25 FRONT ST - BUILDING INSPECTION (2) a
The Commonwealth of Massachusetts i
�, I•.� Department of Public Safety
Massachtewtes Slab Building Code(780C.MR)Seventh Edition
�\ City of Salem
• Building Permit Application for any Building other than a I- or 2-Family Dwelling
p (rhis Section For Official Use Only)
loll Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block 0 and Lot 0 for locations for which a street address is not available)
b?S Frzou-T ,Sr -sti2tavn Wl4 L,1054?& 5b4AX--?/
No. and Street City /Tuwn Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or cluck all that apply in the two rows below
Existing Building)q Repair❑ 1 Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents bring supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brie,ffp�re�xription of Proposed Work: CG �' - (JS*'
t/ r
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) O
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 8:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r A-2nc❑ A-3 ❑ A4❑ A. ❑ B: Business ❑. E: Educational O
F: Facto F-1 ❑ F ❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1.2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4❑
S: Storage 5-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB
SECTION 7:SITE INFORMATION frefer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: 5ewage Disposal: Trench Permit: Debris Removal:
Public❑ C heck it uulsldr Fluud Lune❑ Indicate municipal ❑ A trench will not be Licensed Disiao.al Site O
rcylnrvd ❑or trench ur .Vecth:
I'nvaw❑ or m.lcntlh Lune: or on srtr acstrm❑
permit is encluseal ❑
Railroad right-of-way: Hazards to Air.Navigation: %IA I l It......, 1'n
\,,I Apphc.lble❑ TC31
lrunsre ocnhm atrpurt appr,och orea.' Is their re%leer ounplatad.'
a 6 nna•nl In Budd vnduvd Ycs❑ ur No❑ 1 Ye,❑ \n ❑ -
SECTION 8:CONTENT OF CERTIFICA rE OF(KCUPANCY
1 dnl.m �,I G"Ik.. ___ Lie Gn-uplsc re pe ul('un.l«tctiun: Occupant Lo.id per I luuf
I Nw, (he building wiltain.,n Spnnk1vr,;l.Icon' Spvclal SUpulalnms
SECTION 9: PROPERTY OWNER AUTHORIZATION
eandAddre..oll'ro 1% 0% er
�` �o I,a cueS fn e N� Ma
Nome(Nnnt))�I' j Nu. and>treet Ciitw/ ruwn ,, Zip
I'noFCt��-1-r/Cl.�t"{�f,l� 4,er LoWe e
Title Telephone No. Ibusne.$) Telephone No. (cell) a-mail addre,.
ppGotble, the propertyn%ner herebv authorizes
IfJ-�oo-ry-j sY4-k;Vsleeb"V14log 3Q f?*M!402 7�tJUSdur(/ w/5"
Name Street Address City/Touvn State Zip
to act on the pro pert%owner'.,behalf, in.ill matters relative to work authorized by this buildin • ermit a > >licalion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
-(It building is loss thin 35,000 c u.tt.tit enclossJ. ace and/or not under Coawruction Control then check how Dan,J,kip Sactiun I0.1)
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
@ICU� 1 iA� � Oc t4-�ol si-er 4y
Co piny Name: ' r E �lo �OZ U O�
Name of Perin Respinsible fur Cunstr e�un License No. and Type if Applicable
3o r'�,4-rzn\/ Pry �`1 �.r
Street Address ity/Town State Zip
9T 2 -7a0g - 0au7 �;is>�a�sC ,UaL�r�ruC,C�u�
Telephone No. (business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.9 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 signed Affidavit submitted with this application? Yes D No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building S Building Permit Fee-Total Construction Cost x_(insert here
2. Electrical f appropriate municipal.factor)-f
y 3. Plumbing E
Note:Minimum fee=S (contact municipality)
d. Mechanical (HVAC) f Z(�d ,,� !�/{/[�
5. Mechanical (Other) S Enclose check payable to W f V w
6..Total Cost f (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby alte.t under the pains and penallies of perjury that all of the information contained in this
application is true and accurate Gu the best of my knowledge and understanding.
G _ _
19ea.e print and sign name ritle elephone.No. Date
�Ircrl .\ddre�. City/Town �Lite ip
Municipal Inspector to fill out this section upon application approval: """��" / 6/
Name Date
i 7
CITY OF SALEM
y g_k
; , It PUBLIC PROPRERTY
DEPARTMENT
.1UI❑R:fy:)RtsCcII.I.
NLtyuR I2C WMHI\Gfu.NSTxet:T 0 SAI iu,MANSACln-sr:rnuiv7^ ;
Tcl.:978-745-9595 • Fsx: 978-74C-9846
Workers' Compensation Insurance : t'(idavit: Builders/Contractors/Electricians/Plumbers
� ) )licant Informatio i �/Q Please_Print Lecihly
V it tTlc: lliusincsYOrBanitalinNlndrviduaU: 62nn�n✓C(/` s -(-d
Address:
Cityisultc,zip: —A'L,-f p�C Phone
Arc you an employer'.' Check (hc +propriate box:- Type of project(required):
4. ❑ I am a general contractor and I (t, new construction
l.� 1 am a employer with ❑
employees(full and/or port-time).' have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 all,❑sole proprietor or partner-
listed on the attached sheet. '-
ship and have no employees - These sub-contractors have 8. ❑ Demolition
working for one in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'comp. insurance 5. ❑ We are a corporation and its
Officers have exercised their 10.❑ Electrical repairs or additions
required.] 11. Plumbin m repairs or additions
3.❑ I ❑m a homeowner doing all work right of exemption per MGL ❑ b P'
myself. [No workers'comp. c. 152,§1(4),and we have no 12,❑ Ruef re as
insurance required.] y employees. LNo workers' 13.Zl Olher { �(
comp. insurance required.]
-Any:q)phcaut that chucks box MI man alas fill nut Ihe.sectien below showing(heir workus cumpensarion policy inliurnatiom .
'I lumeuwnen who submit this anidavit indicating They we doing all work and then hire outside contractor must suhmmil a new al'r vit indi,admg such.
:C',mlrcon%thll check this box mind atlached an additional.,heel showing the name of the sub-contractors and their wurken'comp.policy infurmanun.
l ant all etupfuyer that is providing workers'campen.sation insurance for troy employees. Below is the policy"lid)ob site
iufonnutiort. ]-
Insurance Company Name—: lAj �1 -... �v/��"
1'Olicy a or Sclf-ins. Lic.rl: - , Wei E w gcG2 F7 -- Expiralro 7 n Date: — r
Job Silo: Address: ?Z—G P)n)L_-�t—r— CityiState/Zip: !!W&A A414--
Attach a copy of lite workers' compensation policy declaralion page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of 1IOL c. 152 can lead to the imposition of criminal penalties of a
tine up fit S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to 5250.00 a Jay againbt the violator. lie advised that a copy of this siate tent may be forwarded to the Ofiica of
Illvcsngalo)lu ul Lite [)IA for insurance coverage vcrilication.
l Jo hereby certify cooler tb plains unr�pe/r/ntufIt' ufperjary that Nye information provided above is trite cur!correct.
tile:cllule _ .. �—=Hsu—�3'L/"r��^� ~ U:1tC' 7 / ^ /
Ofjiciul use only. Do not write its this area,to be cuntplered by city or tolvn official
City or Town: Permit/License 4__._-__ _. ..
Issuing otulhuri(y (circle one): -
I. ISoarJ of Ilm:alth ?. Building Dcparnneut .l. Cityi fomn Clerk 4. L•'leclricnl Inspector 5. Plumbing Inspector
6. Other
1. Contact l'crsull: _ .-- Phone q:
Information and Instructions
.>lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, 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
,rf the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee 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."
NIGL 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." -
Additionelly, hIGL chapter 152, y25C(7)states"Neither the commonwealth not any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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)namc(s), address(es)and phone number(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 the city or town that the application for the permit 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.cure to till in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pennio'Iicense 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 affidavit must be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
1 i.e. it dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
the 01I Ice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The D.parnnent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Otflce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
ii,t'iscJ 5-26-05
www.mass.gov/(fia
y s CITY OF SALLM
PUBLIC PROPRERTY
'-` '- DEPART'NIENT
.... ?It : 6. , 1 , 1 -
Construction Debris Disposal Affidavit
(re(Iuited li,r all demolition and renovation work)
In accordance the sixth edition of the Statc Building Code, 7S0 CNIR section 1 1 1.5
Debtis, and the provisions of%lGL c 40, S 54;
Building Permit 4 is issued with the condition that the dcbris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11. S I50A.
The debris will be transported by:
Y4
1 name of hatder) �\
r S �
1 lie debris will be disposed of in
(name "t taahty)
1❑ddresn,d lacdily)
�icnalurc of pcnui[applicant
Talc
NOTICE NOTICE
TO TO
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give
you notice that I (we) have provided for payment to our injured employees under the above
mentioned chapter by insuring with:
3
W
TWIN CITY FIRE INSURANCE COMPANY
NAME OF INSURANCE COMPANY
o ONE PARK PLACE, 300 S. STATE ST. , 7TH FLOOR
x CVRAr`TTCF.r NY 13202
` ADDRESS OF INSURANCE COMPANY
76 WEG FW4428 09/15/10
POLICY NUMBER EFFECTIVE DATES
® HARTFORD FIRE INSURANCE COMPANY PO BOX 33015
SAN ANTONIO TX 78265
NAME OF INSURANCE AGENT ADDRESS PHONE
HOODCO SYSTEMS, INC. 30 BARRY DRIVE
TEWKSBURY MA 01876
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment
to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the
Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The
employee may select his or her own physician. -The reasonable cost of the services provided by the treating
physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related
injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such
attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Form WC 88 20 01 C Printed in U.S.A.
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'Engineer and a h
Architect
Specifications
TO DISCHARGE
PIPING
TO REMOTE MANUAL
PULL STATION
TO /TO GAS VALVE
FUSIBLE f SHUT-OFF
LINKS
® O c
OO D B
OPTIONAL
MINIATURE
SWITCH
28.125 CONNECTION
A� mzs<,vc
Flow Uae
oo<ena Model Point No. A B C D Capacity Weight10,625 PCL-300 8.00 25.06 30.81 22.75 10 53 tbs.(FRONT) TOGAS (SIDE) PCL-460 10.00 25.06 30.81 22.75 15 83 tbs.SHUT-OFF PCL-600 10.00 35.81 41_56 33.50 20 108 tbs.
General reignition. Expanded capability provides remote manual actuation, gas
equipment shutdown, and electrical system.shutdown.This optional
The Kitchen Knight®II Restaurant Kitchen Fire Suppression System is equipment will enhance the basic system functions and be applicable
a pre-engineered solution to appliance and ventilating hood and duct when designing custom configurations to suit a particular customer's
grease fires.The system is designed to maximize hazard protection, needs and/or comply with local codes.
reliability, and installation efficiency.Automatic or manual system
activation releases a throttle discharge of potassium.carbonate Suggested Architect's Specifications
solution on the protected area in the form of fine droplets to suppress
the fire and help prevent reignition after the discharge is complete. The fire suppression system should be of the stored pressure, wet
chemical pre-engineered fixed nozzle type manufactured by
System Operation - Pyro-Chem.A carbon dioxide cartridge is designed in compliance with
_' Military Specification"MIL-C-601 G", and shall be used as the
The Kitchen KnightTm Restaurant Kitchen Fire Suppression System pneumatic releasing device for the system.The cartridge shall be an
has been designed for protecting kitchen hood, plenum, exhaust duct, integral part of the control head assembly.The wet chemical storage
grease filters, and cooking appliances(such as fryers,griddles, cylinder shall be D.O.T.-rated for stored pressure of 225 psig, and a
ran eto s upright broilers charbroilers and woks from grease fires.
9 P , ) 9 pressure gage shall be provided on the cylinder valve for visual
The versatile state-of-the-art wet chemical distribution technique, inspection.The system shall be capable of automatic and manual
combined with dual independent activation capability-automatic
P P Y
actuation.Automatic actuation shall be provided by an appropriate
fusible link or manual release—provides efficient, reliable protection number of fuse link detectors mounted in series on a stainless steel
the moment a fire is detected. Once initiated, the pressurized wet wire input line to the control head. Manual actuation shall be provided
chemical extinguishing agent cylinder discharges a potassium by turning a handle on the primary head and/or by an optional remote
carbonate solution through a pre-engineered piping network and out pull station with a dedicated stainless steel input line to the control
the discharge nozzles.The wet chemical discharge pattern is head.
maintained for a duration of time to ensure suppression and inhibit
October 1, 2001
One Stanton Street
Marinette,WI 54143
PC2001192
Fhe system shall have been tested to the UL Standard for Fire Features
Extinguishing Systems for Protection of Restaurant Cooking Area,
UL300, and Listed by Underwriters Laboratories, Inc. It shall be • UL and ULC Approved
installed in accordance with the National Fire Protection Association . Complies with NFPA Standard 17A and 96
Standard No. 17A Wet Chemical Extinguisher Systems, and No. 96
Standard for the Installation of Equipment for the Removal of Smoke • Meets the requirements of the Building Officials and
and Grease Laden Vapors from Commercial Cooking Equipment, and Code Administrators - -
comply with all local and/or state codes and standards. . Approved by the City of New York Material and
E Equipment Acceptance Division
Typical Installation
T
6
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.�' 7. CYLINDER CONTROL UNIT-Integral design,rdquires'no separate 5. REMOTE MANUAL PULL STATION-Simple operating instructions
release pressure cylinder-separate wire cable activation lines for with a double action release avoids careless system discharge-a
automatic fusible link and optional remote pull station provide an 150'wire cable run with 1/16 inch cable and 40 corner pulleys
added measure of safety-an easily accessible manual release maximum-a dedicated wire cable input line to the cylinder control
"` mechanism which provides an option to the automatic fusible link and, head provides a true back-up in the event fusible links are fouled.
e9% depending on local codes, can be used in place of a remote manual 6. FUSIBLE LINK KITS-Accommodates both series and terminal
pull station- unique fool proof technique for achieving necessary input placement to minimize inventory and simplify ordering-all necessary
z : wire cable tension. components included for efficient assembly and installation-a 350' F
2. PIPING-Unbalanced piping network simplifies application design fusible link standard-other temperatures available-20 fusible links
,y .. and installation-no separate piping to connect system pressure on a 1 50'wire cable run with 40 corner pulleys maximum provides
cylinders to extinguishing agent container. Schedule 40 stainless, substantial hazard coverage.
chrome-plated and black pipe can be used. 7. AUTOMATIC GAS SHUT-OFF VALVE-Complies with
_ 3. CYLINDERS(DOT-4BW-225 Rated) -Contain Pyro-Chem requirements pertaining to the shut-off of fuel as described by NFPA
Potassium Carbonate Solution stored at 225 psig-pressure gage for 17A-after regular maintenance/service check can be reset at control
visual maintenance checks-3.0, 4.6, and 6.0 gallon sizes provide 10, head for convenience of service technician-a 100'wire cable run
+^ IS, and 20 flow point coverage respectively, offering a broad range of with 30 corner pulleys maximum provides mounting flexibility.
q- application coverage. 6. CORNER PULLEYS AND ACCESSORIES-Designed to ensure-�
4. NOZZLES-Fixed and Swivel head nozzles have been established reliable system function, as tested by Underwriters Laboratories.
y to relax placement tolerances.
'd