operate a business or to construct buildings in the commonweutt6 for any Applicant"lie has not produced acceptable evidence of cumilllunce with the Insurance coverage required:' AdJitiunully, bIGL chuptcr I5'_, a23C(7)states"Neither the commonwealth nor any of its political subdivisions shell enter into any contract for the performance of public work until acceptab iaence of cuntpliartce with the insurance requirements of this chapter have been presented to he contracting authority.", Applicants Please fill out the workers' compensation atfdavit completely,by checkng the boxes that apply to your situation and if necessary, supply sub-contructor(s)nama(s),addresges)and phone numbers)along with their c employees ertificule($1of _ _ insurance. Limited Liability Companies(LLCworketn'tcomped emationity ainsurance(If an)LLC or with uLLP does have er than the members or partners, are not required to carry cnlployaes,a policy is required. Be advised that this•affidavit may be subtnd d to the the Department I1 industrial s, rcrumador roe city or town insurance that application,cOn'crisige- Also be for the permita toll vigil x being requested,not he ihparvnent of should Industrial AcciJenu. Should you have any question!regarding the law ur 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 a ro Mato lino. City or Town Offlctsls Plca h sc be sure at the affidavit is complete and printed legibly. The Department thus provided u space at the bottom due affidavit for you to I m ill out in the event the Otlica of Investigations has to contact you rcgording the applicant. 1'I:asc be surceo rill the la Penn it licellse e applicationsnunib in any given yearwhich will be used ,needeonly submitonel affidavit indicating tcurrent that must sub p ormation I if necessary) and under"Job Site AJa pe the marked ant shouci vvor town maylocations be provided to the ur policy mt or marked b ilia y p Y I stamped Y audit that has been official y D t be filled out each t a uftl affidavit nws wwnl•"�\ copy it* o permits or license!. A new atliaa t on file for future pe valid affidavit to commercial venture P that a business r v ••nt as roo related to an applicant P Year. Where a home owner or citizen is obtaining i license or NOT trequired to complete this affidavit. ' t i.e. a dug license or permit to bum leaven cte.)said perxon is 1 Ile t Ytiicc of Investigations would like to hank you in advunce for your cooperation and should you have any quesumts, please do nut hesitate to give us a call. fhe Ucparunent's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of fovesdgadons 600 Washington Street Boston, MA 02111 'rel. N 617-727.4900 ext 406 or 1-877-MASSAFE Fax M 61 7 72 7-7749 www.mass.1ov/dia CITY OF S'u.E.NI, NvL-ksSACHL:SETTS • BULMLNG DEPART\I INT t 130 WAsHLNGTON STREET, Y°FLOOR TEL (978)745-9595 FAX(978) 740-9846 K15IDFAr FY DitISCOI L MAYOR IHO.�GU ST.PtERas DIRECTOR OF PIBLIC PROPERTY/,BCB.DLNG CO\L\nSSIONER 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 Al 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: l/t/a�..v,� sI/arm ('p2.%l�✓i� (name of hauler) The debris will be disposed of in (rianne�off facility) c (address of facility) signature of permit applicant date dcbna.df J.w 1 l N It tow �e • I f �r • b oc'K ADD itoltiv o T asf k '^ s wM►oow t ooe�e �hien q�� Clue4��� AowAtit E frefa e,q . _s Jf�ew. 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