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30 GROVE ST - BUILDING INSPECTION (2)
gr-++-1-. v&7S7 52- 5- / 4 Z -75 The Commonwealth of Massachusetts �Ufl Department of Public Safety Ma2Pssachusetts State Building Code(780 CMR)g lerm it Application for any Building other than a One-or Two-Familwe g (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) Jy 6-ru✓e 3J1,ee7L ^,, 07970 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ .Addition❑ I Demolition 0 (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 10 Is an Independent Structural Engineering Peer Re/view required? Yes ❑ No 91 Brief Description of Proposed Work:�p,no r'i 7wOFs d r<!z JZEti-ltsli�,f�yt Ceh� 'eCAb/,j!Z&ti Or` �/+ 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 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) SO 0 0 Total Area(sq.ft.)and Total Height(ft.) 15-0 G SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential RAZ R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-20 U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ BIB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal. Water Supply: Flood Zone information: Sewage Disposal: A trench Licensed Disposal Site U tr will no'be p Publics Check if outside Flood Zone❑ indicate municipal!i} required®or trench or specify,- Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 10 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No Ea Yes 0 No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: Andrew Seaman ! Project Manager (SOMWBA Certified) Unlimited Removal & Demolition Anything you want to get rid of-can us! www.unlimitedremoval.com 49 Munroe Street Office:781-596-9594 Lynn,MA 01901 ,` 781=593-7889 Ce/1:508-868-7054 Email.'Unlimitedremovai@verizon.net Fax:781-596-1035 .. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner (' .!/4(IryU�iy�i(uv_ Co/ 7o C/-O,/ 011r, Name(Print) No.and Street City/Town Zip /4,�_rM6,Y,ec�trLer Property caner ontact ormation: , C/ tLetan e"F Ialli,i &r-_ffZ- 2_E "L Title Telephone No.(business) 'Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes q!jmc/,2r0 e St Z#,e 2 Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 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. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor _Un 4 MI>r,0&thovttb-&n.e/r fl oh Company Name 1 ` �1 Name of Person Responsible for Construction License No. and Type if Applicable !Se 9fnyA/-oe S'X Zk174 IAz 0/90/ Street Address City/Town State Zip 94, _ Unl,Mife�� eyww� � (2iizon ./I�T Telephone No. usiness Tele hone 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® No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ /D 0 0 01 10 1.Building $ U Building Permit Fee=Total Construction Cost x J (Insert here 2.Electrical $ appropriate municipal factor)=$/0)0750,60 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6,t;'Df,fcliO/, 6.Total Cost $ /ot 0 Ulf, 50 (contact municipality)and write check number here SECTION 13: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 to the best of my knowledge and understanding. i P�olease print and sign name Title Telephone No. Date — 17,m/0-P $ L Az C1q u Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot #for locations for which a street address is not available) ?U 6v ro ve SLip2/ J-.`ems 01 C/7U No. and'Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No LI Provider notified and Release obtained? Yes ❑ No CQ Gas Shut Off? Yes ❑ No 0 Provider notified and Release obtained? Yes ❑ No O Electricity Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Cd Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No f3 Other (if applicable) Yes ❑ No El Provider notified and Release obtained? Yes ❑ No EY Other (if applicable) I Appendix 2 Construction Documents are required for structures that must comply with 780 CVIR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Docr.nients* Mark'V where applicable No. Item Submitted Incomplete Not Required 1 Arcltectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan(Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program ram 14 Fire Protection Narrative Rej2ort 15 Existing Building Survey/Investi lion 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance X 19 Hazardous Material Mitigation Documentation 20 t Other(Specify) 21 Other S ec' 22 1 Other(Specify) `Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority,having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci /'Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Discipline Expiration Date Street Address City/Town State Zi CITY OF S.U2Ni, M.-1SSACHUSETTS BulIDING DEPARTM NT #• 130 WASHINGTON STREET, 3"a FLoop. �"a TEL (978) 745-9595 FAX(978) 740-9846 K[NIDFRi EY DRISCOLL MAYOR T Homs ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BItI.DING CONMSStONER 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: UnllMIleAke Irk✓f6h Ql:nuIifron (name of hauler) The debris will be disposed of in Lt/rin d/CtNftC��YC��ion (name of facility) 2/77`ICu»me�c«l Sy Lvr�h Mx 0/70; (address of facility) signature of permit applicant date dcbtiu�T.duc t • i CITY OF S.Uym, iN'LxSS.ICHLSETTS • BUnDING DEPARTMENT 120 WASHINGTON STREET,Sao FLOOR TEL (978)745-9595 FAX(978)740-9846 KiNiBERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BL'1IDL]1G CO\L\DSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLlibly dame(Busimss'OrganintioNindividuap: 0h Address: 'If M4,4 ra to, S1i P e� L� City/State/Zip: L/EwA AG_ 0/f o/ Phone#: 7fl- 5116 `f5-- 7/ Are you an employer'. Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employces These sub-contractors have g. ©Demolition workingfor me in an capacity. workers'comp.insurance. y9. ❑Building addition required.] ired.]workers'.comp.insurance S. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their p 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.(No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)r employees.(Aro workers' 13.❑Other comp. insurance required.] Any applicant that chucks box#I most also fill out the section below showing their workers'compensation policy information. t I lomcownen who submit this affidavit indicating they are doing all work and then hire outside contraction,most submit a new affidavit indicating such. 'Contractors that check this bon must anached an additiomd sheet showing the name of the subcontractor and their workers'comp.policy infomtatim. l um an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob she information. {� Insurance Company Name:_77_1'✓C!/iGli�rS /� Policy#or Self-ins.Lic:#:!AJ-0197,5- // d F✓—Z -13 Expiration Date((:'' , Job Site Address: 20 (moo✓P Si'ieot City/State/Zip:�ll/r, /y/r 0/970 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 criminal penalties of a fine up to 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 S250.00 it 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. l do hereby certo under the pains and penaties of perjury that the iaformadant provided above is true and correct Signature:gnature: 4 Date' Phone#: Z�/' S�1r�' V l e- ' Official use only. Do not write in this area,to he completed by city or town ofliciaL City or Town: PermitlLicense# issuing Authority(circle one): 1.Board of Ilealth 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: y 1 ,•; - _ 21894 UNLIMITED REMOVAL&DEMOLITION " ` ` PA.BOX 1378 - �y NORTH SHORE BA _ y . . MARBLEHEAD,MA 01945 53-7� NK 129-2113 - - - 781-596-9594 - - •. 1/8/2014 PAY TO THE ; .. ORDER OF CITY OF SALEM - `' $ —75.00 Seventy-Five and 00/100�� DOLLARS D CITY OF SALEM . - 8 MEMO , „' .. - _ -• AIJIHORIZED SIGNATDRE _ DEMO PERMIT: 30 GROVE ST 11802 &894110 1:21134 & 2981: 8030028963114 UNLIMITED REMOVAL&DEMOLITION 21894 CITY OF SALEM 1/8/2014 DEMO PERMIT: 30 GROVE ST 75.00 NORTH SHORE BAN DEMO PERMIT: 30 GROVE ST 75.00