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60 GROVE ST - BUILDING INSPECTION (3) d/ 31 ao The Commonwealth of Massachusetts j Department ofpublic Safety rrV� 6 Massachusetts State Building Cade(780 CNI R) Building Permit Application for any Building other than a One-or Two-Family Dwelling M (This Section For Official Use Only) V_ ( Building Permit Number: Dale Applied: Building Official: ION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) SECT r r F2r1vt'Sr h'/ alg7 mo L tG�i-4SE I No.and Street City/Town Zip Code Name of Budding(if applicabl42 SECTION 2:PROPOSED WORK. - o -a I— Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the t•3»rows 48V Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition Please fill out and submit TP pentR Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: - - Lai r t Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Nr Is an Independent Structural Engineering Peer Review rec aired? t^ 0,� es Brief Description of Proposed Work: 1 )e�L DP�eT� U/Z�l�?�J n N//�TC/Z T7 f C'Ift 3�I Y7 P y/ _rn SECTION 3:COMPLETETH[S 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): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/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-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ FI. High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ L Institutional I-1 ❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ I Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ fIB ❑ f[[A ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: Not Appli able-A— Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed ❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIPICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Cyr Cav l% 6o 6&V-' sT SA�✓�i rw�— G i�7G Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Olen P/2 4ZFl�aa 70 — (Zd BeIC?c9��I�o�Cb//P row Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the 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 by this building permit application, SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If buildingis IcssYhan 35,000 cu.ft.of enclosed space and/ or not under Construction Control then check herelAand 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 A- TG 2 S-eCompany Name 17 I C�'�t l C- Name of Person Responsible for Construction License No. and Type if Applicable lly 230.3TOyi sT 157A49 " A-14 01 a' Street Address City/Town State Zip g?g-&F056-2 �30Ua3�1- Pot re 30® Y4f/00,co? ? Telephone No. business Telephone No. cell e-mail address SECTION 11:VVOKKFRS'CONIPFNSA P ,N INSURANCH: fTIDAWY 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 th suance of the building permit. Is a signed Affidavit submitted with this application? Ye No ❑ SECTION 12:CONSTRUCTION.COSTS AND PERMIT FEE. Item Estimated Costs: (Labor Total Materials) o[nl Construction Cost(from Item 6)_$ L Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ d. Mechanical (HVAC) $ Note: Nlinimum fee=$ (contact municipality) 5. Mechanical Other S Enclose check payable to 6.Total Cost $ (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. o nCA-'V1e 2 C�ff=T�7� � print : rat ���j�fitle /,,tom Telephone Date Street Ad less City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date CITY OF SiUzNf) UXSSACHUSETTS ©t i=\,G DEPAIMLE.VT 120 WASHLNGTON STREET, 3' FLOOR TEL (978) 743-9595 1<11CBERLEY DRISCOLL F.kx(978) 7404845 IVLaYOR I T fOSLASSTTMRRB DIRECTOR OF PuaLic PROPERTY/BLUDLNG Co.\WISSIOV ER Construction Debris ;Disposal At'tidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5 Debris, and the provisions of NIGL c 40, S 54; Building 1#Permit is issu ed with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by rMGL c 111, S 150A. The debris will be transported by: y 'ZT (name ofhauter) The debris will be disposed of in Gvc) CQ GkA f S TZ-- _Z7n e (narne of facility) (address of facility) i ., rc of p• tt applicant 'late CITY OF Jill . -NL Iy NLNSSi11..HUS -. L 1J 'i,:r.".'�'I• s BuLDING DEPARTN NT ` 3 120 W.NSHLNGTON STREET, 3'a FLOOR TEL (978) 745-9595 F.ir(978) 740-9846 KI\6ERf -Y DRISCOLL VY,iYOR Tlgows ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CO>LMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibim Naive (Business.OrganlrationAndivitlual): / O v -U Ire-- Pr Address: /Oc - � "tr y ,Zi�1�S c Y T 'Z Ze— �Suf7e 3/33 C City/State/Z-ip:� �xfil 01 1S Phone M: 2a-9`t�7 o`SfD Are you un employer?Check the appropriate box: - Type of project(required): �am a employer with 4. [11 am a general contractor and 1 6. ❑Ncw construction employees(full and/or pa -time).' have hired the sub-contractors 2. 1 ant a sole proprietor or partner- listed on the attached sheet.t El Remodeling - ❑ P P ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition (No workers' camp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their MO Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions myself. (No workers'cump. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t cmpluyees. (No workers' 13.0 Other comp. insurance required.) •,any applicam d,at checks box et must also GII out the auction Mao,showing their workers'compensation policy intiumaiion. 'I h,mmmrcna who suhmil this affidavit indicaing they arc doing at1 work and then hire outside contractors mmt submit a new alydavit indicating such. ;Cnntrncton thul check this box most anachat an addiliunat:hest showing the n:une of the subwoniracton and their workers'comp.policy information, l mu un errtpluyer tlfat is pravidinK workers'eunfpeasadun insurance for my eutpluyees. Below is the policy and jub site insurance n. ��n ti �k Insurance Company Nmne: �/� J—JS Policy q or Self-ins. Lie. tl:— � _c�'„i__. fl epiration Date cf lob Site Address: �0 (./''�� J T' City/Slate/Zip: ,lttach 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 ot'MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and,t fine of up to S250.00 a day against file violamr. Be advised that a copy of this statement may bo forwarded to the Office of Investigations of the DIA for insurance coverage verification. - /do hereby certify ender the pules a penalties a perjury that the fafurrnmiun provided above is true and cG _ �3 a- `e Sinn' I t Data: Pro, is W5"F 0 S'4�"3 Ojjivial use only, no nor write in this area, tube compleled by city or town njjielal City or Town: ___.. . .__ Permit/I.Iccnse q Issuing Aulhuriiy(circle one): I. Board of stealth 2. Building Department 3.Citylfutro Clerk J. Electrical lnspector 5. Plumbing Inspector 6.Other . ...___ Contact Ise rsnn___ Phone 0:—_—___..._—_—.— ___J � 2 Sel2vpce � - �fl��`� 778 -3�v ' CITY OF SALEM ROUTING SLIP New Construct' Certitic_ of 9Q�" � ./J. Occupancy .Qr-M" LOCATION DATE ASSESSORS DATE 93 Washington St. CITY CLERK -DATE 93 Washington St. BLIC SERVICES DATE 142kP 12 Washington St. ( s WATER DATE 120 Washington St. CROSS CONNECTION J YC^" DATE 1 �l All 5 Jefferson Ave PLANNING DATE 120 Washington St. DCONSERVATION DATE 120 Washington S ELECTRICAL DATE 48 Lafayette St. LO O FIRE PREVENTION DATE 29 Fort Avenue _mot HEALTH ��, vt,� DATE /�'��� &f4i F_ 120 Washington St. BUILDING INSPECTOR DATE 120 Washington St.