22 HAWTHORNE BLVD - BPA B-15-214 ri
� �`�. l� i I "1 la � I �'-� 2,�
� `� The Commonwealth of Massachusetts
^'1 i M1�� Deparhnent of Public SaFety
� l V y M1'Id55dl'h115CII5 S�atc 6uilding Cude(780 CMR)
� Building Pemiit Application For any Building other than a One-or Two-Family Dwelling
- � � .(T7iis Section For Official Use Only) -
� 6uilding Pertnit Number. Date Applied: 8uild'u�g Official:
1
,�^ SECTION 1:LOCA'CION(Please indicate 61ock k and Lot M for locations for which a sheef address is naf available)
�V � .�� cs/'�i/C-f� O/97 d
a2-N�w-rh o��.e �ceu
No.and Slreet City/Town Zip Code Name uf 6uilcling(if applicabte)
SECTION 2 PROPOSED WORK �
Editiun of MA State Cudu used_ If New Cunstruction dieck here�or check:ill that apply in the�wo rows below
Existing&�ilding Repait ' rUteration /Addition❑ Demolition � (Plcase fill ou[and submit AppendLr t)
Change of Use ❑ Chnnge of Occupancy ❑ Other ❑ Specify: �
Am building plans and/nr cunstmction ducwnents being supplied ns part of this permit applic.ition? Yes O Nu ❑
Is an fndependentStructurel Engincering Peer Review reyuimd? Ycs ❑J No ❑ �
6rief DescripC�yon of Propused Work; G /'17 � C� �
�awd" �4A.�2Th�.z1.-�s� �oars2 i('��c��� f /fi5�if�r
� SECTION 3:COMPLETE TfIIS SECTION IF EXISTING BUILDING UNDE2GOING RENOVAT[ON,ADDITION,OR
CHANCE IN USE OR OCCUPANCY
ChiKk here if an Existing Building InvestigaHon and Evaluallon is enclosttl(See 780 CNIR 3-k) ❑
Esis[ing Use Group(s): Propused Use Gmup(s):
SECI[ON 4:6UILDING HEICHT AND AREA
� . Existing Proposed
No.of Fluurs/Sturics(include basement levels)dn Area Per Fluor(sy.ft.) �
Tot:il Arca(sq.ft.)and Total Height(ft.) ' ,
SECTION 5:USE GROUP(Cbeck as a plicable)
A: Assembly A-1❑ AQ O Nightclub ❑ A-3 ❑ A-4❑ A-5� 6: �Dusiness ❑ E: Educatianal ❑
F: Facto F-1❑ P?❑ FL• Hi h Hazud H-1❑ H-2❑ H-3 � H-#❑ H-5❑
L• Institutional f-1❑ I-2❑ (-3� I-}❑ M: MercanNle� R: Residential R-l❑ 2-2❑ R•3❑ R-4❑
5: Storage SI❑ S2❑ U: Utility❑ Special Use O and plense describe beluw:
. Special Use:
SECTION 6:CONSTRUCIION"fYPE(Check as a licable) �
IA ❑ 16 ❑ IL\ ❑ 116 O Iffe\ ❑ ❑IB ❑ IV ❑ VA ❑ VU ❑ i
SECTION 7:SITE INFORAG\TION(reFer to 980 CMR 111A for defails on each item)
4Vater Suppl Plood Zone Informa[ion: Serwge Disposal: � Trench Permit: Debris Remuval:
.. Public� Check if uutside flaod Zune❑ InJicate municipal �\trench will not be �Licensed Dispusai Sitc❑
reyuimd O ur trench ar specify:
Priv�ate❑ or indenlify Zone: or on site sysfem❑ F�i�������y E��dnsed❑
ftailroad right-of-way: Fiazuds to Air Navigation: �i\i��,i i i � nmmi� i n I �� ��,1 r wr.c
Not r\pplicable❑ Is Slructure within airpurt approach area? � Is their mview completed?. .. .
nr Cunscnt to fiuild cndoseJ❑ Ycs O or Nu❑ Ycs❑ i�lo ❑
SEC7'ION H:CONTEN'I'OF CGRTIF(CA'fE OF OCCUPANCY
I:ditiun ul Cudc Usc Group(ti):_ �PVpe of Cuntitnictiun:_ Occupant Lo,�d per fliwr: - _
Ducs thc builJiny,cunt.�in an Sprinklcr Systcm?: _ Spccidl Slipul.Uions: _._
�
sccrrorr v: raoesR�owHsii�wrtioa�zrcriorr
Name anii Addnss of Property Owner � ��SC�� J f' '
Sa/�n ldcS�:s�cr��`� IQcwi7t !°,��r,e�el Syy/� � 70
Name(Print) No.and Stmet City/"Cown Zip
Property Owner Cont�. t(nformalion:p p C"�� '
/Yll�riC���SP ftZ—/(l1.UhGR—� �/�(/ `� ���/ 7'� ""�
'lille � Tclephone No.(business) "Cdephone No. (cell) e-mail address
If applicable,the property owner hereby autl�orizes
�ol2n /�l4�v�?-Y .�OII E�2tl veJ .J'7��f S�/es� !�'/A' O/�i70
Name Street Address City/Town State Zip
tu act on the ro er uwner's behnif, in nll matters rclative io whrk authorized b this buildin ermit a lication.
SEC'TION 10:CONSTRUCTION CONTROL(Please fill aut Appendix 2)
If bui�din is iess thnn 35,000 cu.ft.uf enclosed s nce anJ or not tmJer Corefruclion Control Ihen check here O and ski Sectimi I0.1
10.1 Re istered Professional Res onsible for Construction Control �
N,me(Registrant) "Cclephone Na e-mail nddress Registration Number
Strcet Address City/Town SI.te Zip Discipline Expiration Date
102 General Cankactor � �
J'o%h f�2��y LLC
Company Name -
�S�l�K f��R�c�-e Y es 0�137 o G
Name of Person Responsible fur Cunstruction Licttnse Nu. �md Type if Applicable
30 /9- f'�-/2n� �Si�eej 3�/e� �� O/�'i?o
Strret Address City/Town , State Zip
�-Y.� 6Yv� --
Tcic hone No. business Tc�e hone No. cell e-mail addmss
SEC'fION 11:�e'Ur.K61tS COnu�eu5n rioN INSua:�:��cti:vt'iunvn' M.C.L.c.152 25C 6
A LVorkers'Compensntion Insurence Affidavit from the MA Department of[ndustri.il Accidents must be completed and
submitted with�this application. Failure to provide this iffidavit will resul[in the denial uf the issuance of the building permit. -
[s a si ned Affidavit submitted with lhis a lication? � Yes❑ No ❑
SECTION 12•CONSTRUCTION WSTS AND PERMIT FEH
��` Hstimated Costs:(Labur
and Mahrials) 'Cotat Cunstruction Cost(from Rem 6)_$
L UuildinK � OOf9 guilding Permit Fee=Tutal Constcuction Cust x_(fnsert here
2. Elccirical S�T� O('70 � appropriate municipal fac[or)_$ - .
t. Plwnbing 5 OU
d. blrchanical (FIVAC) � � Op� Note:�lininwm fee=$ (contact municip:ilily)
S. biechanical Other �S Endose check a ��ble tu
v r•
6.Total Cust 5 (cuntact municipality)and write check number hem
SECI'(ON 13:S[GNATURE OF UUILDING PERhtI'C e\PPLICANT
6y enl•ruig my namc bcluw, (hereby attcst under thc pains anJ pen�lties of perjury that all of the informatium m�tained in lhis
� �ip lica io is true and accur.rte to the bes[of my knorvledge and understanding.
� ' �Jwr�e.n— �]�-y� N�� 3 as
lea.e mt and si na ie Title Tclephu�ie Uu. Date
�0 w �12�STYL-G�e7� ,��-Kw.. � n�G�o
. Stmet AdJress City/Tuwn State Zip
� i�lunicipal Inspectorto fill out this section upon application approva4
Name Datc
�A
�� � The Commonwea[th ofMassachusetts
Department oflndustrialAccidents
s ; _ I Congress Street, Suite I00
' — Boston,MA 02114-2017
- � www.mass.gov/dia
� �\'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
` TO BE FILED WITH THE PERMITTING AUTHORITY.
- Applicantlnformation � _�/ PleasePrint Le¢iblv
Name (Business/Organization/Individual): JO�11'r /q/[7/'e �
Address: 3d A Q2o /�. ST2�� %
City/State/Zip:, ��Pf�.r dJi//� (�/S]�hone#: /�P %�� 6`1�/ 6
Are you an employer?Check the appropriate box: � TyPe oT P1'oJeCt(feyulr¢d�:
�� 1.�1 am a employer with employees(full and/or part-time)t � 'J, �NeW ConStCUCtiOn
2. a sole proprieror or partnership atid have no employees working for me in $, �$ e�ing ,
any capacity.[No workers'-comp.insurance requved.]
3.�I am a homeowner doi�g al I work myselL[No workers'comp.insurance required.]1 9. emolition
� ]0 Q Building addition
4.❑I am a homeowner and will be huing coniractors to conduct all work on my properry. I will -
enaure that all conhactors ei[her have workers'compensation insurance or aze sole 11.0 Electrical repairs or additions
� , proprietors with no employees. � � �
. 12.Q Plumbing repairs or additions
5.❑I am a genera]contracror and I have hired the sub-contrac[ors listed on the attached sheet 13.�Roof ieflaiis
These sub-connactors have employees and have workers'comp.insurance.= -
6.�We aze a corporation and its officers have exercised their right of exemption per MGL c. 14:�O[her �
152,§1(4),and we have no employees.[No workers'comp.insurance required.] ,
'Any applicant that checks box N I must also fill ou[the sec[ion below showing their workers'compensation policy information. .
i Homeowners who submit[his a�davit indicating Ihey are doing all work and Ihen hire ou4ide contrac[ors must s�bmit a new affidavi[indicating.such. �
tContractors that check this box must a[tached an additional sheet showing the name of the sub-contrac[ors and stare whether or not those entities have .
employees. If the sub-contractors have employees,they must pmvide their workers'comp.policy number. � �
I am an emp[oyer that is providing workers'compensation insurance jor my employees. Below is the po[icy and job si[e .
information. . '
Insurance Company Name: .
- Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy namber and expiration date).
Failure to secure coverage as required under MGL-c. ]52, §25A is a crimina]viola[ion punishable by a fine up to$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$250.00 a i
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverag verificatio � -
I do hereb e ' un r e parns and penal ies ofperjuty that[he information provided above`is true and correct �
Si ature: � Date: J �\��
Phone#: � � �b
O�cia!use anly. Dn not write in this area,ta be camp[e[ed by city or town officiaC
City or Town: Permit/License# �
Issuing Authority(circle one):
. 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other "
Contact Person: Phone/!:
�
.
Information and Instructions `
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuan[to this s[atu[e,an emp[oyee is defined as"...every person in the service of another under any contract of hire,
express or implied,ora]or written." �
An employer is defined as"an individual,par[nership,association,corporation or other lega]entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the]egal 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[hree aparhnents 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 the grounds or building appurtenant thereto shal]not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states[ha["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 auy
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 performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contrac[ing authority." �
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partr�erships(LLP)wi[h 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 Industdal
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavi4 The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Deparhnent of
Industria]Accidents. Should you have any ques[ions regarding the]aw or if you aze 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 permiUlicense number which will be used as a reference number. In addition,an applicant �
that must submit multiple perntiUlicense applications in any given yeaz,need only submit one affidavit indicating cunent
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 starnped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or]icenses. A new affidavit must 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 dog license or permit to bum leaves etc.)said person is NOT required[o complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Deparhnent of Industria]Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised o2-23-15 www.mass.gov/dia
. -
`�'' � Ma$iveTEC tel (617) 437-6461 fax (239) 236-0444
. 31 Munroe Street
Environmental Science.Survey, Civil Engineering, Lynn, MA 01901
Urban Design,Architecture&Landscape Architecture
FIRE PROTECTION NARRATIVE
FOR
22 HAWTHORNE BLVD
SALEM. MA
The building is a Type 5 Wood Frame Construction, a Mixed Use Business/Commercial
Renovated building. Sprinklers have been specified. The Means of Egress fire ratings and
use of existing stairs will have been approved by the Building InspectorAll fire codes,
(Local, State, and Federal Codes) shall be adhered to. We met with the City of Salem Fire
Department regarding the Life Safety Plan and the revisions he advised have been effected.
All Smoke, heat and carbon monoxide detection system, EXIT signage and emergency
lighting types and locations shall be as approved by Building and Fire Officials, as well as any
requirement for fire sprinkler system to be designed by appropriate licensed Professional.
The contractor is, responsible for obtaining all required permits. Building Official and all
appropriate building component officials are responsible for final inspections and issuance of
Certificate of Occupancy and 780 CMR 8�h Edition Chapter 34 / IEBC as necessary.
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