24-26 GREEN ST - BUILDING INSPECTION 1�
The Commonwealth of Massachusetts
I- Department of Public Safety
IWII �. d•�.j \la,..tdtu.vl 1.St.ur Building C',rde(,'SO CSIR)`•vvnth Edlnnn
City of Salem
Building Permit Aillicition for any Building other thirsts I- or 2-Family Owellin
I rhls in For Offlc,l U,e Unly)
Building 1'enntl.Number: Dale Apphrd, Building In>pectur
SECTION I: LOCA LION (Please indicate Block a and Lot or for locations for which a stnef aJdress is not avails blN
<52y- 261(zrce4,j F 21c1lz.w, MA O/9-110 i
\u. and Street Ca% /rulvn Lil+Cuale .Name us Budding(tl opplicable)
SECTION 2:PROPOSED WORK
It New Cun>(rucnun check here O or chrck all that apply in the two rows beluw
-Euming-Building Ed
-Repair --Alleratiun- -Addt/n)n4- - muliliam-O-(Rlrasr/i)Lw/�analsubm+M4) dla-14—O _
Change of Use ❑ 1 Change of Occupancy O Other ❑ Specify:
Are building plans andlor cuRstructiun documents being supplied as part of this permit application? Yes No ❑ J
Is an Independent Structural Engineering Peer Review required? A c _ Yes ❑ Nu O� ,n
Brief Drscrtpliun of Proposed Wurkr 'r n e1 f lQ[e. 1e: C
irl 1��t:o.-�, r• u:t 'i r e f' tit' h
i�wbT f`r la. d. In l S f Ver c vl.tde/'
In
l
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR 14
CHANCE IN USE OR OCCUPANCY
Check here it an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ '
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 7I0CMR 14: Proposed Hazard Index 780 CMR 34:
SECTION its BUILDING HEIGHT AND AREA
Existing Proposed
rNu. Fluors/Stories(include basement levels)&Area Per Floor(sq.ft.) 00
Total Area(.sal.ft.)and Total Height(ft.) �Ofl
SECTION 3-USE GROUP(Check as applicAbId .R
A: Assembly A-1 O A•2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F•1 ❑ F2❑ H: Hi Hazard 1`11-1 ❑ H-2❑ H-3 ❑ H•4❑ H•5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Merrill 11e❑ I R: Residential R-10 R-2 R-3 0 R-4❑
S: Storage S-1 ❑ S-2 ❑ I U: Utility ,
Special use❑and please describe below. _
tiprctal Use: •
SECTION A:CONSTRUCTION TYPE(Check as a licable)
IA O IB ❑ IIA ❑ IIB ❑ IiIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7: SITE INFORMATION(refer to 780 CbIR I11.0 for details on each items
F I W+ter Supply: Flood Lone information: Sewage Dispoah Mrfenchit: ' Debris Remural:1'4 ,c❑ Check tt uul•ldv I1,a•d Lune a lodtc.ne municipal❑ ot he Ltcrmcd Ut.)•.�.,d?rtr❑I'rtaaly❑ urmdennll Lune- ur un deer.l, rench „r -f,vka%
trm❑ .a•.1ItailrwJ ngHazards to Air Navigation: .1... ,, ,.,,• Ihcn n•a w+t „n,l•Ic I'd'
..rt ,.'nl t,•limld rnJr••c.l❑ 1c•❑ ,•r Nil lr• Cl ❑
SECTION g:CON TENT OF CF.RTIFICA TE OF OCCUPANCY
I .lieu nt . Il ..ly' _ l.•r l.,,.0 y.t —_�
__ (t)c—t l-.,n.IfU,loot _--- ltc:u)•.un l ••dal/'rrlL„n
16n• Ih, l•tnl,6nq, nn.tm.n+� `nnAlcr?t-lem' ._ _ . .
l `poc tat`(sputa been. i
SECTION% PROPERTY OWNER AUTHORIZATION
\'.urn auJ .\.Idrenn ul I'n pvrle Owner
fZ��,pu.k.! 'Vmr\tyreelJ-C ��fl ��LrnM(h.Ul �`�i•'-L .�S-� -- _ILA
\.min tl'ruu) .\'a.and?Iran Cih, Lnvn ,',I
I'n pvrlc lhurer( onlact Inlurmanun: A a�tr @ C0-n4 Ay1o✓JC 1
��a P ram. �. . 47 I
(illy relephune No.(busman,) relephonr No. (cell) I
If applicable. the pn•perit m nvr hereby authorizer
Name Strad r\ddrrnr Crn'i Town Stale Zip
to act on Ihr j,roVvrl% .n.nee',beh.11f,m all matters rclatne to work authunzed by thin buddm •j,rrnuta • lic.rtu it,
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
I II L•u •ddm it ls.s thin,S.lalu cu.It.of rnduvJ •ace anJ/or nil uudvr C.m>tnunun Cuntrul th.•n check here O aml •ki .5a•Ji... Ill II
10.1
Re istered Professional Responsible for Construction Control ltc5.Cor•�n
se
02-0 ohnaSe el"'? a 3o I O 5
(R�-is-t . -e ep one u. e-mallid ess egutration Number
/A T�v.✓ 33,.9�.4f\� cSci NA- � AkcA I'1'CGT-
Street Addr is U City/Town State Zip Discipline Exprrauun Dale
10.2 General Contractor
3A"v,_ ajE?,s evo-iL(
Co ,ny Na Con3 (�t���vSosz_ d l 9 5
Meal r '.b(c,�-�
Name of Person Rrspsmsible f�1tr Cunsi rtictiun License No. and Type if Applicable( M�
q S1 Nal(�i c✓ 'ref
Sptrye�etgA§21' � �Q City/Town �l A tat�mGpa,,r`
r rn-11J'.J�— el '
Tele hone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'CQWENSATION INSURANCEAFFIDAVIT(M.G.L.c.152.§ 25C16)) _
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 the application? Yes 0 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE ,
Item Estimated Costs:(Labor
and Materials) , Total Construction Cost(from Item 6) s E
1. Building f 0,WD Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical f 000 appropriate municipal factor)=E
3. Plumbing f ajoi
- Vote:Minimum fee f�^ (contact municipality)
a. ISlechanical (HVAC) f
S. Mechanical (Other) f Enclose check payable to
6. Total Cost f fy0 000 (contact munici alit )and write cheJk number here 1S 13ex0
SECTION 17:SIGNATURE OF BUILDING PERMIT APPLICANT
Hy entering my name below, hiarCebv attest under the painsand penallles of perjury that all of the mfurmatiun o-n hu nr.l in Ihin
r)plicate in true end accurate h Ihr rnt of my knowlavigr and underntandrng,
r i .I •n i mune role L-0cl.hnnr \ U.ne I'L•.i v pen 1 , n ib
�b rvl 1.fdr"' lit\ : rursn Lrte (I• J
I
\luniripat Inspector to lilt out this section upon application approval:
Cl.�—
CITY OF SALEM
PUBLIC PROPRERTY
V<- DEPARTMENT
.isus w:rr:iglM:\111
�1\ 12C WaenM:I O.N S is EL•1'a SA EM.M.\ ill Is 31972
Vll-.'I3-9395 • F.\x. 978.741C-4S46
`lYorkers' Compensation Insurance Atftdavit: Builders/Contractors/Electricians/Plumbers
lipDlicant inrormation / Please Print Leeihly
p`
Vanrt Iliuutxss/Orpam rain vindlvwlual): /A L411^ "P,LJ IJ
Address:
City,Srarc:%ip ,104vt M !� 1`� �77 Phoneil:
:\re sou in e lit ployer°Check the appropriate box: - 'Type of project(required);
1.Q r am a employer with 3 _ 4. 111 am a general contractor and 1
r''
emlployees(fu11 JntUur purl.-time).` have hired the sub-contracture New cultstruction
2.0 1 ant a tole proprictrx or partner- listed on the auachcd sheet. : 7• ❑ Remodeling
ship and have no ornpluyccs These sub-contractors have S. 0 Demolition
working Air me in any capacity. workers'comp, insurance. q. 0 Building addition
I No workers'comp. insurance 5. 0 we ale a corporation and its
required.) ofticcrs have exercised their 10.0 Electrical repairs or additions
3.0 1 ant a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. (No workers'comp. c. 152, q 1(4),and we have no 12.0 Rtxit'rupairs
insurance required.] i cmpioyws. (No workers'
comp. insurancerequirtd.) 1J.❑Uthrr
•,\ny:�pphcaa that chucks box el must ahlo fill oul lie wcuvn Wow rhuwing thair workai cumpunuaiwl puticy inliyntalim
'ilumm,wuan whu.ubmil this affidavit indin,ina Ihuy ara doing all wark and then him outside emmrnetom mual.uhmil a new ai'fdavit inaiW ina umh.
4'.mtr i,wv li a check this boa m,at aoachcd an iddilional shed showing tha natne of the mbsontrwtoo,and their wurken'camp.policy informaiuq.
/arts art svupfuyer that Lr providing rvurkers'tutnprncation insmrance fur my eurp/uperr. Behaty is the pull y Irnd job.rite
iujoruruffun.
Policy Al or Sclr-ins. Lic.Of: __.. . . __ Expiration Date:
'Job Site Address: C'itylslate/Zip:
Attach it copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required coder Section 25A ur:`IGL c. 152 eaa lead to the imposition oferiminal penalties ofa-
rinc up to S1.500.00 and/or one-year imprismnmcnt, Js well as civil penalties in the Turin of a STOP WORK ORDER and a fine
of up to S250.00 it day aguinst the violator. Be advised that a copy of this slaicmunt may be Ibrwarded to the Office uC
IIt\'i aIhJll,Jlit UI the U for ins rarcc c,ivcra,e\cl'llication.
/Ju hereby rerlijy ur Jer die p, n.s and peou/ties•u/perjury that the information provided above is true and correct.
�n•.r.nt,rc: q G� ly t.. 2
Official use only. Od not write in this u"o,to be completed by city or town ojjiviaL i
i
Cilv or'l'own: Purinit/I.Icense 0._
Issuing;Aulhurily(circle title):
I. IL,ard of Ilralth 2. Iluildim„ Department .1.Cilw rune Clerk 4. Electrical inspector 5• Plumbing Inspector
6. Other
Cwuaet fcnuu: -- -. I'hmle tl:
Information and Instructions
%f:1Ss.lchusCtts Liencral Laws chapter I j2 1'cguires a I I elnllloy'ers to provide workers compensation for their clllployees.
Pursuant to this statute,an emplurrr is detined as"...every person in the service of another under airy contract of hire,
c,,pre»or implied, oral of written."
\n empluyer 1%defined as" rsh
an individual,purtneip,association,corporation or other legal entity,or any two or more
r the foregoing engaged in a joint enterprise, and including the legal representatives Of a deceased employer,or the
rCICIVCf or IrUsICC UI .al Illdivldual, 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, cunsooct e
ion 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 employee"
MGL chapter 152. Q25C(6) also states that"every state or local licensing agency shag w•itithold 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, �IGL chapter 15?, a25C(7)states"Neither the commonwealth nor 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 rill out the workers' compaisation atfidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) name(s),address(es)and phone number(s)along with their certiftcetc(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 renmled 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 u workers'
compensation policy,please call the Department at the nunnber listed below. Self-insured companies should enter their
.elf-insurance license number on the aEEroeriate line.
City or Town Omelais
Please be sure that the affidavit is complete and printed legibly. The Department has provided u 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.
I'leuse be Sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
lhat must submit multiple pennitllicellse applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)undamder"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 die 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 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 016ce of lllvesflgations would like to thank you in advance fur your cooperation and should you have any queStlOns.
please do nut hesitate to give us a call.
the Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
"fen. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax p 617-727-7749
Itaci.ed s-20-05 www.mass.gov/dia
CITY OF SAL&M, A1YL-1SSACH1USETTS
BLIIDLNG DEPARTU&NT
130 WASHLNGTON STREET, 3'FLOOR
TEL (978) 74S-9595
FAX(978) 740-9846
KIN
BERIEY DRL4COLL
MN THO.uAS ST.PMRRR
DIRECTOR OF PIBLIC PROPERTY/BUUMLNG CONWISSIONER
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
I It, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
� g MA
(add iss of facility)
signature of permit applicant
�. a3
(late
lcbnvl!•I•k