6 HALSEY WAY - BUILDING INSPECTION (2) t 1 I
1
1►, ^ The Commonwealth of Massachusetts
1, 1 Department of Public Safety
%lassachusetts State Building Code(780 CMR)Seventh Edition
City of Salem
� Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block p and Lot B for locations for which a street address is not avail ble)
to WdO 4 70 JI:�'/- z:�.
No. and Street f City /Town Zip Code Name of Building (if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply.in the two rows below
Existing Building 0( Repair❑ 1 Alteration K I Addition ❑ Demolition ❑ (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 ❑
Is an Independent Structural Engineerin Peer eyv-requi�reX( 6�, �/ Y ❑ Nue'7❑�
/A )/Brief D,essriptirII ro14 ILd/rk U/ N 7 IYA 4//!H f L- L1J W*—,-/ill
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 Use Group(s): Proposed Use Group(s): S
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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-2r ❑ A-2nc ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi It Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 14 ❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3 ❑ R-4 ❑
S: Storage S-I ❑ S-2 ❑ U: Utility ❑ Special Use ❑ and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 11B ❑ IIIA ❑ IIIB ❑ 1 IV 1 VA VB ❑
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:
A trench will not be Licensed Disposal Site ❑
Public ❑ Check if Outside 1:1nud Zone❑ bW IC,Ite municipal ❑ A ❑or trench nr. n •-
Private❑ or indentity Zone: or on site system ❑ required - F ecif%:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I:\ I lists Sri:c , nvni>�inn It �iv I'nn�.:
\Ot \pplicible ❑ Is their rev ie%c completed?
of I, nment to Build rnClO.ed ❑ Yes❑ ur No❑ Yes ❑ \n ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Gdnion of Code Lsr(,rouplsl: rcpe of Conslnldion: OCCLIpant Load per I=1OOe
1)nen the budding contain an Sprinkler?ystetn Special Stipulations:
S
SECTION 9: PROPERTY OWNER AUTHORIZATION
Na c ai A idress of Pr �uf v Owne
Vt �U:ram - j e�4 � e 4P
Name(Print) No. and Street - Cifv/Town Zip
Properth 0%%tier Contact Information: /� -711 d7 'L3
Title Telephone No. (business) Telephhon No. ell) e-mail address
If,yPt,�livevihrpr rrt o er ruby P ��riz}rrf--
� CEj ( 1�1L
Name Street Address City/Town State Zip
to act on the pro pert% owner's behalf, in all matters relative to work authorized by this building permit a >>licatiun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,000 cu. tt.of enclosed space and/or nut under Construction Control then check here O and skip Section ItH)
10.1 Registered Profession I Aesponsible for Construction Control
Pr 7 S7
Na (R strn Tel hone . o e rfiail ad _Registration Number
g 0A
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name: C'�'J Q -
n
e P�® on R�pu sibbllee oriCu rctiun License No. and Type if Applicable
cIf
Street Address f� /Town �Zip
Tele hone No. (business) Telephone 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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ - 'appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipalit )
5. Mechanical (Other) $ Enclose check payable to z <
6.Total Cost $ (contact municipality)and write check nuns er here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv attest under the pains and penalties of perjury that all of the information containedIthislp li ltionistrue andaccurate to the best r T' knoevledtiean d and +landing.I l: iot n•.r i-sigr /1 �le L'Iephone \ �.
streeccttt Addlv,< Ciitt`t///Tm%n 'State
.Municipal Inspector to fill out this section upon application approval r 17h,
\'ame Date
CITY OF SALEM
- •. ,.j
PUBLIC PROPRERTY
DEPARTMENT
..`I .. i: I \\ l,l ll\,.., y 11d1.1 r � 1.\I I \I, \I-.\"\� ',. •, i . • .I'� -
'i.'Lih,
Construction Debris Disposal Allidavit
(required air all demolition and renovation work)
In accordance \%ith the sixth edition of the State Building Code, 780 CNlR section I 1 1.5
Dcbi is, and the provisions of 1v1GL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The dchris will he transported by:
(name of hauler) -
'I he debris will be disposed of in
yladdress ul'IaalilV) "J�///�
,�gnauvr ut p:nnit ajlphcaut
t taw
v
i
Ma"achusctts - Dcp:uYhnCnt of Public Salo%, j-
�7h, ). BnardidBuitdin_ Re"I'Lifinm and Standards.i
Construction Supervisor License
License: .Cs 28786
Restricted to: 00 +1—nA•
GLENN T FULTON
PO OOX 325
MARBLEHEAD, MA 01945
�_L J•fi�` Expiration: 4/20/2012
('o uuni>!ionrr Tr#: 21965
w `r Bonrd of�t OBuilding Reg ullaucti o-eld aurc�nfellJ F
Sland:uds 1
BOfl1E IMPROVAMEN7 CONTRAC70R 1
x Registration..,118759
Expiration'- 4?2012011 Trh 281772
Type: In j
U.-LTON J'2
109 TEDE g$'Q ST
,MAR Bb -N t�/lU MA 01945--
_ Aduumstrator
A
CITY OF SALEM
I�
PUBLIC PROPRERTY
'• DEPARTMENT
,1\11t1 N:FY:)AMA 4.1,
�1.1Yt to 12^�WASHING I ON S IXELT• SAL E.M.MAYSACI n-%i i s 0197:
*1'1•.1.: )7tW45.9595 • F.1x: 97x.740•9:346
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
� ) ilicant Information / Please Print Le ibly
Na Rle ll3uciucss/OretannatinN/ idual
Address: / ��/v�� > - -7
City,slareizipV Monei.': d ��
:\re you an employer! Check the appropriate box: 'Type or project(required):
1. 1 am n employer with am 4. ❑ 1 a gen 6. ❑eral contractor and 1 New construction
❑
employees(full undlor an-111110 have hired the sub-contractors
P' 7. �Remodeling
2 1 :tin a sole proprietor or partner- listed on the attached sheet. :
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. nsumnce. 9, ❑ Building addition
l No workers' comp. insurance 5. ElWe are it corporation and its 10.❑ Electrical repairs or additions
required.) officers]lave exercised their
right of exem tion er N(GL 11.❑ Plumbing repairs or additions
3.❑ I am a P'
homeowner doing all work S P
myself. )Ko workers' comp. c. 152,j 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. LKo workers' 13.0 Other
comp. insurance required.] 11
-Ally u,pilcaut that chicks box dl must also rill out ale xeclialt w.ow showing Ihvir workets cumpensuliwt pulicy infurmutioa
' l lumcowm:n whu submit this affidavit indicating They are doing all work atul then him outside cuntraelon must auhmil a new affalavit inditmtmg wch.
4',mtrwturs Iha1 check this box mull ensiled on additional sheet showing the name of the subKonlrwlJn and their wurken'comp.policy informanun.
/ant oil employer that is providing workers'c•ompen.cal, in,nl Ace far sty emtployees. Below is the policy and job site
inforvmation. f/fr:;
Insurance Company Name: 4��• ��'r �__ - .. _._...---------- ��gkiy�7�
Pulicv if or Self iris Lic.tt: Expiration Date: /'.t/,
Job Site Address:U G k city/State/Zip: 5'6�*
Attach o copy ar the workerT—, mpensation poly•y declrralion pulse (showing;the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.N16L c, 152 can lead to the imposition of criminal penalties of a
tine up o)SI.900.00 and/or one-year imprisonment,us well as civil penalties in the form of a STOP WORK ORDER and a fine
of till to 5250.00 a day oguinst die violator. lic advised that a copy of this statement may be forwarded to the Office of
Invcangaunns ul dW DIA for insurance coverage vcrilication.
I
l do hereby certify under the pains t and penaltiIf iry that th information provided mbo/co ids fr re mod correct.
Si�'aalure: �J 6.�7v Dot•' l l �/�
Pluwc fi: / / r /
Ojjic•iul use wry. Do mot write in this area, to be completed by city or lown official
Cityor'fown: _.. _ Pcrmit/Liccnsc'd.--_-_ _
Issuing Aulhurily(circle one):
1. Huard of Ilvalth 2. Buildin: Dcpartulent 3. Cityi fawn Clerk 4. Electrical inspector 5. Plumbing; Inspector
G. other .--
Contact fcnon: _ - --. Phone Y:
Information and Instructions
M assachusetts General Laws Chapter 1:52 requires all employers to provide workers compensation for their employees.
Pursuattt to this statute,an empfuree is defined as"...every person in the service ufanother under any contract of hire,
e• press or implied, oral or written."
An e,nployer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
or the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,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, construction or repair work on such dwelling house
or on nhe grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
. MGL chapter 152. §+25C(6) also states that"every state or local licensing agency shall withhold 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. MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performiance of public work until acceptable evidence ofcompli;uue with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit 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 certificate(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 returned 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 a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permitilicense number which will be used as a reference number. In addition, an applicant
that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"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 the city or town inay be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit niust 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. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The 011 ice or Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please du not hesitate to give us a call
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investigadons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE
itcvised 5-26-05 Fax M 617-727-7749
www.mass.gov/dia