10&12 GRAND TURK WAY, 25&27 FLYING CLOUD - BUILDING INSPECTION l�
; The Commonwealth of Massachusetts
l► �� I Department of Public Safety
�/;1 .,_,�.Z llasaahtw•tt>State Building Code I, CJ1R)S-%-ernh Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspectur:
SECTION t: LOCATION(Please indicate Block Is and Lot 0 for locations for which a street address is not available)
No.and Street OW/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Cups ruction check here❑or check all that a pply in the two rows below
Existing Building RepairuylAlteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 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 Engineeri Peer eview rewired? ( •Yes ❑ No ❑
Brief Description of rop Work: l 30
- i t .✓
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 UseCroup(s): I Proposed UseCroup(s): f
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 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Rosiness Cl E: Educational ❑
F: Facto F-I ❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ I-3 O I-t❑ M: Mercantile❑ R: Residential It-t❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2 O U: Utility❑ Special Use❑and pleaw describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIAO IIBD IHA ❑ 11I80 IV 1 VA VB ❑
6 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 ti uuterdr Fl.xai Lana•❑ Indicate municipal❑ .1 Irrnch wdl not be L,cenvd '_"Nposd Site❑
1'nra o
te❑ or indenutc Zone:_ r on•.,te.%"tem ❑ reyurred❑or trench ur�Ikafc:
f - permit i.enclu.ed ❑ _
I Railroad right-of-way: Hazards to Air Navigation: %1A I Irt.•na t".•unmwon IL...,,... P'."—:
\.d \i•Id rC.dde❑ I.}Io iiltd') „ cr
.a t un�rnt w Iiudd endo'ed ❑ 1e,❑ ur Nu❑ 1'e.Cl \u ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
C.ht nm.,1 ("0e Cv(1wupi.1. r\pcul l,m.trucoun: Occupant I,od per f I....r
I1.•o•tht•bodd...q omt.un.ot 5pnol.ler}a.tam'' �,fa•cial Supuhtwn•' I,
.-. 823 ��3nl V2
SECTION 9. PROPERTY OWNER AUTHORIZATION
N ar an •Address of Pm •rtir 9-ner a
Name(Print) No.and Street City/Town Lip
P o•e h'lhvner('.mtad lnfor alitnt
Title Telephtttw No.(boons%) Telephone No. (cell) e-m nl address
I(ap(+I"•able,t p 'M, t o�L erebvy autho lzes �
i z r7- S �� f S7�✓C�BT 7 tir�J7�Ti �
Name Street Address Cily/Town Stale Zip
tar act on the +no lc.nvner behalf,mail matters relative to avork authorized t+v this buildin• .ermtt a+ lication.
SECTION to:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(it buiWing is Ie.s thin 35,110111ay.fr.of tr kiwd r and/ar not u dkv C.artruction Cuntrul then check here 0 and skip SrAion 10.1)
10.1 Registered Professional Responsible for Construction Control
N r $ ' t T ne N email a Registration Number
Street Ad . City/Town State Zip Discipline Expiration Date
�Ut(
10.2 General Chittractor
cam aH Namey.
Name of Petwn Responsible fur Construction Lioensehfo. and Type if A�pyf�cable
l
L
(jl /HCs95 V87
Telephone No.(business) Telephone No. cell)- e-mail address
SECT70N 11:VMRKERS COWENSATON INSURANCE APM VIT(M.G.L.c.1SL 6 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 theiguance of the building permit.
is a signed Affidavit submitted with this application? Yee No O
SECTION IM CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(labor
and Materials) Total Construction Cast(from Item 6)=E Q3
1.Building E -
Building Permit Fee=Total Construction Cost x_(Insert hem.
2.Electrical - E appropriate municipal factor)=E
3.Plumbing E
4.Mechanical VAC) E Note Minimum fee=E (contact municipality)
5.Mechanic (Ott E Enclose check payable to
y_Total C. E o (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering nn name below,1 hereby attest under the pains and penalties of perjury that allot the information contained in this
application is'true and accurate to the best of my knowledge and understanding
.
PI t •pn L1�d. n rtam rill r re ephone No. [hue
" 2 t r
Str.x9 -lddre.. C Ih .ncn to Gp
1
j Stunicipal Inspector to fill out this section upon application approval: _ -
\ame / Date
J
�Vf1&mo -oJMassad=dts -
Department of IndusMal Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print-Legibly
Name(Business/Organization/Individual): i 6T&�
Address: ���Q r
City/State/Zip: /(/ Phone
Are_yo an employer?Check the appropriate box: Type of project(required):
1.13'I am a employer with 3 _ 4. Q i am a general contractor and I 6 Q New construction
employees(full and/or part-time).` have hired the sub-contractors
2.Q I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. Q Demolition
working for me in any capacity. employees and have workers' 9 Q Building addition
o workers' co insurance comp' insurance t
re 5. Q We are a corporation and its 10.Q Electrical repairs or additions
required.]
3.Q I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.E]Roof repairs
insurance required-)t c. 152, §1(4),and we have no
equu� ] employees.[No workers' 13.Q Other
comp. insurance required]
•Any applicant that checks box#1 nwst also fill out the section below showing their workers'compensation Policy information. _
t Homeowners who subrait this affidavit indicating they are doing all work and then him outside conaactots must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub ennonetors and state whether or not those entities have
employees. of the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site
informeraom
Insurance Company Name: �d'LCtI� yILLL
Policy#or Self-ins... 411
�Lic.#: X,91%2 9/�i X/r2I,D f�Expiration Date:`p 7�
Job Site Address:/O le. (� � �//L/i�?�3 �7 "`Our ity/Stawzip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crituhle penalties of a
fine up to$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 to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
_ Investigations of the DIA for insurance coverage verification.
E I do hereby c jy der the airs an penalties ojperjury that the info anon provided above is true and correct
Si r
Phone#:
F
l use only. o not wrUe this area,to a completed by city or town ofj aL
Town: PermiUMcense Authority(circle one):
d of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
r
t Person: Phone#
F
Suggested Affidavit for Home Improvement Contraltor Permit Application
Far ow"ust only NAME OF CRYfrOWN
rctmtt Nay � ��417
Uatc
AFFMAVrr
home Improvement Contractor L w
Supplement to pumit Application
MGL. 142Amqui=that thelcoortstruction alteration,trnWa[ion it nhodcrn'vation ooah+rtsidn io hwcnhcnt rcmowl-dcmoli
wr Erucaaofonaddtiontoanc Pmcdstint avnKroaoghiod buitdnteoataintat st icastanc but not atone than fourd%ellinc units
to struetutu which arc adiaccnt to such scsidcnoc or buildlnf be dour by+c6ataod onatraclots. c[h outahn ac«ptrons along nth c
roquitchaeats• JO
t ` - Cost GYt/ . .jJ
Type of Work: L-St.
�;/i ��
Address of Work is l� �/ 4n ✓''°i7' 141; d�t�1
Owner Name: ��
Date of Permit Application: /�� b y /0
I hereby cer"that:
Registration is not requited for the following reason(s):
Work excluded by law
Job under S1.000
Building not owner-occlspied
Owner pulling own permit
Other(spedfy)
Notice is hereby given that:
OWNERS pUUIKG THEIR OWN pERMrr OR DEALING WriH UNREGISTERED
CUNTRACPORS FORAppLICASLEHOMB McROVEMEVT WORKDO NOTHAVE
AOC ESS TO THE ARBLTRATION pROGRAM OR GUARAMT FUND UNDER MGL
c 141A
f Signed under penalties of perjury:
I hereby apply for a. i as the agent f th nen
&MV
Date ntratxor Name Registration No.
OR:
Notwithstanding the above aotim I hereby apply for a permit as the owner of the above property:
Date Owner Name
CITY OF S.0 E\,ta 1�W&-kcHusEaTs
BUILDMG DsPARTJIENT
t 10 WASHNGTON STREET, Vo FLOOR
"I EL (978) 745-9595
FAX(978) 740-9W
(CISI$ERLEY DRISCOLL
MAYOR T HOMM ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDL\G CONOMSSIONER
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# 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:
Oc)'7g0
(name of hauler)
The debris will,be'17ose}1 of in :
(nafne of facility}
00
c
(address of facility)
kz
signature of permit aRplicant
/�o
date
•irbnaalTJc