12-14 HAWTHORNE BLVD - BUILDING INSPECTION =� The Commonwealth of Massachusetts
� I
Department of Public Safety
1` ;7 \Lissac Imsetls Stale Building CaJc(780 C\IR)
•`""'1 Building Permit Application for any Building other than a One-or Two-F.unily lhv• ' ig
(Ibis Section For Official Use Oniv)
Ruilding Permit Number: _ Dale Applied: - Building Official:
SECTION 1:LOCATION(Please indicate Block If and Lot R for locations for which a street addres not e)
/ -A#V, IJlPeA ee /A0 (�C4P v _ arm rRr� Lac ---
No.and Street Cit /Town -- Zip Code Name tit Building(if applicable)
SECTION 2:PROPOSED WORK
Fdition of;\I:\State Code use' — If New Construction check here❑or check all that apply in the two rows below
Fxi.stint; Building ❑ Repair Alteration le I Addition❑ Ucnuditiun O (Please till out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: �tt �i / Parm.�r
Are building plans and/or construction documents being supplied as part of this permit application? Yes Cl No W
Is an Im ependent Structural Engineering Peer Review required? Yes ❑ No Q'
Brief Descron of Proposed Work: �.�ivw mgh.Q. � ��mTP—�[ �i�•Gr. i !—ft_ 3
3f" _
T!✓IBC Y_O./I. " —�E l -4 m!.✓ &4R /�A-A ALH—'!'Tc _let jrT -
SECTION 3:COMPLETE'THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDFrION,Olt
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR.LL) ❑
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.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A4❑ A-5❑ B: Business ❑ F.: Educational ❑
F: Facto F-I ❑ F2❑ If: High Hazard 1-1-1 ❑ - H-2❑ H-1 ❑ FI-4❑ 1I-5❑
I: Institutional I-I ❑ 1.2❑ 1-1❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R 2❑ R-1❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: ;
Special Use
SEC rION 6:CONS'I-RUCTION 7-YPE(Check as applicable)
IA ❑ III ❑ IIA ❑ IIB ❑- IILY ❑ 111B ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMA HON(refer to 780 CNIR 111.0 for details on each item)
Water supply: Flood"lone Information: Sewage Disposal:
i'rench Permit Debris Removal:
Public❑ Chock it Outside Flood Zone❑ Indicate nmuhicipal ❑ A trench will not be I.ireusod Disp is,d Site❑
required❑or trench or specify:
Private❑ Or indentilY' Zone: _.—.. or on,its v)snm ❑ permit is rocused ❑ _ _ -
1t.11Ir11Jd rg11t-Ilt-WJy: 1la/ardltll .\Ir NJY rgJnUll: \I \ i,;,i, �.�.. �.. .� a .,, .
.\'ot.Applicable❑ Is S;Irm tore within airport approerh area? Is their review omplrleJ?
Or COneanl tO Budd encn,ed ❑ )es❑ or No❑ I lbs❑ ..\'o ❑
SEC"I'TON 8:CON'FEN'F OF Clilt I IFICA I F OI'OCCUPANCY
1-11 111011•ll C\dv Usr Group(s): _ 1\It IC nsirw mm: Ore upmn l.teld par I ...r:
Pow,the huildinl;conl.lin.In'�pmukh r Svdens tit rcial Stipul moos
t1-I 1, To ,
Sl:("[ION 4: 1'ROITR'IY OWNER AU ri IORIZA'IION
N,m e and Address ul Property Owner a
• c.
v✓_Ol_rvr e9.s11� �L R ---
Name(Print) — - No.and Street City/ruwn Zip
Property Owner Cuulact Information:
---
I'ille [ telephone No. (business) Telephone No. (cull) a-mail address
If applicable, the property owner hereby authorizes
n % M/8 - __0 I ??
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)
1f building is less than 35,001)cu.ft.of enclosed space and/or not under Construction Control then check here O and ski r Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No a-mail address Registration Number
Street Address City/Town Stale Zip Discipline Expiration Date
10.2 General Contractor
Company Name
lykgK /0930?
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zipper \'
�(7.LS:2-b T5(927-s, Wlc9�1� Yvr�ri•Cdr.,
Tcle,hone No. business Telephone No (cell e-mail address
SECTION 11: l.:,'( t,\wl NI•t nl.vv I Ni I H IA 'u M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the NIA Department of Industrial Accidents must be COmplulud 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 a lication? Yes❑ No O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) S_
I. Building S -0, Building Permit Fur-Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=3
t, Plumbing, $
I. .\Ic'c'hanical (HVAQ $ Note: Minimum (a' (contact nmu 'l palily�
3. ,\loihoniod Olhur 'S Enclose check payable tO
h.Total Cost $ (Contact muniCipalih')and write check number here -__--_- ---__
SECTION 13:SIGNATURE OF BUILDING PERNIIT APPLICANT
14v entering my n,ume below, I hereby attest under the pains,md penalties of perjury that all of the information iUn L111ICd in this
dl+plication N Irue.unl airurate to the best of my knuaw ledge and understanding. 33 dU Q y Q h
ISO
uc prior,Ind Sign one u f
le Icl Ihunc No. D,me
titrcet .\ddress Cna/roman State Zip
\lunicipil Inspector to fill out this section upon application approval:
--- Name Date
bL "ITS
C["I'Y OF S,�L.E.ms 1 1WS.1CH('SE
1` BUILDING DeP.WME.\T
120 WASHLIIGTON STREET 3"a FLOOR,
TFL (978) 745-9595
F.x(978) 740.9846
!mot\115ERLEY DRISCOLL
AM 1 I wn"ST.PiFun
DIRECTOR OP PUBLIC PROP ERTY/111:RDf\G CO\LMISSIONER
Workers' Compensation Insurance A177d3vit: 0uiiden/Cuntruc It)rsfE[cc tricians/Plumbers
111pllcant Information Plea'le Print Legibly
MUM;IHminc,.a UrWtetraliamlmlividual): -//Y✓ ' \ f�/R-/ /'L�`C
Address: 7 a'•F- IiV'irl r.N,,,l
CilyiStatc/Zip: , (0,, 1., /t14- Phone N:_te 6�7
Are you an employer?Check the appropriate box: KinAimailam
prn)cct(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and tew,construction
employees(full and/or part-time).* have hired the sub-contractan
2P Jim a sale proprietor or partner• listed on the attached.heat.) I. modeling
,:hip and have no employees These subcontractors have molition
working for me in any capacity. workers'camp,insurance. ilding addition
(No workers'.comp.insurance 5• ❑ We are a corporation and its
rciluircd.1 officers have exercised their ctrical repairs ar additions
).❑ I am a homeowner doing all work right of exemption per MGM mbing repairs or additions
myself.[No workers'comp. C. 152,41(4),and we have no of repairs
insurance required.( t cmpluyecs. (No workers'
comp insurance...... .� er
-.wy applLwd dW ahuvYr but el mwr also 0I1 out the washes bulow.howiny their token'camlwnmlan pulivy inAi mudo0.
'I Lvnewnvw who tuhmit thin amAnvis indlcaing they an dalny all uvre and thin him uurlide can tncfale mwr mhmh a maw anlJaril indiainy.uch f\mtrxwn that vAvik Chia bw owl machvd an addinunal.Aael ehuwiny the owns althe rvbauntrutam and their workon'Willis.policy inlwrwnon.
/aim an employer that lr providing workers'compeurallan hrruranee%r my etnp/ayeea Below is the polky and job site
injururutlan.
I nourutce Company.Name:
Policy 4 or Sclr•ins. Lie. it: Expiration Date:
lob Site Address: CilyiStatef2ip:
\ltaah a copy of the workers' compematloe Policy declarallan page(showing the policy number sod expiration data).
Kiilum to sccura coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penaltids of a
rinc up to 11,500.00 and/ur one-year impri.ennment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to 51j0.(10 1 Jay against the violator. lie advised that a copy of ihis,ralnment may W furwardW to die 00%d of
Iner,tig.tiuns ui the MA fur insurance Coverage verilicaliun.
l do herrby certi/y""Ofha pains and reaulder cif perjury that the infurarallmr provided above i.e true turd correct.
L
OI/icial nee uuiy. Oa not write its dti,arra,m he cull, lefud by city up Iowa njjlor'aL
fora err llnvu:. __ -- ._ _ 1'crmiul.lecma i
?,.ilia-,•\uihurily (circle une)t — _'
I. 1{unN ill Health !. Iluildlm�I)epartmcut ). ('il yl rolvn C'terk J. (•:ftefricul Lt,pecfur i. Phan Ding Inipdefar
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' MARK RHYMER"' , n x�'` `� .'�. i• .W. 'b:
�` PO BOX 448 '• � "�t t �
SALEMj`MA 01970
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^� CITY OF S,V-&,f, Akss.1CHUSETTS
ALLOLNG 0FPAAnLLNT
110 WASHNGTON STXW, 1io Ft CC
Tt:t. �97tn la!-9S9S
Ic1a®FJtLFY DRI3COL1. RVt(918) 144984
MAYOR MO..%WST.P[F. "
DIRECTOR O/PL 811C PROMITY/amnLNG COmmss(ON Eit
Construction Debris Disposal Affidavit
(required for 4 demolition and renovation work)
In accordance with the sixth edition orthe State Building Code, 190 Cy41R section 11 I.1
Debris, and the provisions of MGL a 40, S 54;
Building Permit b is issued with the condition that the debris resulting from
This work shall be disposed of in a properly licensed waste disposal racility as defined by NIGL c
11 I, S 150A.
The debris will be transported by:
(nano of hauler)
The debris will be disposed of in :
( Wt0 '1
(n�m�of fudi )
Warrir of rulbly)
urnamroufpermitrpplic�
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