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12 HAWTHORNE - BUILDING INSPECTIONr The Commonwealth of Massachusetts Department of Public Safety IU/A .y Ma.,sachusett,State Building Code(780CMR)SeventhEdition City of Salem Building Permit A lication for any Building other than a I-or 2-Family Dwellin (This Section For Official Use Only) Building Permit Number: Date Applied: Building Inspector: SECTION I: LOCATION (Please indicate Block 0 and Lot N for locations for which a street address is not available) 11cu-r71,4ene 3/e/m N4- O/t7o .mmstrZra. Ava •e yNo.and Street Cih• /Town Zip Code Name of Building(it applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building I Repair❑ 1 Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) ! Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Propt,_sed Work: keat404w-D`e -T,t W. e/ru-tZ- fs/rl'K, Re/�l.ce T�l•e Swttrj:t.���r ,deb/wc� w,r 0cperessw.c. �Yoac r dr-.,�/s Ne�/Jlu.m/Jrn e .r s er ac'cr rsrny ' 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): r 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 Q A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hii Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ L• institutional 1-1 ❑ 1-2 Q I-3 Q 1-f❑ M: Mercantile❑ R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ ISpecial Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) rAO IB ❑ IIA ❑ 1100 IIIA ❑ IIIB ❑ IV ❑ VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Flood Zone Information: Sewage Disposal: Trench PermitI- aterSupply: Debris Removal:blic Q C heck if outside Flood Zone❑ Indicate municipal ❑ A trench will nut nsed Disposal Site❑ eah•❑ or Indenlilc Zune:_ or on site pvstem❑ required ❑or trenpecify: permit is enclosed Railroad right-of-way: Hazards to Air Navigation: xlA I li,t,-ri�C',-un111nom Rvo iv„ 1'r,,, \'ot Applicable❑ Is Structure tnthm airport appn�ach area' In their ret m% completed.' Or Comenl to Budd enclosed ❑ 1'es❑ or Nu❑ Yes❑ Nn ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Itditinn of C ode: L se Grnu +(sl: r% +e of Comp 1 _ p trui uon: Occupant Lund per Pluur: Does the building omt,un an Sprinkler S\ tern Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Pn rtv Owner �� •- SJr I A) Ovvy Anf1 �S' 4-C1 Name(Print) No.andSlreet • Citv/Tuwn Sgateim m n OIQlIp Pr operty 0%%ner Contact Information: 1-1 - I _' ��!�.-yl I F� •���fC' 'l� � 1 6 - I i.� �`11� 6 P I t �C o .C oly Title Telephone No.(business) Telephone No. (cell) a-mad add >, If ap plwable,the property owner herebv authorizes 111A-9K Yl R' 74 "A4 PDT �1y8 Sg/P.m Name Street Address Citv/Town State Zip to act on the pro+erty o%%ner's behalf, in all matters relative to work authorized by this building permit a >ilication. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If buildin•is less than 35,UIN)cu.ft.of endued s acc and/or not under Construction Control then check here Candskip Section 10 I 10.1 Registered Professional Res onsible 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 IVWK R A-mER al /a NJ hK RhyNlF R 4r4i,gAeH l—eTZ Cumpan Name: /bA /� Rr4YM,ER Cknar S Ltc /02&87 Name of Person Responsible for C nstruction License No. and Type if Applicable 79 k/ -,A4sr. PDT <}� S /1,V � 01 Street Address m a City/Town State Zip a.xe73- tvJzi�7iT�J E/%irrr! edopl Telephone 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 O 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 - 3. Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee - (contact unicipality) 5. Mechanical (Other) $ Enclose check payable t 6.Total Cost $ l A/ ©o C7 (contact municipality)and w check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICAN 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 bes m_v knowledge and understanding. Vl- Please pant and sign name title Telephone No. Date titreet :Address City/Town e Zip .Municipal Inspector to fill out this section upon application approval: Name I)ate o- l37 I � ' CITY OF S.U.&M, NLASSACHUSETTS EJL'B.DLYG DEF.uMillUNT 120 W.%SHlNGTON STIM, 1r FLOOR TEL (978) T45•9S95 FAx(978) 740.994 KBIHFAI-EY DRISCOLL 71106W ST.PIRRIIS MAYOR DIRPCTOR OF pl:BLIC PROPERTY/SL'CLDNG CONMISSION EA Workers' Compensation Insurance Affidavit: Builders/ContractoNElectrlclanslPlumbers a r Ileant InfnrmatlaA A Pleue Print legibly m Nad L luuar.+�.orymtarionlro4e�duall: MAKK ` r RA)( M-'E D Address: POTS 24 S 7Lf w tl,o,fz d7 TT Ci1yistawzip.. -I" FM hA- 0B16 phone* Gc�-s33 - 328� Are yes as employs'Cheek the appropriate boa: Type of project(requited$ 1.❑ I am a employer with 4. ❑ I am a 1eneral contractor and 1 e• Now construction employees(full and/or part-timel.• have hired the subcontractors 2. I a soh peoprietor Ammer- listed on the artachad sheaL: 7.,.❑Re ckleling- +hip ip and hiw fro cmpbyees Them iub•etintraetas have t. ❑Demolition working for me in any capacity., warkera'comp insurance. 9. []Building addition iNo workers'comp insurance S. Cl We on a corporation and is 10.❑Electrical repairs or additions rcgulncJ j otrkas haw exagised their ).❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.(No workers'comp c. 15Z 41(41 and we have no 12.❑Roof repairs insurance required)t ctnpk7cos.LNe workers' I).❑Otiw comp insurance required.] 'Any apparme then cheda boo A mum Aw fill um the unliou beho aoeing lbeir eaM*axeso atim paliey,ir18nel idoo, '14wKuwwla rhs aubwil Ain aAldavn indlodee they me Joey as wok ale than him eurii eoeoaeran clerk rA m b a over atitdwd indkri g wlak. !C,wn ela Itan climb Ain ban mud a"whot as adilkvW shed amrily dw em w ergo wr►ewaraafale"it their wabwa'Camp P lky iakmmtlen. f van on emplayar that prod/lra workers'cosyeas den burnree for my earpfrym &*Am/s the pNley andlea SW info►mardos. In..urmce Company Name: Policy e or Self•ins. Lie.e: Expiration Date: lob Sirs Adtkea CityiStatdZip: .utaek a copy of the workers'compensation Peggy doebntbm Asp(showing the policy number sad otplr@dM dlMe)6 Failura to 36Cnra covanp a required under Section 2JA of MGL a I52 can lead to the imposition of criminal penalties of a fine up to S I.500.00 anJlor one-year imprisonmem,as well as civil penalties in the farm of a STOP WORK ORDER and a flee of up to S250.00 a day illainst the violator. Ile adviwd that a copy of this statement maybe forwarded to the Ot7lce of Ill\Cf11J1:111UN ul'dla n1A for insurance covcralpa vciAwation. /Jo hereby rnrify unln the pains and penr/der el per/rq Mae the informative provided above is true and a rr►ees P•nre d' G7 � 53 8� 1 O/Jlcir/use an/y6 Do nor write in this arru,take.urwp/elrl by city or tour r,//h•irL I City orruwa: eermiN.IrenuM__. Nsuinit Aulhung Icircle one): I. ❑uard ul Ilraith I. Ruddlny Mparfmcat ). Cityfrown Clerk 4. Electrical lnvpntor S. Plumbing Inpecto► 6. Ulher _ Lontael Person: . _ ... Phone a: . ,S CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT . IW Hlr\ I.HN •II ..%I% it I_'Q W.\i111%1.0NSt'x Ll•T Trl:47tl-N •)iN3 77S.74 98N+ Construction Debris Disposal AtTidavit (required lur all deniolition 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 p _ 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 t 11. S 150A. The debris will be transported by: MkIZ K RArYME- rz plume of hauler) The debris will be disposed of in : puune ul ita�lty (address orlinility) Signature of lentil(atltllll' nl date Massachusetts - Department of Puhlit• � ;f,t. Board of Buildin_ He.-ulations and Standards Construction Supervisor License, t License: CS 102387 v =; s Q i e Restricted to: 007 MARK RAYMER PO BOX 448 SALEM, MA 01970 --�- �-j/ Expiration: 8/1912012 S ' ('onuni>sionrr .Tr#; 102387 .r