36 HAZEL ST - BUILDING INSPECTION � I � � �� z'1Z�
• � ,���,r�-�rn��'vta�
� The Commonwealth of Mag��cl�s�t�ts p �; 3�
� _ Deparhnent of Public SaEc��
`'"'^ Massachusetts S[ate Building Code(7S0 CN(R)
^ Building Permit Application for any Building other than a One-or TwwFamily Dwelling
1
� � ('Chis SecHon Foc Official Use Onl )- . -
,� Building Permit Number: Date Appiied: �Building Offici:il:
� SECCION 1:LOCATION(Please indicate Btock#and Lot M for locatione fo�which a street addreSs is nobavailable)
1
� 36 I-la2t\ Sl- S�ler }ti� c��`t1U
� No.and Street City/Town Zip Code Name of Building(if applicable)
� SECTION Z•PROPOSED WORK.
Edition of MA State Code used_ [f New Construction check here�or check all[hat apply in the two rows below
Exis[ing Building @� Rep.ir❑ Altemtion Addition❑ Demolition ❑ (Please fW uut xmd submi[Appendix 1)
Change of Use ❑ Change of Occupancy �� Other ❑ Specify:
Are building plans and/ur construction docwnents being supplied as�art of this permit.pplication? Yes No ❑
Is an[ndependent Structural Engineering Pecr Review reyuired? ' Yes 0 No ❑
8rief Descrip[ion of Propose�i Work: �v.��'��r� e [1 w S�4�r CeSt � n ��i 3*Q LQ_nr�
—�
SECTION 3:COMPLETE TfIIS SECtIOIV IF EXISTING BUIGDING UNDERGOING RENOVATION,ADD[TION,OR
CHANGE IN USE OR OCCUPANCY � �
Check here if an ExisHng Building Investigation and BvaluaHon is encfosed(See 780 CMR 3l) ❑
Existing Use Group(s): t c t E Proposed Use Group(s): �
��,�5 {y�, �d� SECTION4:BUILDINGHEIGHTANDAREA �
Existing Propuse��
IVo.of Floors/Stories(incluale basement levels)&Area Per Floor(sq. f[.) .3
Total Area(sy.ft.)and Total Height(ft.) � �{p `l U �
� SECTION 5:USE GROUP(Check as a plicable) . � �
A: Assembly A-1 ❑ A-2❑ IVigh[club ❑ A-3 ❑ A-1❑ A-S❑ B: Business ❑ E: Educational ❑ �
F: Facto F-1❑ F2❑ H: Hi h Hazud H-1 ❑ H-2❑ H-3 ❑ H-�1❑ H-5❑
L• Institutional I-t❑ 42❑ F3❑ [-1 O M: Mercantlle❑ R: Residential R-10 R-2❑ R-3�R-4❑
S: Storage S-1 ❑ S-2❑ U: UHlity❑ Spetial Use O and please describe beluw:
. Speciil Use:
SECTION 6:CONSTRUCTION'I'YPE(Check as ap licable)
�. IA ❑ ID ❑ IIA ❑ [B ❑ IIIA ❑ ❑IB ❑ IV ❑ VA ❑ VB O
. SECT[ON 7:S17'E INFORMATION(refer to 780 CMR 111A for details on each item)
Water Suppl : Flood Zone[nformaHorc Sewage Disposal:
Trench Permit: Debris Removal:
A Uench will not be Licensed Disposal Site
Public Check if outside Flwd Zone❑ Indicate municipal reyuired O or[rench or specify:
Private❑ or inJen[i(y Zone: or on site system❑ �ermit is endosed❑
Railmadright-of-way: HazardstoAirNavigation: �in__Il�,to�g,C„�nm{+.4[onucy�c���,i'.nxr:,<:
Not Applicable❑ . Is Struc[ure within airport approach area? Is thcir review mmpleted?
or Consent ro Build endosed ❑ Ycs O or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
[di[iun of Code: Use Cruup(s): Type of Cnnslruction: Oaupant Load per Floor:
Dues the building cont:iin an Sprinkler S}'stent?: Special Stipulatiuns:
GQ�l�1_. C�tJ T ' 2,
� .,.5•r• ! - SECTION 9: PROPERTY OWNER AUTHORIZATION -
Name and Address�of'Property Owner i
� .c.`nar��- �uf�a 3�O 1-1<� �I S � S� 1eh 6147u '
Name(Print) ' ` ` � ! „��,'.No.and Street City/Town Zip
Property Owner Contac[fnfonnation: �
Title � Telephone No.(business) Telephone No. (cell) e-mail address � '
[f applicable, the property owner hereby authorizes �
Nevne Street Address City/Town State Zip .
to act on[he ro er owner's behalf,in all matters relative to work autltorized b [his buIIdin ermit a lication.
� � � � SECTION�10:CON57ItUCTION CONTROL(Please-fill out Appendix 2)�� � � � - �
If builJin is less[han 35,000 cu.ft:of enclosed�s ace and or not undec Construction Control�then check here O and ski� Sedion 101
101 Re istered�Professidnal Res onsible for Construttion Control � � - - �
Ivame(Registrant) Telephone No. e-mail address Registra[ion Number
Strcet Address City/Town Sta[e Zip Discipline Expiration Date
10.2GeneralContractor- - � � � - - � � - � � � � � � � -
Cf�QI- 'tS I� �h,G �P4
Comp1any Name ' 1 c y� n�
C^4r �GS Hlw��t4 � J 1- /? �y � �oo��e � � zf z�]/�-6
Name of Person Responsible for Cons uction License No. and Type if Applicable
�6 '/� .�o. n, wr. '1 � o-� .Sa �eti-, �ii Vl9?a
S[met Address City/Town , State Zip
� �14.& �}�'i� l38o SO�-�32. 138u Cl.a � �»c�eti �, 4 h�w��� • Ce n,
Tele hone No. business Tele hone No. cell e-m.' address
� SECTION11:4YOItI:h7S'COA�IPENSnI'fOi�iWSUR:1NCViAeFIUi\Vt'f M.G.ti.c.152 ZSC6 �
A Workers'Compensation Insur.�nce Affid,vit from the MA Deparhnent of Industrial Accidents must be completed and
submit[ed wi[h this application. Failure to provide this affilavit will result in the denial of the issuance of[he building permi[.
Is a si ned Affidavit submitted with this a lication? Yes O No ❑
- . � � � SECTION 12:.CONSTRUCTION COSTS AND�PERMIT FEE� � � � �
Item EsFvna[ed Costs:(Labor
and Materi:ils) Total Cons[rudiun Cost(from Item 6)_$ a� i V�b
1. Building � IST� BuilJing Permit Fee=Tutal Construc[ion Cos[x_([nser[here
2. Electrical $ �� appropria[e municipal factor)_$
3. Plumbing � �a:�<<• $ �'3 tro 0
4. Nechanical (HVAC) $ Note:b(inimum fee=$ (mntact municipality)
S. btechanical Other � Enclose check payable to
6.ToF.il Cost $ a� po o (contact municipality)�nd write check number here
SECTION 13:SIGNANRE OF BUILDING PERMTT APPLICANT �
6y entering my name below,[hereby at[est undez the pains and penalties of perjury that all of the information contained in[his
application is true e�nd accurate to the best of my knowledge and understanding. .
C..�� r �.t s �� ir� � �ir4 CGI,�'Lc� ��� 56& _531��U
Pleve print an sign name 1. Title Tciephone No. Date
8 �/�1 �a W. m : 1 � 1 re �c �'e h �^1 c U l�'i 7U
Street Address City/Tuwn State Zip
�lunicipal Inspector to fiR out this section upon applicativn approval: " � � � `
Name Date
�'r ��� � 7 �r � pA. �� w;�� be �.P a � ra� 3 �'«� �,,,
�har�o C �) �nc �ey 61� - 755 -a9G�j
I�-- - — -- -- -
�J' — I la- � � p � �—/�
� � ' ��
I ' �
Gi^y�/�/�
a,i^.�.���^"_ _ Ci�/L/� •
��i']����i ��,/ � � — V .
� � '�fv ,
��
�
r
�
�
Q.
r
< �
--�� �
� �
a
:7" N
�'\ • The Commonwea[th ofMarsachuseds
Depar[ment oflndusiriaJAccidents
'� I Congress Street,Sxite I00
Bostou,MA 02I14-2017
www massgov/dia
Workers'Compensation Insuraoce�davit:Builders/Contractors/Electricians/plumbers.
TO BE FII.ED WITg'lgE PERNIITTING AUTHORITY.
Aonlicantln[ormstlon P1euePrint Led6h
Name�us�ess�orgamzarion�taaiha�): C��.n��t f H � n ('�G ti
. Address:_ Q % .S In N, w, '''� Q �,�
City/State/Zip: S c ��e � I�^t Phone#: S b S'-9 3 a • I 3 S d
Me yoo m emplpyer?Check fhe approprlate bos: . .
- 1�pe of project(require�:
1.0 I am a emplqu with - emPmYeea(full mNm part-time),•
2.�amasolepuoprieCoror �� ❑NCWCOnSWCt1oD
parmriship md have oo employees wwlting foras in
�Y�Peci7-(No workets'�comp.'vismance mqu'ved] $• 1�-7�Ca10de�IDg
3.❑I am a homcownv doiog all woik myseK[No workus'comp.ma�uar�ce�equ'ved.)1 9. LYLemolitlOn �
4.❑I am a homeowna md will he 6mng contrzqms tu conduct all work nn m 10❑Bililding eddition
msure dut all contractors eitha have wo+kers' Y P+ePe+h. I will
���or$���'oYar compensation IDsumce or are sole 1 I.❑E1CCtijCBl[epaIIS 07 8ddlliOns
lZ.❑P]IIIII}lltl�7CP8j�$OI8da760II5
5.❑I�a Be�a1 co�actor md I have LirW the subcontrectors listed on the aasrLed sheet. .
7Lese sulxonuaums Lsve employees end heve wo�kas'comp.mywapce,i 13.0 Roof repa'vs
6.❑We are a coryoistion end i�offiws have r,xucised the'vrig6t of exemptipn per MGL t. 14'���
157,41(<),a�d we have�w employus.[No wmkas'cwnp.msmance ro9u'ved)
'�Y aPPlic�t that chetlo hwt#1 must alw 5➢out dre sation below ahowing the6 wmkas'cnmpwsepm yo&ry mfmmation.
1 Homeownm who subimt this affidavit iodiceting thry ero do'mg all woxk end t6m hire oufsde coutractors musl au�i[a new e6davit indiwting such.
jContracton tlnt chetk Wis 6ox must atm�8ed eo addi�onel ahat showing the n�e of the subanheUois and state whetha or not t6ou entitia 6ave
wployea. Ifthe sub<ontractors heve emPloyas.�heY must provide t6e'v wm�is'comp.policyn�6a.
I am an employer that is pioviding workers'compen.sa[fox insuranrejar my employees, Belnw is fhepolicy and job site
injormatinn.
Insurance Company Name: -
Policy lf or Self-ias.Lic.#: Expfration Date:
Job Site Address: ��,����P.
Attach a copy ot tLe workers'compenssUon poBcy declaratioa page(showing the pollcy number and e:piration date}
Fail�ue to secure coverage as required imder MGL c. 152,§25A is a criminel violatioa punishable by a Sne up to$1,500.00
and/or one-year imprisonment,es well as civil penelties m the fo:m of a STOP WORK ORDER and a fine of up to$250.00 a -
day agaumst the violator.A copy of tUis statement mey be forwazded to the Office of Investigations of the DIA for insurence
coverage veri5cation.
I do hereby eeiYify under the pains and pendlfes pjpp,rjury that the injormalioe provrded above is bue and eorrecG
� 7 / � /�
Si eture: . Date:
hone#: L� � - p
O�cral use on1y. Do not write in this area,to be eompleted by ci[y or town ofjiciaL .
City or Town• Permlt/License#
Issuing Aut6or►ty(circle one):
1.Board of Health 2.Building Department 3.Cky/1'own Clerk 4.Electrical InspeMor 5.Ptumbing Iaspector
6.OtLer
Contact Person• Phone q•
Information and Instructions � �
Massachusetts G�eral Laws chaptra 152 requires all employers to provide workers'compensation for tbeir employees.
P�asuant to this statute,an employee is deSned as"...every pe[son in tLe service of enother under my contract of hire,
express or implied,oral or written."
An emp[oyer is defined as"an individual,parinership,association,coiporation or otha legal entity,or any two or mare
� of the foregoing engaged in a joint enterprise,and'mcluding the legal repres�tatives of a deceased employer,or the
receiver or vustee of an individual.parmershiP,associatirn'°r ot6er legal eot'q',�P�OYi°B�Ployees. However the
owner of a dwelling house havmg not more than lhree�apactrneMs and wbo resides therein,or the occupant ofthe
dwelling house of another wbo employs persons to do meintenance,construdion or*epair work on such dwelling house
or on the groimds or building appuctenent thereto shall not because of such employment be deertted to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall wi[hhold the issuance or
renewal of a license or permit to operate a business or to coostract buildings in the commonweakL for any
applicsnt who has not produced acceptable evidence of comptiance with the insarance cwerage required."
Additionally,MGL chapter 152,§25C('n states"Neither the cormnonwealth nor any of ifs political wbdivisions shall
enter into any contract for the perfmmance of pubiic work until accepteble evidence of compliance with the ms�uance
requirements of this chapta have been presented to the contrac6ng authoriry."
Applicants
Please 511 out the workers'compensation affidavit completely,by checldng the boxes that app]y to your situation and,if
necessary,supply subcontractor(s)name(s),address(es)and phone number(s)along with iheQ certi5cate(s)of
ins�uance. Limited Liability Companies(I-LC)or Limited Liability Pmtrieiships(LLP)with no employees other than the
members or pariners,are not required to carry workers'compensstion ins�v�ce. If an LLC or LLP does have -
employees,a policy is required. Be advised ihe[this affidavit may be submitted to the DepartmeM of Industrial
Accidents for�confirmation of insurance coverage. Also be sare to sign snd date the affidaviL T'he af5davit s6ould
be retumed to the city or town that the application for the pemut or]icense is being requested,uot the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are requ'ved to obtain a workers'
� compensation policy,please call the Depaztrnent at the manber listed below. Se1f-insured wmpsn�es should enter their
self-ins�aance license number on the �ate line.
City or Town Officisis
Please be s�e that the afSdavit is complete and printed le��bly. The Depamn�t has provided a space at the bottom
of the at5davit for you to fill out in the ev�t the Office of Investigations has to contact you regard'mg the applicent.
Please be sure to 511 in the pemriUlicense number which will be uaed as a reference aumbet. In addition,an applicant
that must submit multiple perntiUlicense applications ia any given ye�,need only subimt one af5davit mdicating current
- policy information(if necessary)and imder"Job Site Address"the epplicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially atamped or marked by the city or town may be provided to the
applicant as proolthat a valid affidevit is on Sle for future pertnits or licenses. A new af5davit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to�y business or cotranercial venture
(i.e.a dog]icense or pemut to burn leaves etc.)said person is NOT required to complete tLis affidevit.
• f
�. T'he Departrn�t's address,telephone and faac nwnber: . �,
The Commonwealth of Massachusetts
Depa�ent of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02 1 14-20 1 7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fa�c#617-727-7749 4
www.mass. ov/dia �
Revised 02-23-15 g
Cj'TYOFSALEM, I�AQ3U6ETT5
� � ' s[�DBr�rr
� 120 WA�m�w7�IS�xaeT,3mFiOc�t
1�L(� 7�lS9S95. •
Fex(°77$ 7�1498�6
SA�IEYDIRISOC�3,
MAYOIt 7}ia�isSST.P�xE
Dmacro9c ca+r�uc�/s�acan�cx�
Construction Debris Disposa/A�davit
(required for all demolition and,.renovation workj
In accordanoe wJth the sucth editfon of the State Building Co�e, 780 CMR, Section 111.5 De6rts;
� and the provisions of AAGL o40, S 54; BuNding Permit At is iswed with the
condition that ihe de6ris resulting from this worlc shall be dfsposed of In a proper�y lioensed �
waste depasit facility as defined by MGL c 111, S 15QA. �
The debris will be transported 6y: �
(� � 1 . ' .
(name of haule �
The debris will be disposed of in: .
�c �� .
(name of facility)
� �
(addre of facility) �
� � � -_���= � � � �
Signature of appli ant
_ 7, ���i ��b :
Date
�
�
0
.� CODE REVIEW
IEBC 2009
' �.I CONSTRUCTION TYPE 5-B
ST IR BATHROOM S IR BATHROOM
SECTION 912 CHANGE OF
� OCCUPANCY w GrayArchitects,lnc.
CLASSIFICATION ° AF������re��tl���Le°�Arcn��u���
� eno.mvsa�.�. sw�.u+.�.ow..mo�mo
a reiu.eres�.o..ruo>er.se.n
e.w��.oxwvumxnEmemm...mm
�_ _._.a___--=--- = �-::, �-_.._., ._._ _ ,.__---, �_: .--_— � ' -THEEXISTINGSTRUCTURE
IS R-3 CLASSIFICATION.
EXISTING WALLS
AND DOOR TO BE EXISTING WALLS -THIS NEW CLASSIFICATION
MODIFIED TO AND DOOR TO 8E FOR THE WHOLE BUILDING
PROVIDE ONE BEDROOM MODIFIED TO IS R-2. �
HOUR FIRE RATING. PROVIDE ONE i
HOUR FIRE RATING. �
SECTION 912.72 STAIRWAYS
OO -THE NEW WALLS WILL BE
S RATED FOR 1 HOUR. NEW
KITCHEN KITCHEN WALLS TO BE 5/8"TYPE X F 36 HAZEL STREET
BOTH SIDES,2x4 STUDS, o Salem MA01970
BEDROOM CAVIN INSULATED.
-THE EXISTING WALLS ARE
TO MODIFIED TO CREATE
ONE HOUR RAT�NG. � -
� 'O NEWINTERIORSTAIR
rc
� ��{,REOIR�,y�
BEDROOM �,�+"'.eq ,
- '� s °no.5185
i �ow
s
�--- —
EXISTING WALLS � I I I - '�Mo�
AND DOOR TO BE
MODIFIED TO EXISTWG WALLS j I I I
���m„
PROVIDE ONE AND DOOR TO BE I- I I I � ���µo��wnw�^��y'..p
,,,,�,M..�m.,�.,�,..n.�.�.�..
�, �...,.�.a�.�,2e.��.o.�.�a.�
HOUR FIRE RATING. MODIFIED TO p �� �w�""m'P'"°"""`""`"
a K�..w.�.A,���,.�.�...�.
W.m x,.�.�w.W�
PROVIDEONE L L L � �°�a�w^�d^�.�^�°.�a
_ _ _ , �_.__.._,_
.d�.
� i � , HOUR FIRE RATING. — ---- i__ I �___ __..�
---- - _ __�
LIVING ROOM O � I I LIVING ROOM _
I� � \ I i � I - I /� �
i � -� �-
�� STAIR� �� pN STAIR
O ! z
� y
O - ,
S Up O rc
UP
. NO. DESCRIPTION OATE
{� O a
F
� o PROJECTNo.15020
� ��RAW N BY'.QL.A.CHECKED BY'0 J.G.
� SCALE:Ae NoteC I
� � � �ATE'.9RBI2�15 ��
� - . SMOKE DETECTOR , OS �
, - � - LOCATION AN TYPE TO BE APPROVED BY THE p�p,Ns
, FIRE DEPARTMENT �
� FIRST FLOOR PLAN SCALE: 1/4��=��-o�� 2 SECOND FLOOR PLAN SCALE: 1/4��=��-o° g I
A-1.0 A-1.0 � A-'�.O
a
� .- _ . — _ — - __ - �
. . ., z2,_a,�
8,_6„ �
w
_
�
0
;� T IR O BATHROOM
� ry Gra Architects Inc.
E AmMlecWraentlLenOncepeArUiceciure
� wo.�vse�,.+-sn.m,w...m...moie�o
e
a re�ne�a..a.ru.ererawn
�.-9`.,- vs. . . I 6MaII:�MYPRCpiECi3�mm.wn
._.._.:_. _�
EXISTING WALLS
AND DOOR TO BE �
MODIFtED TO =
PROVIDE ONE �
HOUR FIRE RATING. U
O � 38HAZELSTREET .
KITCHEN � SalemMA01970
BEDROOM
� U
i
� � NEWINTERIORSTAIR
(h
� � 6�gtfREU.IBCNi
p4Q�t�\S J.C,y'�•
No.S 1�
� ; :ws
. � . . _.. . .. �4Nof -
,x,,.� .__.� ._. ..._.. ___..."_�_._. ,
3�_8 -
NEW EGRESS STAIRS
EXISTING WALLS ;j 15T @ 11"16R 7"
AND DOOR TO BE OS { 1.ONE HOUR RATED WALL CONSTRUCTION. ;
MODIFIED TO 2.TREADS 11" b " �
PROVIDE ONE �i 3.RISERS 7" ° p��� a�„� .^°��^_.
' HOUR FIRE RATING, i 4.HANDRAIL ON BOTH SIDE.
i
_ LNING ROOM i I I q
,. `� � ,� A I I �
I y
�I O STAI ��,�
0
�
rc
�D
P)
NO. OESCRIPTION DATE
F
PROJECT No.15020
�DRAWN BV:QL.A.CHECKEO BY'.D.J.G.
SCALE�.Ae Notetl
'O�_O^ � ONTE:B/2BI2015
0
' SMOKE DETECTOR OS
� LOCATION AN TYPE TO BE APPROVED BY THE � PL4NS
FIRE DEPARTMENT
� THIRD FLOOR PLAN SCALE: 1/4��=��-o�� � A-1.1
A-1.1 �
0