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12 HANSON ST - BUILDING INSPECTION (6)
L a • � i The Cununonwealth of Massachusetts - i De ar nl v 'p t t It of I abbe Safety \Ia+,dr11 u,c1 is titoly fill dJ log G dv(I,40 l.\I It) Building I'erniit Application for any Building other than a One-or l'wo-Family Dwelling (Ibis tint(it lit For Official Use Onh') Building l'cront.IVunlber I I,Ile Apirl iv, : _ __.,,_ Iluilding Official: ___ S ECI'ION 1: LUG',\IIUN (I'lease Indicate Block H and Lut If fur locaHolls for which a street dddress is not available) Nt1. .Ind titrcttK.�©p ' il}! I'„t"ll �_ � /Ip --Code .Vamvv�fit,iill inK (it dpplirable) __ SECTION 2: I'ROPOSFD WUItK IfJilion nl \I:1 Stall-CnJr uu•tl _ It.New Conslnit tion thvtk here❑or check Al ih,lt a r + ..._ _ 11 Iy in the hvu nnvv baluw F:\1111111; Budd inllk Rvpair❑ :\Iteration ❑ Ueulolilion ❑ (Pivase lill out and subnlit.\ppvnJi.x 1) Change of Use ❑ Change of Ovtul"Inty ❑` Other ❑ Specify - _ :\re building plum and/or t'oostru,tit it k"w'"I'vills beillg sllpphed Is llart of lhi.s perllllt apphf,tlioll? !i•s ---,Nu ❑---- - - Isan lndcpvndcnl Slniducal Engineerin• 'vcrR vi,w na�lj�ucd? ll Brivf Uvncriptinn of 1'rtrpo rd lV Irk: ' L a2�� •, Yes ❑ Nub re.Nt3�• L r1 SECTION 3:CONII'LE'fE TIIIS SLCHON IF EXISTING BUILDING UNDERGOING KENOV,\PION,,\UUI'1'IUN,OR CHANGE IN USE OR OCCUPANCY Chuck here if all Existing Building Investigation and Evaluattun is enclosed (Set-7,40 C.\IR.14) ❑ G\islingh'seGnntp(s): _— Prlkposed SECFION J: BUILDING IIFIGHT AND AREA Existing Proposed .No. of Floors/Gtarics(include basvntent levels)4 Area Per Fluor(Sy. it.) "1' Z I'otal Area(sq. ft.) ma romi Height(ft.) tiEC`I'ION is USE GROUP(Check as a liable) 1: Assembly.A.] ❑ A-2p Nightthlb ❑ A-) ❑ :\-I ❑ A-i❑ 0: Buslness.l3� L: EJucatiunal ❑ F: Facto P•I ❑ P2❑ II: Ili h Haetrd II.1 ❑ 11-2❑ 1I,\ ❑ 11.4❑ I: Institutional 1-1 ❑ 1.2❑ 1,1❑ I-a ❑ AI: Mercantile❑ I I-S Cl It; ItesiJun Hal R-I❑ R-2❑ R-1❑ R-J ❑ S: Stum`e S-I ❑ S-'_❑ Special Use❑,Ind pleast'dicstrille below ti U: Utility❑ tiprtial C'se . SEC'IION 6:CONSTRUCNON IYPF. (Check as a t licable) 1.\ ❑ lit C3 II.\ ❑ flu ❑ IIIA ❑ [fill ❑ FVPO 1 \'.\ ❑ \-It ❑ __- SI'.(71UN 7: SIDE I.NFUIV f,%IION(refer to 7,41)('.\IR I I LU fur Jvtails on each it ill) ivater supply: Flood Lune Information: Semige Disposal: French 1, croft: Ucbris Itcuun'al: ---- 1'ul,htN3'— Chrkk ll ,nlnldv Fl,nvl l,atc Ind n it, c nu n n rlki P,l l .\ it ok it kcdl o e n t be I It ,vd 1)1,1,1-,,it ;ovCl Prl\ale❑ „r Ind,otIl\' / "rollrtc,t Hrm p nnr. Irllt,wd ❑nr ln•nth IIr,prt 11% I, ,. , rn rrtnit I,e hard ❑ It,ri lro.nl rit;hLu f-w•y: 11.vards to Air.\ae igation: , �I, Irw)ury n Abut I pinY.y,pn•.It lr .Irra' hlbrlr lrclrw ,rnl ql-tree' •r t vnout h IluJd rw lus,',I (7 . - - -_-_-- ShCllONS: ( ONO-NI OF( hl(Ill l('.\, F—()IT (IC CCI'.\.\('Y _--1 I Phil, it I I,-JI' 1, ,, l ill'Id I\ ,v,gl ilH lltl, rt -- 1 II t\,n1tn111 , .IJ IrrIL• v Il, i . Ihr l•IuLIInI,, ilLlm .m -pnnAlrr tit,erne' •t SF( I ION 9: I-l(O I,I [(I Y OWN I It %Uj I I()IjIL,MON Lild .%lit[[ 1'rolli-iti, 0,% wr g7 457J f64 i-mvit No, and Strivi citv/ Owner coilla,I I Illortli'll it'll: Dille l',,lephooe Nil (IltisillLI'S It ayplii, lit I Hito Im,1101IN' Limier lic rL,b), Ili HILL ri/v.4 4!A ---- -- ;title Name Street Addre ,kill I t,.lt I net the proper ly tv lier"Iahall, in all mat tv ci relative in IL:ofil ,auii or i/L, a Vill lika Li low. I o:CONSTI UCHON CONTROL(Please Z) 5Ecrlotlil to:CONSTI liter 'heck littifir 13 andikil,Svi:lion Ill 1) If till I I,I ILL It is IC.S.4 111.111 35ARA)LU- it,of 4"Ce'iil`V/')r"Lit under I'ler itusisterLd Professional Res eonsi it Construction Control Registration Number N-ilit . strant) N0. pie I vi allio K C 'PA Eviration Date 1, %V State Lip Discipline tiurct 1\111imss City/rover 101 General Contractor WILL C./ tf -67— 'awi Ni NPfl 12 659�43 Type if Applicable si License No. NwIle. if lltL[Skijj RQsptmMUIe ftir Construction )Ie e 4,A 1� !!�o 4� -, city/-rt)%v State Zip Sl,eQt kIldress ef 0 IL r r,,ivolitme No. �Ilun llclis) rvivilione No, (cell "A IZAM I .. I 1 11 "k.1 I M.C.L.J C. 1514 25C(6)) scil.. 1', 12] 11", t "All•I N \I rialAcclue"Is Intist UQ ClItIlpivIlLAI'llh, A 111C"""' Department crill affidavit will result in the denial of the issuance of the L"llic"119 V ,,,Llllllttc,l with this application, Failure it,provide this, Yes C3 Na C3 I.9a.qi&nc%I Affidavit iltibl"ittell.1vith tilts SECTION I&CONSTRUCTION COSTS AND PERMIT FEE ItemEstlill.1tetl Costs:(Labor and Alaterials) total construcli'm Cost(fromItem6) -5-- anittling Permit Feel v Total Construction Cost x .(Insert here I ,appropriate municipal factor) -5 0" — 2, Iricol =0 004D IIPpr municipal Note; \101,11111111 ire ' 5---- Medwill"ll 01VAQ ((l111L,r) 1:11cli,se div,k Imil.lile to (I lo(alcOlt 1 5 3 -) ,,ill L,rite diet k lilt mber here SEc r ION 13: j[(;,N,\I U It E OF B U I L DING i,Eltm rr \IIVL Ic,%N r j.111%1 rt-rltiry that.,If ,1 the '"I"rill-Itioll wiltmil'-d Lit thl, M ,11wrilli; me mute blow, I hereby itiv,t under Hit- l,aw /Al"ll iItr 1)lLlr.ltL-ill lilt'N-lt A MIN '111" till'I er"I'lill"lit 4� Av I iLjt'{,Jj"11" \kI Patc ,frlift it ,,fit I 11i've'torto till nut tlli,4 ve,tion upon 111plic.16,111 ipprov L,L b CITY OF SALEM, NLkSSACHUSETrS BL'mLDLNG DErARTJtENT N 130%V.ASHLNGTON STREET, 3° FLOOR TEL (978) 745-9595 Fnr(978) 740-9844 Kl-,tBFRt EY DRISCOLL T MAYOR Y-iOaL�S ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/BCILDNG CONLMISSIONER 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 4 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: 4OIY`' Ljf PLt �-- (name of hauler) The debris will be disposed of in (name of facility) uddress of faci ity) signature of permi applicant /IQ 1'2 date i� CITY OF S.1 EN I, XSSACHUSETTS BUILDING DEPARTMENT • Ja, 120 WASHINGTON STREET, 3'o FLOOR TEL (978) 745-9595 FA.e(978) 740-9846 KI\fBERLHY DRISCOLL MAYOR THOMAS ST.PIERRH DIRECTOR OF PUBLIC PROPERTY/BUILDING CONINI SIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers A a ilicant Information Pleas int Le ib1 l Name(Business,organizatiowindividual d Address: 3K.75 T CitylState/Zip: �`�� Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1 iE•-am a employer with. 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hind the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached shect.: 7• ❑Remodeling 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 comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 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, 41(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp. insurance required.) !3.❑Other •Any appli[e u drat=s box NI muse[also fill out the uctioo below showing their workers compensation policy information 'I I,xneuwners who submit this a0ldavit indicating they am doing all work and then hire outside contractors most submit a new affidavit indicating such. :Contrxtors that chock this box most atlwhod an additional sheet showing the name of the subaomractors and their workers'comp.policy infiam Lion. I um an employer that is providing workers'compensation Insurance for my emplayeex Below Is the policy and fob site infermmlon. e_ . Insurance Company dame: � Policy#or Scif--ins. Lie. #: Expiration Date: 3 r C/ i-T ` Job Site Address: 12- aR'yy, " �� . City/State/Zip: SC IL a^s 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 S 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 S2M.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. I do hereby ref v u s r1aff ' s and penalties of perjury/flat the informWlon provided above is true and correct r Dard: &IQk 2- Phone OJTc•ial use only. Do not write in this urea,to be completed by city or town official City or Town: Permit/LJcense Issuing Authority(circle one): 1. Board of health 2.Building Department 3.Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other-� Contact Person:Person: .- ---- Phone th J CITY OF SM.E.M. AksSACHLSETTS BUMJDING DEPARTSM—NT la• 120 WASHINGTON STREET, 3'n FLOOR e"F TEL (978) 745-9595 FAX(978) 740-9846 KIN(gEnr F.Y DRISCOLL MAYOR THOMAS ST•PIFJM :DIRECTOR OF PUBLIC PROPERTY/BuMDL\G CONLl1ISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers A t licant Information 1 ( Please Print-1Legibly1 , NalnC(ousinvss.OrganizaiianRndividual):I ''1'c�C �,v--, ct ,c rt lHl r, WO,/�r� Address: 3o ee rwoJ A ✓t . City/State/Zip: trel�4 D 91 r Phone IF: �8 �� q [ Z Are you an employer?Check the appropriate boi: Type of project(required): I.®.Jam a employer with T— 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time),' have hired the sub-contractors - 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet,2 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y P h'• 9. JjQBuilding addition [No workers camp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their ME]Electrical repairs or additions J.❑ 1 ant a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions - myself. [No workers'comp. c. 152, 91(4),and we have no 12.❑ Roof repairs insurance required.)t employees. LNo workers' !J.❑Other comp. insurance required.] •Any applicant out cheeka box al must also GIl uut the section below showing their workus'compensation policy infunnation. t I tnmeuwn•rs who submit this aftlttnvit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. :Conrmcuns that chuck this box must attached an additional sheet showing the name of the subcontractors and their workers comp.policy infotmmion, !am an employer that Is providing workers'compensation insurance for my employee:, Below Is the policy and Job site insforrnation. Insurance Company Name: Policy Al or Self-seas.Lic, #::,[ — 1 Expiration Date: Job Site Address: /2 ` r 4A ro" Cit Jstatcai [ Y p:_ nt► 4 O k7� 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 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. 1 do her reify« r e pains and penalties of perjury that dte infarmadon provided above is true and c orrect. Date: Phone Y' [ 76 �7 ql - — Ofjicial use only. Do not write in this area,to be completed by city or town official City or Tuwn: _.__ Permit/f,lcense Issuing Authority(circle one): 1. Board of Ilealth 2.Building Department J.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6,Other --_---,.--- Contact Person: ......_.__.....------ Phone it: CITY OF S.U.E-M, NL-uSACHUSETTS BUILDING DEPART-M&NIT 130 WASHINGTON STREET, 3° FLOOR -0 T EL (978) 745-9595 Fnx(978) 740-9846 KINtgFRT RY DRISCOLL MAYOR T'HO.%tAS ST.PtERRH. DIRECTOR OF PUBLIC PROPERTY/BuimD c-CON12MISSIONER 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 willbe transported by: (name of hauler) �I The debris will be disposed of in (name of facility) 3� k/L 1 A4 (addre s of facility) s gnature of permit applicant 1101�- date anr�„tr,i,x i CITY OF S.U.F-,NI, NL-�ss kcHL'SETTS BUIIDD;G DEPARTMENT P 120 WASHIINGTON STREET,3"o FLooR TALL (978) 745-9595 Ram(978) 740-9M 1Qo,I8ERLEY DRISCOLL - MAYOR T HoNus ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWISSIONER CONSTRUCTION CONTROL DOCUMENT C/ Project Title: 1�.[LoPo� � � Date: 2J r� Project Location: �,� H�1�So&t r`)T �, n Scope of Project _ ADD 1 o ( oY T[w)C� I�[�t/�'i In accordance with SECTION++6-0-H4-.43of the edition of the Massachusetts State Building Code : I, 104d C(WW Mass. Registration Number ACC]7(n2— being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: [ ) Entire Project ,� Architectural [ ] Structural [ ) Mechanical [ ) Fire Protection [ ] Electrical [ ] Other(specify) for the above named project and that to the best of my knowledge,such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. II Furthermore,I understand and AGREE that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved by the building permit and shall be responsible for the following as specified in section 116.2.2: 1. Review of shop drawings,samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit,and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. I Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent comments. Upon completion of the work, I shall submit to the building offs ' ort as to the satisfactory completion and readiness of the project for occupancy. Signature and Seal of registered professional: � OF M9S.