Loading...
25 FRONT ST - BUILDING INSPECTION 1 £ ' A The Commonwealth of Massachusetts ` Department of Public Safety . AIassaduucllS Slatu 1uilding Code(780 CMR) `."'•` Building Permit Application for any Building other than a One-or Two-Family Dwelling (Phis Section For Official Use Only) Building Permit Number: _ Date Applied: -_ Building Official: _ SECTION 1:LOCATION(Please indicate Block k and Lot#for locations for which a street address is not available)- 5+�o>vl 1-S+ ._S_ F}(I tin C1161�1­0_ ale 06skc SL No. and Street City /Town /ip Code Name of Building SECTION (if applies �Ic) — SECTION 2: PROPOSED WORK Fdition of NIA State Code used If New Constriction check here❑or check all that apply in the two rows below Existing Building ❑ Repair .\Iteration ❑ Addition ❑ Demolition ❑ (Please fill oul anal 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 $1 -- Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:_ Rlp nLrQ_ e Jito(vva- 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 CMR.11) ❑ Existing Use Group(s): Proposed Use Grou p(s): SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Fluor(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-I ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ 1? Facto F-I ❑ F2❑ N: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ 1-1-5❑ 1: Institutional 1-I ❑ I-2❑ 1-3❑ hl❑ AI: Mercantile❑ R: Residential R-I❑ 12 '❑ R-3 ❑ R-{ ❑ S: Storage S-1 O S2❑ U: Utility El Special Use❑and please des ribe below: ,t Special Use � SECTION 6:CONSTRUCTION TYPE(Check as applicable) l IA ❑ IB ❑ IIA ❑ FIB ❑ LILA 13 111B ❑ IV ❑ VA ❑ V13 ❑ SECTION 7: SITE INFORNIA'rION(refer to 780 CNIR 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 umutiCipal ❑ A trench will not be I-iCensed Disposal Site❑ required ❑or trench or specif}'__ Private❑ or indcnlily Zone:. or on site sslcm El required is one lased ❑ __ ___ Railroad right-of-way: hazards to Air Navigation: �i l iI.i�., • . �.���.�... 1. 1' . .Not Appli,able❑ Is Sirurture within airport appro.teh area? Is(heir rcvirw Completed.' or Cmx911 to Build enC lased ❑ lcs❑ or No ❑ 1,.S❑ No ❑ SEC"I 10N 8:CONTENT OF CERTI I9CATE OF OCCUPANCY 1`111111111 of Cod ' L'sc Grog p(s): _____._ I\'pe of Cone t roc I ion: - _ lkcup•mt I,lad par 1:111o1: _ F)oes the building Conlaim eo Sprin klor';I lIo d:_.___.. __-tipe,ial Stipulations: r ' SECTION9: PROPERTY OWNER AU H IORIZATION Nanm and Address of Pro rty Uwner - �o� r �e l sec e S SH(2 _ Olit�o Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 1�- CO-OLt� 505�1a3 acn 2 v air+ ; 41:, Of� "Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, Ilse 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 bV this building Verinitapplication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 33,000 cu.ft.of enclosed space 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. a-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Le.sAZ Os.,a Name of Person Respot able h Construction License No. and Type if Applicable Street Address City/Town State Zip "Fole phone No. business Telephone No. cell a-mail address SECTION 11: E1;'u ia\II'1 :N3A I ON IV;1JKA\R'If AI-tll41 VI I M.G.L.c.152.§ 2SC 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 a lication? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)=S I. Building 5 ) v'Oa Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=5 t, Plumbing $ +. Mechanical (HVAC) S Note: �\iininrum fee=3 (contact munici alit S. \lechanical Other $ Enclose chunk payable to b.Total Cost S C�(� (contact municipality)and write check no ber here f SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my nano below, I hereby attest under the pains,n d penalties of perjury that all of the information Contained in this Application is true and CC Irate to the atst of my knowledge and understanding. �iAf�QiW01 -- SL'g9A3 Please Ise print and sign name 1 ttle -Trlephon No. )al All tilreet Address City%Town • c Zip 1 \lunicipal Inspector to fill out this section upon application approval: Name Dat — // Massachusetts - Departinent of Public Safer% t Board ut' Building Regulations and Standards Construction Supervisor License License: CS 84117 r •x• ¢ v.yw" «cc .• .a. .ice>; :, JOSEPH W JURASEK 26 DARMOUTH RD MARBLEHEADj MA 01945 kro- Y� Expiration: 3/21/2013 (l nnm i�eiom•r Tr#: 11011 cQll SI H 7?1 631-o�a5 CITY OF SALEM PUBLIC PROPRERTY i° DEPARTMENT ofIy 1,11t,•11 11C IVnan.\ulu.\ilsFbl' • intro. M.t>inr.ln rr I L ;Iv)� fr.1. 77t.:1Sviu5 • I�tx vIN•'tC.r,rM Workers' Cumpensatlon Insurunce %intiavit: BuilderyCuntrocturs/E)ectrlclynsIFlumbers � ) !!!cant In unnutlo PI ' inf Legibly V;I11'1C IIhwIIW%rr7raanuninw lnJlruluulC ph I .\ra,ou an employer'! Check the;ytpruprIato box:I ❑ I ;fin a cmpluyut with 4. O 1 ;fin a gWneral eualraelor and I 1 y pe o(proleat(reyulred): '•❑ anpIuycex(lull antYurpart-lime).• Nova hired the.rub-cuntracturs ('' ❑New cuaxfiruetiun I,fin J sole prnpriefile ar panner- listed on rho anachcrl%heat ❑ Remodelins L"wiv have no umpluyeng These subcontractors have file Ina in any capacity. tvorkera'camp, insurance. e' O Demolition ers'comp, imlurenee J. ❑ Wean a corporation and its 9. ❑Ouildind addiliun 3. ) )RTcanIlava eramincd their 10•❑Electrical repairs or additions rYWutvnu Juiny all work ofeaemptionparh1CL IL❑PlumbinY rcpuirx fir atklitione o wnrkcn'comp e. 152,)1(4),and we hove no required.) r :mpluyaas. (P,a tvorken, 12❑ Ruttfrcpairs Wnmft insurance r%: irud.) 17.�UtLar Roalact ea 54;vt �o t''1�p•5gtlw'uy Ih,e eLucb xar el m W1 dlru 1111 wl IN W01ors Indyw dluwure Ihrir wwkW'Wunrlwrwllun ln,ller I."IMM r inrurinuiW► ' I n hy w u16nti1 this arTdrWl indkarins it"41nlrnwoln INN 040 Ih,r bm ara l aaahre.m addlrt as Jtr:p rtt,w`aW Ihpr hip uW%iM euernrree nrwl is vo a rltlw URJrvN inJhuein y uyl.huH rhuwu, Iris nays 0/thlr wk.arrachrx and rMe wuAm,comp. Y NL /old"all emp/ayer 1/101 It prurld/gr workers cuorpenrndon Lrsarrtnae/fir/ray emp/aJ'eee. Bdurr is/A %y un%aill% ife In%uruncu Cuntpaoy .Name: I'T(,l.Y 7{@.I (J(J�QI��,�� (S 5 I'alicy 4 fir Sulf•ins. Lic.h:rj—�t''�7"l'y�� Q � u`� Eapirallon Date: — /fib Site Aildreis: ,tLAA „ � q /± .tttacA n Wu p rv---�_Cllyrstate/Zlp: ©�t,�(� pY of Ilm trorkers'cum eniaNna policy ducleratlun pays (showlnp the policy nuotbur and crplratlue dues, 1-alluru to%ceuro cuceraye u required under Seaiun?!,\ ul'.�IGL c. I1]eau lead ro the im lilt, up to i 1.5110.IM irldlur uue-year i ipri.r,rwckliu as ,sell as Wild pens C a in that o iAitln ufpoTUp of criminal lxnaltisa of a of up to i'10 00 a Jay Iraillm Isle riol.rmr. Ile atIV14Wd that a Wu URK ORDER and a fine hn.%Il�au,nu u(;Iw UL1 :or ntruallxa .I,rcr�,u wuliuhtm. pY of thlr olalcmunt may be IYfwatJed to the Utlicu of /,/u/tetchy tWr l/y tar, ygpypyinr,tnr/ rn/Net /prr/ary Amid l/rein/unnel/ale rvri,/e,/u fir P e ix ae uod rorn•r4 o �-. 11///riot rt y fin/y, ""'of brill in How urcu, tube cump/rled by city up/ono ul//ciat ' ( Fly or I'n Irn: _ !,ruin \uthuril VWnnit/LIh'matl 4 ' y (circlo noe): I Ib,.rr'J of Ife.Jrh 1. Ihaldur; Ikp.Irunvat I. l:itl.'I'unlr Clerk J. L''IccttiW.11 h1+Y.c/fir �, I 1 ('lambing Inryccror l'...uac1 !'tome —��.. I,h... Y• information and Instructions , eve sari in the s.rvice of another uo,ler•ury :omnct of hire. �Lut.I:hu:eus G:^grief n r,nvplu�re is dcfnuJtas �II eugryo�rs to provide wutken' co,npensahon hu their cnuP ogees. 11w,u.ms to uus .14tu :vPrcas or ,nplied. oral or written." orauun or other legal cnnry, Of any two or more \n vrnpluper I,dclincd as"an Individual. Purtndnhip, dilidt he le Cory 1 fe reaC111Jltve!of 3 de:ta�eJ Ce,empI l{owvver the s J n a fume enterprise, and ituluding the legs P tom vntplo) .,I the I�Iregumg engagc a,menhtp, a[sociauoa or other legal cnacy,emp Y g ' ecetver of uuatee of.m indivtJuol. phred owner of a dwelling house having not more than ores to do maintenance-a. d nhtructiun uides rhePube deig k uecein.or the nto h dwellcupant of ing house .Iwrll,ng huuid of mother who emp Y p+ or„n the vrounds or building appurtenant thereto shJII not because of such employment be deemed to be an elnpluyer." �3C 6 also testes thrt''wery state or local1leenslag rudely shall withhold the Issuance or th IN the corstraccal .\tGL chapter 132. t}- O required-'* ren+sysl life license car pdrntlt to operate •huslneu or to construct: wltk theslnsurane�overall stivalreger say i 71 rates"Neither the commonwealth not any of its political subdivisions.+hall ;,pplicunt "Ile hot not plim151 d acceptable evidence a of comp %wicionully, )IGL :huptcr 1 3-, 5-3 t enter into any contract tar the perfor n An„1nreJblo the contracts g alut'hor�ityddancd of cwuPli utcs with the insurance requiremenls of this chupler have been p' Applicants DP to our situation mid,if cal and Phone number(!)slang wick then certiltcatals)of pleat.++ rill out the worker!' compettsadon silt Jtheda(completely,by checking the boxes no amployt.�ts other than the necessary, supply sub-eontraetor(s)ntrrsle(s). have required to carry workers' contpdnsatibodn�ptri?ltnd to the or LLP af�Indusstr'ial insurance, Limited Liability Companies(LLC)or Limited Liability partnerships members car partners, are not ld employees,a Policy is rdqutted. 1)e advised that this affidavit may drtment of \ccidenu for conllrmation of insuranco covurage Also be fun to slgcs and date the uftldavinot the ta Tile affidavit thou ilt .% cidentdd to the city or town that the•replication for the ponnit or license is being requuded•to obtain J workers' nu haw any qudstiooa regarding{the law of if you an K4 anies should enter their I ndustriul ,\cuiddnu. Should y nttrttant st the nwnbat Iisud below. Self-insured comp compensation policy. Pig " call the pep self-insurance license number on the a ro riute line city or Town ofAelats rtmant Ate provided u space at the bottom the applicant. please he sure that the affidavit is complete ;utJ printedof Invlegibly. The epa „f the affidavit fur you to 1111 out in the cvcnc the Ot11ea of Invastigatians has to contact you regarding f the. be sure ro till in ihd purmiUlicenso nootbdr which will be used as a reference number, In addition, is applicantsit car and under"lob Site Address' the applicant+Anu1J write.,all locations in l' Y Iliac,moat iubmit.multiPle Penniulicatse applications in any given year, need only submte one etc butprovided wee sty policy iatorMJli'In tit necessary) ed of marked by the city or town may tuwnl.",\ cupY of the affidavit that has been officially iL stamp' etmia or licensee. Anew Jc1lJavit must be tilled out each permit not related ro any business car commercial venture Applicant as proof that a valid aitizcn i is can file for 1Ltuw p y ear. Where a home owner or citizen is es Cie.rig i license or P I i.e. a dug llcmtse car permit w burn leave cue.) sail Per+can is VOT required our:o I era(spit attJhltuu J ii you hard any yudsuotts. I h: ,>tli:e of Invesligatiuns wuuld Iced w dtartk you in adv:utcv fat y P plua,e du nut hesitate to Vic us a:all. fhc U:paruncnt's address, oalephune and faa numbde The commonwealth of Masstichusetu Deparvnent of industrial Accidents O(flee of Iavndgadans 600 Washington Street goston, MA 02111 •del, q 617.727F� 6ext 11406 Of1 .877-MASSAFE 49 www.mus.gov/dia �l I CITY OF S,V-&Nf, NLASSACHUSETTS BctlzLNG DEP.IATIE\T 110 W.1SHL`tGTOM STRM, Y°FLOOR TLL (978) 743-9595 KIMBERLEY DROLL FAX(978) 740.9846 MAYOR THows ST.PMXAS DmEY Too or PCBLIC PROPERTY/BCQ.DLVG COJL\IISSfONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) fn accordance with the sixth edition of the State Building Code, 780 CMR section I 1 I.5 Debris, and the provisions of MGL a 40, S 54; Building Permit 0 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: ,19 Jv raa�k (name of heuler) The debris will be disposed of in : (name of r„11 4=ess Of racilllY) lG.. " acute of permit applicant ,ra(e