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50 FREEDOM HOLW - BUILDING INSPECTION (11) r The Commonwealth of Massachusetts II, ,Y Department of Public Safety •...,.J' ..\lessachuselts State Budding;Code 1780 CMR)Seeenlh &iitiu of Salem BuildingPermit Application for an Buildingother than y a 1- or 2-FfW 64 City Z I (ThisSv&iun For Official Use Only) Building Permit Number: Date Applied: (k -26Qd Building;Inspector: SECTION 1: LOCATION (Please indicate Block N and Lot N for locations for which a street add is not available) No.and Street Cite /Town Zip Code Name of Building;(it applicable) p SECTION 2: PROPOSED WORK p - If New Construction check here❑or check all that apply in the two rows below x Existing Building❑ Repair❑ 1 Alteration 0 Addition❑' Demolition LT{Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engmeerm k,Peer Review re..juired? 11 Yes ❑ No ❑ Brief Description of Proposed Work: K�MCh/`2 IC �-C.�Q n C4� i r<e:tS t-4s? NQCt rk Lo r rt w ' e Pit) i 4 }c o.>! o� a .v w c ao4S h "114CEI In_1 i'vtnl "-r-NU10, 11 J!© 7d.wa/o SZM I/FX 36 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 Croup(s): Proposed Use Croup(s): r 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.) l SECTION 5: USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H:-Hi Qiazar-4 �11 U-Q ❑ H-2❑ t H-3 ❑ H-4 ❑ H-5❑ 1: Institutional I-1 ❑ f-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3I —R=4❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe o : Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA too IIA ❑ 1180 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Su I Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: PP Y� Public ❑ Check it outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑ required ❑or trench or Ipecl R�: I'n eah•❑ or mdentilc Zone: ur un site�l.tem ❑ permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: NIA I Ii.nmr c �nnmin�i��n I<, i, I'ri•rt..: \ot Applicable ❑ I.Structure lcrthin ,lirport approach area.' I. their rev irw omipleledl r l nn.cnt to Rudd cnc o.cd ❑ Ye, ❑ ur No❑ Yes ❑ \o ❑ SECTION 8: CONTENT OF CERTIFICA"fE OF OCCUPANCY I`.,Blinn nl G,de: L,e Group(J: TN peot Comtruclum: ()ccupanl Mad per I-luor 1),"r, the buildup;con6un mi Sprinkler Sc.lem' Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Vim;me.ln � idryz+� f�'n, --5�^�nrr C �nl l2 9�\ m tM0� vv� Ow Fr2 rN H� K�( LQ r ul Name(Print) No. ,Ind Street C ih'/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 pro pert%owner's behalf, in all matters relative to work authorized by this buildin • permit a p pliauion. - SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If buildin•is less than 35,otx)cu. it.of v,ciosL%t s pace and/or nut under Constrwtion Conlrul then check here O and ski Section IU.I) 10.1 Registered Professional Responsible for Construction Control touts '( Nvu,\- 1d `t&I_ dyq- 1434 Name Rrgistnnt) eiephune iVS•." emmlad'dress Registration Number 12 4� seh S� { vs YYIGSS _ �1a of D� 9'- 3- 20 Z Street Address City/Town State. Zip Discipline Expiration Date 10.2 General Contractor N zisA 14�, /� y Company Name: n olC °T me)r) 1&'7 S N.�n a of Person {irsponsi or Cun.tntctiun y�� / // tense No. and Type if Applicable CGS► Sov71-, A NSA /e(t(Y ke �ivr 112et a Street Address -y�� City/Town /- 1State Zip 7kJ 774-Sbol 7�-J.`/�(- 7 7 l0U is n^e1lt 1(el � tCG.Lrda zCGclr'+ Telephone No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6) _$ / 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor) _$ 3. Plumbing $ A. Mechanical (HVAC) $Note: Minimum fee=$ o/ntact m itc pa�ity) 5. Mechanical (Other) $ Enclose check payable to 1 6. Total Cost $ (contact munici alit )and write check nUnber here SE ON V 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 contained in this application is true and accurate t the best of my�Jkm/jWIedge and understanding. ,toolSTrY[2 /Q o�: %i�12? ou4^ee flea se pnnt,m 1 sign name Title Telephone No. Date. Gtrevt Address Cityi Town }fate Zip Municipal Inspector to fill out this section upon application approval: Name Date � � of � # CITY OF SALEM •�� PUBLIC PROPRERTY i;?z•.r�o DEPARTMENT ,itin:NI rY:iKIALL I. \IAYt is 12:WASHING 10N S I RUT • SAL F.M.M.,YSAU It ir:I l a 5197^� lli.:978-745-9595 0 FAX. 978.740.9846 Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers y ilicant Information Please Print_Leiibly NjIMe //113uciitcss/Ott anivatioNlnJiv,dual): f i•�r./Ufs 7- /w/f, � Address: I�� (US X 3T q City,Srarci-/.ip: 3(u '� f& -- Ll(5`D(9 11hone i:: -7 � - a-y y' W3 ,/ 6 - Arc you an employer:' Check the appropriate box: � ' 'Type of project(required)i " 1.❑ I :till a employer with 4. El I am a general ci)tflractor and 1 6. ❑ New construction y mployces(full jail part-Linte).• have hired the sub-contractors �/ listed on the attached sheet. : 7• �etnodeling 2 1 ant a sole proprietor or partner- ship ind have no employers These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition I No workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL I I.[] Plumbing repairs or additions 3. 1 ys a homeowner doing all work c s152, c 1(4), nd w•have no myself. [No workers' comp. a12.❑ Roof repairs insurance required.] t anpioyces. INo workers' 13.0 Other comp. insurance required.] -.Airy upphcaut that chucks box dl must also till out the uctiaaw,uw showinu their worker cumpensatioo putiey information, ' I lumcowoers who uibmit this nifidavil indicating They age doing an work and then him outside conuxton must auhmil a new alGdavil indicating.umh. -C,mirm o"that chuck this box loran mlachcd an adJiiiunal shcel shuwiny the name of the sub.ontractors and their workers'coll policy information. l run wt coiptoyer that is providing workers'c'mnpcnsntion insurruice for niy employers. Below is the policy and lob site inforaurtiom Insurance Company Name:__..._ I'nlicv 4 or Sclf-ins. Lic.f1: .. _ . ..._.._ Expiration Date: Job Site Address: ._ Cityistate/Zip: Attach it copy of like workers'compensation policy declaration page(showing;the policy number and expiration date). 1 Failure to secure coverage as required under Section 25A ul'NIGL c. 152 caii o lead-r tlie-ilnpcsition'of criminalalties pen of y- j tins up at S1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine i of up to S250.00 if day against life violator lie advkcd that a copy of this siatcmcnl may be lurwarded to the Office of it his'rsugaunhs ul'Lhr DIA for insurance covcragu ecritic,uian. l da hereby crrtify a4 r th�ilns ton p ntdtics ofperjtiry,that the inforinution provided above is trite and correct. Suur• -- - - - 7% Date- Official ose wily. Do Plot write fit this area, to be coutpteted by city or twvn oJJiciat. l City or fawn: _._-. _. Permit/l.iccnse 4__ .--_- Issuing Authurily (circle one): I. Board of IlcaUh 2. iluildin' Dt:partiocut 3.Cityi fowu Clerk 4. L•'lectrical Inspector i. Plumbing Inspector 6. Olher --_ - Contact l'crsuu: _. . ..-_ Phone rY: Information and Instructions ,Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursu:mt to this siatuic, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more „f the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trusted of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction 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 shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." .additionally, hIGL chapter 132. §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfomiance of public work until acceptable evidence of-compliwice with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractors)name(s),address(es)and phone nuntber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to tile city or town that the application for the pennit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or 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 appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference nwnber. In addition, an applicant that must submit multiple pennidlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new atfidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. I he 0 nice of Investigations would like to thank you in advance fur your cooperation and should you have any questions, please do no hesitate to give us a call The Deparonent's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston, MA 02111 Tel. 1# 617-727-49 00 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax N 617-727-7749 www.mass.gov/dia y s CITY OF SALEM PUBLIC PROPRERTY 'Z DEI'ARTMENT 1M 1' i Construction Debris Disposal Affidavit (reCluircd lirr all demolition and renovation work) In accordance with the sixth edition of the State Building Code;,,780 CMR seciion Il 1.5 Dcbris, and the provisions of MGL c 40, S 54; Building Permit h is issued with the condition that the debris resulting front [his work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I 11. S 150A. The debris will be transported by: I name of hauler) The debris will be disposed of in lyHn 017 / (uatnr ul laci ity) hyPn L Nrrn Yf2� (;Te.+.,d lacihIV) a¢nahuc nl prnnit epphcant ,late